The process of starting, continuing, or ending mental health therapy can feel overwhelming. This is the 2nd post in a 2-part series about “What Happens in Therapy?”
In Part 1, I talked about the process of figuring out what you’re looking for in a therapist, searching for a potential therapist, and making the initial contact with them. You can read the full post here.
This post picks up after that initial contact is made and takes a look at things like a pre-scheduling consultation, the intake process and initial appointment, ongoing therapy sessions, and ending therapy.
Pre-Scheduling Consultation
Not every therapist offers a pre-scheduling consultation. Many therapists who work within agencies or large practices where someone else creates the policies may not have the option to offer these consultations. You are also more likely to have the option for a pre-scheduling consultation with therapists who are private pay than with those who accept insurance.
I provide a free, 15-minute, virtual consultation to folks who are interested in working with me. We schedule a time to meet and I provide a link to a HIPAA-secure virtual platform for us to have the consultation. Since I provide therapy services via telehealth, I find that having the consultation virtually allows for potential clients to get a feel for what telehealth may be like.
I include time for the following during my consultations:
- Ensure the potential client is located in North Carolina (where I am licensed to provide therapy) and is aware that all my services are provided via telehealth. I also ensure that potential clients are aware that I am private pay and do not accept insurance.
- An opportunity for the potential client to ask any questions they may have. This can include anything they are curious about as far as my approach to therapy or even my own experiences and identities. You are welcome to ask anything that may be important for you in making a decision about therapy. It is my job as the therapist to determine my own boundaries in how much detail I am willing to share, or if there are any questions I am not comfortable answering.
- Gathering some brief details from the person seeking support about what’s bringing them to therapy. Gathering some information about any past experiences they may have had with therapy.
- Providing an overview of how I approach therapy, and why my approach may (or may not) be a good fit for them.
- Discussion of whether they want to move forward with scheduling at this time or take some time to think about their options. Or, if I am not a good fit, discussion of some other resources or referrals who may be better able to meet their needs.
- If the potential client decides they want to move forward with scheduling, I provide information about my intake process and we choose a date/time for their initial appointment.
Intake Process
My initial appointment with clients is 90 minutes long to allow time for covering lots of ground as we’re starting to form our therapeutic relationship. A few things have to occur before this appointment can happen. I give the client an introduction to the online system that I use for scheduling, keeping records, and managing billing. Each client creates their own secure account, or Client Portal, in this HIPAA-secure system. This is where I can share documents with them and where they can view their upcoming appointments.
We take the necessary steps for them to set up their private Client Portal account, and I let them know that several forms will be available there for them to review, complete, and sign. I also provide instructions on how to contact me if they have any issues accessing the forms or any questions about the contents. It’s important to me that all potential clients understand the forms and have all their questions answered prior to getting into that initial session.
The number of forms required to get the therapy process started can feel overwhelming. Some are required by licensing boards, some are related to laws around providing healthcare, some forms are necessary depending on the types of payment accepted by a therapist, and others are personal preference for the therapist.
Intake Paperwork
Below is a list of forms that are required before I begin therapy with someone. However, I’m happy to go through these forms with the client and to answer any questions they may have to help make things more accessible and ensure folks are fully informed and consenting to our work together. I do require that all paperwork is completed at least 48 hours prior to the initial appointment to allow time for me to review it and prepare for our time together.
My initial paperwork includes:
- Professional Disclosure Statement – describes my education and professional experience. This form is required by my professional licensing board.
- Basic Demographic Form – gathers basic information about the client, including address and phone number.
- Communication Consent Form – explains the limits of confidentiality with email and provides option for client to receive emails regarding scheduling.
- Practice Policies and Procedures – details various policies related to my counseling practice. This includes, but is not limited to, costs for various services, cancellation policies, details of confidentiality, and my social media policy.
- Telehealth Informed Consent – covers the potential risks and benefits of telehealth services, provides guidelines for engaging in telehealth.
- HIPAA Notice of Privacy Practices – details of how medical records are maintained, utilized, and can be accessed. This is a US legal requirement for all providers of medically-related services.
