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Jenn Pagone, LCPC - Consultation Agreement

Clinical Consultation Informed Consent and Agreement


Jenn Pagone, LCPC

IFS (L3) Certified, Assistant Trainer and Approved Consultant

EMDRIA Certified and Approved Consultant

Syzygy Institute Certified, Trainer and Approved Consultant


Pagone Psychological Services, PLLC and Equid-Nexus, LLC

PO Box 405, Marengo, IL 60152 (Central Time Zone)

773-339-7949 | jennpagone@equid-nexus.com

I am delighted that you are investing in clinical consultation and have allowed me to be a part of your learning journey. This document provides important information for our Consultant/Consultee relationship. Please email me with any questions at jennpagone@equid-nexus.com. 

My Virtual Consultation Practice Offerings:

  • IFS with or without equine engagement
  • IFS informed EMDR with or without equine engagement
  • IFS Certification Consultation
  • EMDR Certification Consultation
  • EMDRIA Consultation for Consultants in Training (CIT)
  • Syzygy Certification Consultation
  • Equid-Nexus Consultation

Consultation Specializations include:

  • Somatization disorders
  • Eating disorders
  • Birth and in-utero trauma
  • Female cancer diagnoses and infertility
  • Intergenerational trauma, including legacy burdens
  • Unattached burdens

Consultation Structure:

I provide individual and group consultation with a participant maximum of four (4). Session structure may vary depending upon reasons for consultation (eg: certification or ongoing support and education) and needs and interests of the consultee, but can include:

  • Case consultation
  • Practice sessions
  • Q&A and Discussion
  • Demonstrations
  • Video review and discussions
  • Didactic learning

The Contemplative Consultation Process

My consultation style considers therapist parts and their reactions to clients. Self-Leadership and attunement are critical in trauma work building strong therapeutic relationships. Part of the consultation process is to more deeply understand your own internal system so that you may have a critical mass of Self-Energy to extend to your clients. Note that this style of consultation differs from therapy as the intention is to help you identify parts that are getting in the way of the client’s process, not to process their experiences. Tailheads emerge because of your increased insight and perspective. These trailheads offer a therapeutic opportunity for you to bring them into your own therapeutic process. In the spirit of IFS and constant consent, you are in control of how much or how little you share.

My Professional Background and Credentials

I am a Licensed Clinical Professional Counselor in Illinois (LCPC) and Wisconsin (LPC). I earned my masters degree in Clinical Professional Psychology from Roosevelt University in 2009, with a focus on women’s health and psychology. My undergraduate degree is in Psychology with a focus on Clinical Criminology and a minor in Women and Gender Studies. In 2002, I worked as a Rape Crisis Counselor and Medical Advocate, and from 2008-2013 I worked as a clinical therapist in a behavioral health hospital and was the program coordinator for a residential group home for women with eating disorders and trauma. I began private practice in 2012 and established Pagone Psychological Services, PLLC in 2014. Whispering White Horse Stables, a therapeutic horse ranch, was founded in 2017. Equid-Nexus, an equine engaged parts work psychotherapy model, was created in 2020. For more information about my services, please click on the following links: https://www.pagonepsychologicalservices.com and https://www.equid-nexus.com and https://www.whisperingwhitehorsestables.com. 

I have extensive training and experience in treating trauma. Some of my certifications include IFS, EMDR, Syzygy and the Natural Lifemanship Institute. I am also trained in Somatic Experiencing, Advanced Clinical Hypnotherapy, and Equine Assisted Psychotherapy. As mentioned above, I am a trainer for several organizations, a conference presenter, a published author, and have 4 years of experience teaching undergraduate psychology at Aurora University. 

Confidentiality Policies, Records and Technical Difficulties 

My consultation services are facilitated via Zoom, a HIPPA Compliant Video Conferencing platform with a Business Associate Agreement. Upon registering as a new consultee, you will receive the zoom link we will use throughout the duration of our time together. You will not receive different links for different sessions.

Limits and Scope of Confidentiality and Privileged Communication:

All information shared with me in the context of clinical consultation is held in strict confidence with the following exceptions: 

  • If the consultee exhibits signs of impairment, or
  • If the consultee exhibits behaviors that are unethical and/or dangerous to the client. 

If a consultee exhibits signs of impairment, unethical or dangerous behavior, I will refer the consultee to appropriate professionals for assistance and treatment. In certain situations where mandated I will also give the consultee a chance to self-report to the appropriate licensure board but if the consultant does not self-report, as a fellow colleague, the code of ethics mandates that I make such a report. 

Discussions over cellular phones cannot be guaranteed to be confidential. Although Zoom for Telehealth sessions are done through an encrypted format even then, although rarely, confidentiality can be compromised. 

