Signing example
Sign a counselling agreement online
A counselling agreement has to show that the client understood, before the first session, exactly when confidentiality can be broken and who may be called in a crisis. In this three page agreement the client initials the limits of confidentiality, makes a separate choice about his emergency contact, and signs behind an emailed code before the counsellor countersigns.
The document, with its fields
The pages as a signer sees them, with the signature, name, title and date fields placed where each party has to complete them.
Counselling Agreement
1. Who this agreement is between
| Client | Owen Takahashi, of 7 Solomon Street, Beaconsfield WA 6162 |
|---|---|
| Counsellor | Imani Rothwell, counsellor, a clinical member of a national counselling association, practising as Stillwater Counselling |
| First session | Wednesday 7 October 2026 at 5:30 pm, in person, 50 minutes |
2. What counselling here involves
Counselling is a confidential, collaborative conversation about what has brought you here and what you would like to change. At the first session we talk about your goals and agree how often to meet, usually weekly or fortnightly. You can talk about as much or as little as you choose. Counselling can bring up uncomfortable feelings before things improve, and there is no guarantee of a particular outcome. You may stop at any time.
Sessions are in person at the Fremantle rooms, or by secure video if we both agree a session suits that better. I do not provide crisis or after hours support; the numbers in clause 9 are for times when you need help between sessions.
3. Fees
| Item | Fee |
|---|---|
| Individual session, 50 minutes | $150.00 |
| Concession session, health care card holders | $95.00 |
| Written report, only at your request | $120.00 |
Fees are paid at the end of each session by card. Counselling sessions are not covered by Medicare. Some private health funds pay a rebate for counselling under extras cover; check with your fund before relying on one. A receipt is emailed after each payment.
4. Cancellations
Please give at least 24 hours' notice if you need to cancel or move a session, by text to 0400 118 524 or by email. A session cancelled with less than 24 hours' notice, or missed, is charged at the full fee, except for illness or an emergency, which I will always waive. If I need to cancel, I will give you as much notice as I can and there is no charge.
5. Records
I keep brief notes of each session: the date, the main themes and anything agreed. Notes are stored in an encrypted practice management system, are not shared with anyone without your consent except as clause 6 allows, and are kept for seven years after our last session, or until you turn 25 if you started counselling as a minor. You may ask to see or get a copy of your notes at any time.
6. Confidentiality and its limits
What you say in counselling stays between us. I do not tell your family, your employer, your GP or anyone else that you see me, or what we talk about, without your written consent. There are a small number of situations where the law or my professional duty requires me to share information without your consent. If any of these arise I will, wherever it is safe and possible, talk to you first.
| Situation | What I may do |
|---|---|
| Serious risk to your life | If I believe you are at serious and imminent risk of ending your life or seriously harming yourself, I may contact your emergency contact, your GP or emergency services |
| Serious risk to another person | If you tell me you intend to seriously harm a specific person, I may warn that person or contact police |
| A child at risk | If I learn that a child is being abused or is at risk of harm, I may report it to the Department of Communities |
| A court order | If my notes are subpoenaed, I must produce them to the court, and I will tell you and ask the court to limit what is read |
| Supervision | I discuss my work with a professional supervisor to keep it safe and effective. I never use your name or details that identify you |
By initialling below you confirm you have read these limits and that I have explained them to you.
7. Emergency contact
You gave the name of an emergency contact on your intake form: Jun Takahashi, your brother, 0421 337 902. Type an X in the box if you agree I may contact him in the situation in the first row of the table above. If you leave it empty, I will contact emergency services or your GP instead, and not your brother.
| Agree | Statement |
|---|---|
| I agree that Imani Rothwell may contact my emergency contact, Jun Takahashi, if she believes I am at serious and imminent risk of harming myself. |
8. Ending counselling
You can end counselling at any time, for any reason, and you do not have to explain why. If I think another service would help you more, I will tell you and help with a referral. Ideally our last session is planned so we can look back at what has changed, but that is your choice.
9. If you need help between sessions
| Service | Contact |
|---|---|
| Emergency | 000 |
| Lifeline, 24 hours | 13 11 14 |
| Suicide Call Back Service, 24 hours | 1300 659 467 |
| Your GP | Dr Siobhan Kearns, Fremantle Family Practice |
10. Concerns about my practice
If you are unhappy with anything about our work, please raise it with me first. If you are not satisfied, you may contact my professional association, or the Health and Disability Services Complaints Office in Western Australia, which handles complaints about health services free of charge.
