informed consent
Informed Consent for Therapy Services – Adult
Psychotherapist-CLIENT SERVICE AGREEMENT
Welcome to my practice. This document contains important information about my
professional services and business policies. It also contains summary information
about the Health Insurance Portability and Accountability Act (HIPAA), a federal law
that provides privacy protections and patient rights about the use and disclosure of
your Protected Health Information (PHI) for the purposes of treatment, payment,
and health care operations. Although these documents are long and sometimes
complex, it is very important that you understand them. When you sign this
document, it will also represent an agreement between us. We can discuss any
questions you have when you sign them or at any time in the future.
PSYCHOLOGICAL SERVICES
Therapy is a relationship between people that works in part because of clearly
defined rights and responsibilities held by each person. As a client in
psychotherapy, you have certain rights and responsibilities that are important for
you to understand. There are also legal limitations to those rights that you should
be aware of. I, as your therapist, have corresponding responsibilities to you. These
rights and responsibilities are described in the following sections.
Psychotherapy has both benefits and risks. Risks may include experiencing
uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness
and helplessness, because the process of psychotherapy often requires discussing
the unpleasant aspects of your life. However, psychotherapy has been shown to
have benefits for individuals who undertake it. Therapy often leads to a significant
reduction in feelings of distress, increased satisfaction in interpersonal
relationships, greater personal awareness and insight, increased skills for managing
stress and resolutions to specific problems. But, there are no guarantees about
what will happen. Psychotherapy requires a very active effort on your part. In
order to be most successful, you will have to work on things we discuss outside of
sessions.
The first 2-4 sessions will involve a comprehensive evaluation of your needs. I will
offer you some initial and then evolving impressions of what our work might
include. At that point, we will discuss your treatment goals and create an initial
treatment plan. You should evaluate this information and make your own
assessment about whether you feel comfortable working with me. If you have
questions about my procedures, we should discuss them whenever they arise. If
your doubts persist, I will be happy to help you set up a meeting with another
mental health professional for a second opinion. While it won’t always be
comfortable, you should feel safe enough to be honest with yourself and me and if
you find that isn’t happening for you with me, let’s be sure you find a situation
where it can.
APPOINTMENTS
Appointments will ordinarily be 45-50 minutes in duration, once per week at a time
we agree on, although some sessions may be more or less frequent as needed. The
time scheduled for your appointment is assigned to you and you alone. If you need
to cancel or reschedule a session, I ask that you provide me with 24 hours notice. If
you miss a session without canceling, or cancel with less than 24 hour notice, my
policy is to collect the amount of your co-payment [unless we both agree that you
were unable to attend due to circumstances beyond your control].If it is possible, I
will try to find another time to reschedule the appointment. In addition, you are
responsible for coming to your session on time; if you are late, your appointment
will still need to end on time.
PROFESSIONAL FEES
In the interest of keeping these services available to people in all income levels, we
will come up with an agreed upon fee for these services. You are responsible for
paying at the time of your session unless prior arrangements have been made.
Payment must be made by check, cash or credit card using a secure online
invoice/payment function.
In addition to weekly appointments, it is my practice to charge this amount on a
prorated basis (I will break down the hourly cost) for other professional services
that you may require such as report writing, telephone conversations that last
longer than 15 minutes, attendance at meetings or consultations which you have
requested, or the time required to perform any other service which you may
request of me. If you anticipate becoming involved in a court case, I recommend
that we discuss this fully before you waive your right to confidentiality. If your case
requires my participation, you will be expected to pay for the professional time
required even if another party compels me to testify.
INSURANCE
I have made the choice not to participate in insurance panels at this time. For this
reason, I have decided to employ a fee policy that reflects what people are capable
of paying at a point that they will value the work and time they put in without it
being a source of stress.