Should you need to send me confidential information, please use the email feature on the client portal on Therapy Appointment. My gmail email (jennpagone@equid-nexus.com) cannot be guaranteed to be confidential.

All records kept in my consultation practice are stored via the online platform Therapy Appointment. My computer is used solely by myself and has password protection activated so that records kept on my computer are safe and confidential. 

Should we lose connection during our online Zoom consultation session I will phone you immediately to resume our session. It is also important to save my phone number: 773-339-7949. 

Session Duration, Scheduling Sessions, Session Fees and Refund Policy

Individual sessions are 55 minutes in duration and are $175. Sessions will be forfeited if you are 15 minutes late and the full session fee of $175/hour (regardless of a different fee structure) will be charged. For group consultations, groups of 2 will have hour sessions and groups of 4 will meet for 2 hours. 

For individuals who engage in group consultation, session fees are split equally at $87.50 per person, per group. If a group is scheduled for 4 sessions, one per month, $350 is due at the start of the first group. No refunds will be given as all group consultations will be recorded and emailed out to each participant. No discounts will be given if you miss a scheduled consultation session.

All group members can also create an account on Therapy Appointment and have a credit card on file within the secured and HIPAA compliant system. You can create a new client account here. Once you create a new client account, I will activate it and then you will be able to schedule, edit or cancel consultation appointments under “Equid-Nexus Consultation and Coaching”. Please indicate “consulting client” under “reason for appointment”. Do not fill out any other paperwork.

Cancelation Policies and Fees 

Cancelation of consultation sessions should occur prior to 48 hours of the set time through either through the portal, email jennpagone@equid-nexus.com  or phone (773-339-7949) and there is no charge for cancellations or rescheduling in that circumstance. Sudden cancellations within 48 hours of the set time not due to illness, accidents or death in the family will be charged my full consultation fee of $175, regardless if we have established a different fee structure. 

Financial Policies

Session fees will be charged to the card you placed on file when you created a client account on Therapy Appointment. You will be asked to update your card should the card discontinues working. All session fees must be paid prior to the next appointment.

Consultee Signature Indicates Agreement with the Following:

I attest that I understand that these consultations do not constitute clinical supervision and that I remain completely responsible-ethically and legally- for the decisions I make in my own clinical situations. My consultant will provide me with an opportunity to discuss clinical cases and issues about which she may have some expertise and she may help me consider options for responding, but the comments made for my consideration are not supervision mandates. 

I also understand that although we may explore my parts that emerge in therapy with my clients and will sometimes need to discuss personal issues that may be relevant to my clinical work, these consultation services do not constitute psychotherapy. 

I understand the potential limits of the confidentiality of this relationship. To the extent possible my case presentations will provide no identifiable patient information. 

If the consultant has an ethical or legal obligation to report confidential information, she will inform me at that time and will give me the opportunity to make the report myself. 

I understand that if my consultant becomes aware that she knows or has a prior relationship with the presented client(s) or if she believes there may be a potential conflict of interest in the relationship with me, will notify me of that fact immediately and will cooperate in helping me find a different consultant. 

I have read and agree to all of the details of this informed consent and understand Jenn Pagone is not responsible for my actions as a therapist to my clients, or for my clients themselves. 

April 29, 2026

First Consultee's Name
First Name*
Last Name*
Phone*
First Consultee's Age Acknowledgment*
First Consultee's Date of Birth*
Date of Birth
I certify that I am 18 years of age or older
First Consultee's Signature*
Second Consultee's Name
First Name*
Last Name*
Consultee's Date of Birth*
Date of Birth
Third Consultee's Name
First Name*
Last Name*
Consultee's Date of Birth*
Date of Birth
Fourth Consultee's Name
First Name*
Last Name*
Consultee's Date of Birth*
Date of Birth
Fifth Consultee's Name
First Name*
Last Name*
Consultee's Date of Birth*
Date of Birth
Sixth Consultee's Name
First Name*
Last Name*
Consultee's Date of Birth*
Date of Birth
Seventh Consultee's Name
First Name*
Last Name*
Consultee's Date of Birth*
Date of Birth
Eighth Consultee's Name
First Name*
Last Name*
Consultee's Date of Birth*
Date of Birth
Ninth Consultee's Name
First Name*
Last Name*
Consultee's Date of Birth*
Date of Birth
Tenth Consultee's Name
First Name*
Last Name*
Consultee's Date of Birth*
Date of Birth
Parent or Guardian's Email Address
Email*
Confirm Email*
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Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
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Parent or Guardian's Date of Birth*
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I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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