- Self-Pay Acknowledgement – statement that clearly outlines that I do not work with insurance companies and that all services are provided as private pay.
- Good Faith Estimate – document that outlines costs per session and projected total costs per year based on client’s anticipated needs. This is legally required for any provider who does not accept insurance.
- Payment Authorization – form that allows the client to authorize a card to be charged for services. This form is secure and encrypted, ensuring no one (even me) has access to the client’s card number.
Initial Session
I reserve 90 minutes for the initial session – some folks use the entire time, while others don’t need the full 1.5 hours. I start these sessions ensuring the person has a good internet connection and is located in a secure, private location within NC. I then verify identity by asking to see a photo ID. I also ensure I have a good phone number to contact the individual in case we have a technology glitch during the session.
Next, I review important aspects of the paperwork they completed and provide an opportunity for us to discuss any questions they might have. It’s important that each client is able to provide informed consent before we move forward with the therapy process.
During the session, we collaborate to discuss what is bringing them into therapy and what they hope to get out of our work together. I have an outline of questions / topics that I find important to cover as we’re getting to know one another. I use this outline to guide the conversation in a way that best fits the particular client. I also make sure to let clients know that I will be jotting things down as we’re talking because I am a visual person and writing things down helps me keep track of what they are sharing.
As we’re nearing the end of the first session, I make sure we spend some time focusing on the client’s goals or what they hope will come from therapy. Based on the information they have shared throughout the session, I then provide my thoughts on how often I feel we’ll need to meet and what recommendations I have regarding the most effective ways to approach our work together. This opens a conversation for the client and I to collaborate regarding those recommendations and determine the best course for moving forward. Generally this involves scheduling a next appointment.
However, there are times where my recommendations don’t fit with what the client wants, and we discuss other options for support. This may include instances where my professional judgment differs from the client’s preference regarding the type of therapy that will be most effective, the frequency at which we need to meet to be effective, or the speed at which we address a concern. I am happy to provide other resources or referral options for folks if we discover that we’re not a good fit for continued work together.
Ongoing Therapy Sessions
Therapy sessions can vary somewhat depending on the individual needs and preferences of a client, and the specifics of what they want to cover in therapy. In general, I prefer to meet with a new client weekly for at least the first month in order to create a strong foundation for our therapeutic relationship and be able to see/hear how things are going for them on a regular basis. Sometimes financial and/or scheduling restraints don’t allow for meeting weekly, and the client and I discuss together what makes the most sense and feels appropriate for both of us regarding scheduling.
Once we are in a rhythm of meeting together, there are common aspects to most sessions. We generally open the session with a check-in regarding how things are going for the client at that moment. This may include a review of any between-session tasks they wanted to work on or letting me know if there is something specific they want to make sure we cover in that session. The remainder of the session is tailored toward the client’s needs and the specific focus of our work together.
Some of the things that may be included in a therapy session are:
- Providing information and/or education regarding a client’s experience or concerns
- Developing skills to help the client deal with their specific coping needs
- Discussing how a client is currently being impacted by their concerns, including options for handling these impacts
- Examining the messages the client received in past situations and how those messages continue to show up today
- Utilizing a specific therapy intervention to address the client’s concerns (for example, Brainspotting, DBT-based skills, or Narrative Therapy)
I reserve 60 minutes for ongoing therapy sessions, and it is my job as the therapist to keep track of the time and provide a transition to wrapping things up. This may include a review of important parts of the session or a discussion of any tasks the client wants to focus on between sessions. We also take a few moments to discuss scheduling of future sessions, if needed.
Ending Therapy
The length of time someone participates in therapy can vary greatly. Some folks have a very specific concern they want to address and are able to find resolution in just a few sessions. Others may have multiple, interconnected concerns and find that ongoing therapy over multiple years is helpful. For some individuals, having a regular check-in with a therapist who knows them well is helpful in maintaining their mental health and combatting future issues.
In most cases, the therapy relationship will end at some point. This can happen for a variety of reasons and ideally the transition will be smooth, even if it’s difficult.