11. Agreement
I have read this agreement, including the limits of confidentiality on page 2, and I have been able to ask questions about it. I agree to start counselling with Imani Rothwell on these terms, and I understand I can stop at any time.
Who signs what
- Owen Takahashi, client
- Initials under the limits of confidentiality on page 2 · An X agreeing his brother may be called in a crisis · Signature and stamped date on page 3 · Verified by an emailed six digit code
- Imani Rothwell, counsellor
- Signature block on page 3: Name, Title and a stamped Date · Email link
The signing journey
Step 1
Five fields
Initials and an optional checkbox for the client on page 2, his signature and date on page 3, and the counsellor's block beside them.
Step 2
A code before anything opens
The client's link shows only the envelope title and his name until he enters the six digit code sent to his inbox.
Step 3
Initials under the five limits
His mark lands directly under the table listing risk to his life, risk to another person, a child at risk, a court order and supervision.
Step 4
A choice about his brother
He types an X agreeing the counsellor may call Jun Takahashi if he is at serious risk. Leaving it empty was allowed and would have meant emergency services or his GP instead.
Step 5
The counsellor signs before the first session
Her invitation arrives once he has signed. Her block prints Counsellor as the heading with her name, title and stamped date.
Every field, and who fills it
Owen Takahashi initials at the bottom right of page 2, under the table of confidentiality limits. Below it, beside the statement naming his brother Jun as emergency contact, he types an X. On page 3 he signs under the agreement paragraph and his date is stamped. Imani Rothwell's block sits beside his with Name, Title and Date. The $150 session fee, the $95 concession, the 24 hour cancellation rule and the help lines are printed in the PDF.
How to adapt this envelope
A couples agreement adds the second client as a recipient after the first, each with their own initials, choice and signature, and a clause on what is shared between them. A practice that sees young people adds a parent as a recipient for clients under the age it requires. For telehealth sessions, add the client's location line from a telehealth consent to page 2.
What makes this valid
In Australia the Electronic Transactions Act 1999 recognises an electronic signature that identifies the signer and shows intention, by a reliable method. Health information such as counselling notes is protected under the Australian Privacy Principles, and in Western Australia the Health and Disability Services Complaints Office takes complaints about health services, which clause 10 tells the client.
What makes this signing flow work
Confidentiality limits are initialled, not buried
The five situations where a counsellor may share information are the part clients most often say they were never told. Initials directly under that table show this client saw it, separately from signing the agreement as a whole.
The emergency contact is a real choice
The checkbox is optional, so an empty box is a valid answer that means do not call my brother. The client's X is therefore a decision, not a formality, and the page says what happens either way.
Only the client can open it
A counselling agreement tells anyone who reads it that this person is in counselling. The emailed one-time code means a shared family computer or a forwarded email is not enough to open it.
Questions people ask
Can a counselling agreement be signed before the first session?
Yes, and that is the point of sending it ahead. The client reads the fees, the cancellation rule and the limits of confidentiality at home, without the pressure of a first appointment, and arrives with the agreement already signed by both.
What happens to the emergency contact choice if the box is left empty?
The checkbox in this envelope is optional. An empty box means the counsellor will contact emergency services or the GP rather than the named person, as the statement on page 2 says. The client can change that choice later by telling the counsellor.
Why does the client need a code to open the agreement?
Because even the existence of the agreement is private. The code is six digits, valid for ten minutes and usable once, sent to the client's own email, and after five wrong entries that recipient is locked out for fifteen minutes.
Does the certificate reveal anything about the counselling?
No. It records the envelope title, the two signers and their emails, verification methods, IP addresses, signing and consent times, the document hashes and the event log. It does not reproduce the agreement's text, and no session notes are ever part of the envelope.
Is a counselling agreement valid when signed electronically?
In Australia, yes, where the method identifies the signer and shows intention, which the Electronic Transactions Act 1999 accepts. The certified PDF, which cannot be edited after completion, is kept with the client's record exactly as a signed paper agreement would be, alongside the certificate.
What if the client declines to sign?
The envelope moves to declined and the counsellor is emailed with any reason typed. The counsellor is never asked to countersign. The first session can be used to talk through the concern, and a revised agreement can follow as a new envelope.
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