Couples agreement | Mesa Valley Counseling

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Purpose and therapeutic relationship

The purpose of couples counseling is to help both people understand and improve the relationship: communication, conflict, trust, and shared goals. The relationship is the primary client. The therapist remains neutral and does not take sides. Work is collaborative, strengths-based, and trauma-informed. CBT principles and faith or spirituality may be included when they are a strength for you.

Client 1 legal name *

Client 2 legal name *

We understand this is couples counseling focused on the relationship, not two separate individual therapies. *

Confidentiality, no-secrets policy, and records

Session communications are confidential except for suspected abuse or neglect of children, elders, or vulnerable adults; a serious threat of harm to self or others; a court order; or written consent. Because this is couples therapy, clinically relevant information shared by one partner is not kept secret from the other. Occasional individual meetings are part of the couples process and may be discussed in joint sessions. One clinical record is kept for the couple. Both clients must agree in writing before records are released.

We agree to the no-secrets policy and understand that clinically relevant information may be shared with both partners. *

We understand a single couple record is maintained and both of us must authorize any release. *

Court involvement

The therapist’s role is clinical support for the relationship only. The therapist will not participate in divorce, custody, or other legal proceedings and will not serve as a custody evaluator or forensic examiner. Both clients agree not to subpoena the therapist, notes, or records.

We agree not to subpoena Jason Cheney, clinical records, or notes in any legal matter now or in the future. *

Limits, fees, and communication

Couples counseling is not appropriate when there is ongoing domestic violence, coercion, untreated active addiction, or other safety concerns. The therapist may end services and provide referrals. This is not legal, financial, or medical advice. The session fee is $130 for 50–60 minutes, due at the time of service. Many insurance plans require verification and some do not cover couples counseling. Cancellations need 48 hours’ notice or the full fee is charged. Between-session contact is for scheduling only. This practice does not provide emergency services. In a crisis, call 911 or go to the nearest emergency room.

We understand counseling may be paused or ended if safety concerns make couples work inappropriate. *

We agree to the $130 session fee, payment at the time of service, and the 48-hour cancellation policy. *

We understand this practice does not provide emergency coverage and we will call 911 or go to an emergency room in a crisis. *

Consent and signatures

Either person may end counseling at any time. The therapist may also end services if the work is no longer productive or clinically appropriate. Electronic signatures are intended to have the same effect as handwritten signatures.

We have read this agreement, consent to couples counseling, and agree to these terms. *

Client 1 typed name *

Client 1 date *

Client 1 signature *

Type your full legal name. Checking the box applies your electronic signature. This page does not record handwriting, a mouse path, or a finger tracing.

Typed legal nameI agree that typing my name is my electronic signature. It has the same legal effect as signing on paper under the federal ESIGN Act and the Colorado Uniform Electronic Transactions Act.

Client 2 typed name *

Client 2 date *

Client 2 signature *

Type your full legal name. Checking the box applies your electronic signature. This page does not record handwriting, a mouse path, or a finger tracing.

Sign by typing your legal name and checking the consent box, then submit the form.

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Couples Counseling Agreement

Purpose and therapeutic relationship

Confidentiality, no-secrets policy, and records

Court involvement

Limits, fees, and communication

Consent and signatures