Natural completion of therapy. This is the ideal situation. Both the therapist and client recognize the progress that has been made and feel ready to terminate the ongoing therapy at that time. This can allow for 1 (or a few) termination sessions to intentionally discuss the progress and any future plans to maintain mental health. This often also allows the door to be left open should the client want to reengage in therapy in the future.
Therapist-initiated end of therapy. The reasons for a therapist initiating the end of a therapeutic relationship can vary. These reasons include, but are not limited to, a transition in the therapist’s role/location or a therapist’s clinical judgment that the client needs a different type of support that the therapist cannot provide. In the case of an ending that is therapist initiated, it is ideal that the therapist informs the client of the need to end therapy with time to process the change and discuss options for moving forward.
In the past, when I have needed to terminate therapy with clients due to changes in role or location, I have provided 30-60 days notice (depending on the setting and the policies in place) to the client. I have offered session time to process the shift, and provided each client with options for ongoing therapeutic or other support (sometimes that included the option to continue seeing me in another context).
There have also been times when I have needed to refer a client to a different type of support, and it was no longer appropriate for me to see them. Generally this has been based on the client’s specific needs. They may be best served by a type of therapy that I do not have training in providing, or their needs may not be best served by virtual, outpatient therapy. In these cases, I discuss the need for ending our work with the client and provide specific recommendations and resources to help them connect with the most appropriate supports.
Client-initiated end of therapy. Sometimes a client wants / needs to end therapy. The reasons for a client ending therapy can include moving to another state where the therapist is not licensed, a change in financial situation, or feeling like the therapist is not a good fit for continuing to work together. A client does not owe a therapist a reason for ending therapy. However, if you just don’t show up for a scheduled appointment, there may be a no show fee involved depending on the policies you agreed upon when beginning therapy.
Personally, I appreciate when clients let me know they want to end therapy or take a break from meeting for a period of time. This can be done in a simple email, stating something like, “I am going to take a break from therapy at this time. Please cancel my scheduled appointments.” You may want to share a bit about your reason or express appreciation for the support you received (if that applies), but you are not required to do either. I work with many folks who have been told their voices didn’t matter and/or who have been trained to please others, so it’s important to me to honor their autonomy and choice when/if they let me know they have decided to end therapy.
Additionally, depending on the reason for ending therapy with me, I may be able to help the person find another form of support that is more appropriate for their current situation. For example, if they are relocating to another state, I can reach out to my therapist network and see if I can gather some names and contact information for therapists in their new location. This is also true if a client wants to try a specific type of therapy that I don’t provide or if they want a therapist who shares a certain identity with them. I’m happy to try to help them find someone who can best fit their needs. This open communication about ending therapy allows me to assist the client (if they want) with meeting their needs moving forward.
Ready To Start Therapy?
I know this is a lot of information, but hopefully you feel a bit more informed about the therapy process. These posts have provided some idea about how therapy happens, from the initial contact to the final session(s). You also have some resources for finding a therapist based on your location and specific needs/preferences.
I am currently taking new clients in North Carolina. I work with adults (18+) and provide therapy via telehealth, so I’m able to see folks located anywhere in NC. I specialize in supporting those who have experienced spiritual abuse or religious trauma, helping them find a path forward that makes sense for them. I also work with body image concerns from a weight-inclusive lens. Additionally, I have lots of experience working with complex trauma, anxiety, life transitions, and grief. I’m also excited to be adding neurodivergent-affirming ADHD/Autism assessments for adults to my practice, with an expected start date of June 2025. You can use this contact form to get the process started for scheduling a free, 15-minute virtual consultation to see if we might be a good fit for working together.
Michelle F. Moseley is a Licensed Clinical Mental Health Counselor in NC. She believes ALL people deserve respect, compassion, and access to mental and physical healthcare. Michelle specializes in working with survivors of religious trauma, and with those who have body image concerns, finding there is frequent overlap in these areas. She also frequently supports late-identified neurodivergent individuals as they navigate the grief and relief of a new understanding of self. You can learn more about Michelle by visiting her website at MichelleFMoseley.com or following her on Instagram – @therapy_with_michelle
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