The Other Therapy
Consent for Treatment
Trevor Brown, MA, LPC  ·  Couples Therapy Agreement
Each partner completes this form separately
Step 1 of 5
Welcome. Please read this carefully.

This document outlines what you can expect from working with me, and what I'll expect from you and your partner. Each of you completes this form separately. Read through each section and acknowledge at the bottom before continuing.

Your right to withdraw

You can refuse any treatment or withdraw consent at any time. Before doing so, I'd encourage you to raise your concerns with me directly. If you decide to end treatment, I'll provide referrals to ensure a smooth transition.

My right to end treatment

I may end treatment if I'm no longer confident I can provide the best care, if fees go unpaid, if sessions are repeatedly missed without rescheduling within 6 weeks, or if behavior consistently undermines the therapeutic process. I'll discuss this with you and provide referrals.

About couples therapy

Couples therapy continues as long as all three of us feel it's productive. There is no guarantee it will save or even improve your relationship. Some couples end their relationship as a result of this work — not because therapy failed, but because clarity emerged.

Goals I won't pursue

I can't help you create a conflict-free relationship, eliminate strong emotions, or help one partner better manage the other's sensitivities. What I can do: help you fight better, understand what's driving the distance between you, and take honest ownership of your own part in it.

Please check the box above to continue.
What to expect in sessions

The hot seat

Both of your roles in the relationship's problems will be addressed. If one partner's defensive patterns are more visibly self-defeating at a given moment, that becomes the focus — not out of blame, but because that's where the work is. This is uncomfortable. It's also the point.

When tempers run high

If things become combative, I'll shift focus from what's being said to how it's being said. If it continues, I'll disengage from the combative partner and work with whoever is able to engage. If a partner leaves early or doesn't show, I'll continue with whoever is present and follow up by email within 48 hours.

Communication between sessions

If you email me between sessions, CC your partner. This keeps the therapeutic frame intact. Triangulation — even unintentional — undermines the work.

If couples therapy ends

If one of you wants to continue individually after couples work ends, the other partner cannot also continue with me and will not be privy to any information from subsequent individual sessions.

Legal proceedings

I will not get involved in legal proceedings (divorce, custody) voluntarily. If subpoenaed, my rate is $360/hour — double the standard rate — covering preparation and any legal fees I incur. The party driving the legal action is responsible for this cost.

Telehealth

Sessions are conducted online via secure video platforms. Telehealth has inherent limitations including occasional technology failures and a reduced ability to respond to local emergencies. If you are outside the US and in crisis, please contact your local emergency services or visit findahelpline.com.

Please check the box above to continue.
Scheduling, fees & payment

Fees

Couples therapy sessions (65–75 minutes) are $225. Payment is due on the day of the session, before or after. I can provide a superbill for insurance reimbursement, but cannot guarantee your insurer will accept it.

Payment methods

Venmo: trevor-brown-7  ·  PayPal: tmbrown1scu@gmail.com  ·  Wise: wise.com/pay/me/trevormayob

Cancellation policy

No charge if you cancel at least 48 hours in advance. Full session fee applies for late cancellations or no-shows. If you miss a session without rescheduling within 6 weeks, you'll be closed out of my caseload. Standing appointments are cancelled after a single no-show; future standing appointments are cancelled after three consecutive cancellations.

Diagnosis & fee changes

Unless you ask me to, I won't assign a formal DSM diagnosis. I reserve the right to raise fees at any time with advance notice, and will provide referrals if the new rate creates a financial barrier.

Please check the box above to continue.
What stays private — and what doesn't

Confidentiality

Everything discussed in our sessions is confidential. I will not share information about you with anyone unless you ask me to, or unless required by law.

Exceptions

I may share information without your consent in the following circumstances: clinical supervision (bound by the same standards); court order or subpoena; credible risk of physical harm to yourself or others; suspected child or elder abuse or neglect; or if you're being repeatedly physically or sexually abused.

Release of information — couples

If one partner requests that information about joint sessions be released to a third party, both partners must sign authorization. Legal exceptions apply.

Colorado licensing & international clients

I am licensed in the state of Colorado, USA. My professional and ethical obligations follow Colorado and U.S. law. If you reside outside the United States, local laws regarding confidentiality, duty to report, or data protection may differ from what's described here.

What the work involves

Therapy often means facing things that have been avoided. The path toward getting better can involve real discomfort. My goal isn't to help you feel better in the short term; it's to help you get better in the long term. You'll likely feel challenged at some point, particularly when I point to what you're doing that gets in the way of what you want.

Social media & recordings

We won't connect via social media. No recordings of sessions are permitted under any circumstances.

Please check both boxes above to continue.
Complete your details below

You're signing on your own behalf. Your partner will complete their own copy separately at the same link.

Your information

Your signature
Draw your signature above using your mouse or finger
Please fill in all required fields, draw your signature, and check the consent box before submitting.
Almost done — one more step

Your details have been submitted. To complete the process, please download your signed consent form below and email it to trevor@theothertherapy.com.

Then email the PDF to trevor@theothertherapy.com to complete your intake.

Your partner needs to complete this too.
Send them this link so they can submit their own copy:
theothertherapy.com/consent-couples
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