PROFESSIONAL RECORDS
I am required to keep appropriate records of the psychological services that I
provide. Your records are maintained in a secure location in the office. I keep brief
records noting that you were present for the meeting whether in person or on-line,
your reasons for seeking therapy, the goals and progress we set for treatment, your
diagnosis, topics we discussed, your medical, social, and treatment history, records
I receive from other providers, copies of records I send to others, and your billing
records. Except in unusual circumstances that involve danger to yourself, you have
the right to a copy of your file. Because these are professional records, they may be
misinterpreted and / or upsetting to untrained readers. For this reason, I
recommend that you initially review them with me, or have them forwarded to
another mental health professional to discuss the contents. If I refuse your request
for access to your records, you have a right to have my decision reviewed by
another mental health professional , which I will discuss with you upon your
request. You also have the right to request that a copy of your file be made available
to any other health care provider at your written request.
CONFIDENTIALITY
My policies about confidentiality, as well as other information about your privacy
rights, are fully described in a separate document entitled Notice of Privacy
Practices. You have been provided with a copy of that document. Please remember
that you may reopen the conversation at any time during our work together.
PARENTS & MINORS
While privacy in therapy is crucial to successful progress, parental involvement can
also be essential. It is my policy not to provide treatment to a child under age 13
unless s/he agrees that I can share whatever information I consider necessary with
a parent. For children 14 and older, I request an agreement between the client and
the parents allowing me to share general information about treatment progress and
attendance, as well as a treatment summary upon completion of therapy. All other
communication will require the child’s agreement, unless I feel there is a safety
concern (see also above section on Confidentiality for exceptions), in which case I
will make every effort to notify the child of my intention to disclose information
ahead of time and make every effort to handle any objections that are raised.
CONTACTING ME
I am often not immediately available by telephone. I do not answer my phone when
I am with clients or otherwise unavailable. At these times, you may leave a message
on my confidential voice mail and your call will be returned as soon as possible, but
it may take a day or two for non-urgent matters. If, for any number of unseen
reasons, you do not hear from me or I am unable to reach you, and you feel you
cannot wait for a return call or if you feel unable to keep yourself safe, 1) contact
your local emergency mental health agency (I can provide these numbers for you
and they are listed in the phone book), 2) go to your Local Hospital Emergency
Room, or 3) call 911 and ask to speak to the mental health worker on call. I will make
every attempt to inform you in advance of planned absences, and provide you with
the name and phone number of the mental health professional covering my
practice.
OTHER RIGHTS
If you are unhappy with what is happening in therapy, I hope you will talk with me
so that I can respond to your concerns. Such comments will be taken seriously and
handled with care and respect. You may also request that I refer you to another
therapist and are free to end therapy at any time. You have the right to considerate,
safe and respectful care, without discrimination as to race, ethnicity, color, gender,
sexual orientation, age, religion, national origin, or source of payment. You have the
right to ask questions about any aspects of therapy and about my specific training
and experience. You have the right to expect that I will not have social or sexual
relationships with clients or with former clients.
CONSENT TO PSYCHOTHERAPY
Your signature below indicates that you have read this Agreement and the Notice
of Privacy Practices and agree to their terms.
_________________________________________
Signature of Patient or Personal Representative
_________________________________________
Printed Name of Patient or Personal Representative
_________________________________________
Date _____________________________________
Privacy Policy
Notice of Privacy Policies – Limits of Confidentiality
“Notice of Privacy Practices”
THIS NOTICE INVOLVES YOUR PRIVACY RIGHTS AND DESCRIBES HOW INFORMATION ABOUT YOU MAY BE DISCLOSED, AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Confidentiality
As a rule, I will disclose no information about you, or the fact that you are my patient, without your written consent. My formal Mental Health Record describes the services provided to you and contains the dates of our sessions, your diagnosis, functional status, symptoms, prognosis and progress, and any psychological testing reports. Health care providers are legally allowed to use or disclose records or information for treatment, payment, and health care operations purposes. However, I do not routinely disclose information in such circumstances, so I will require your permission in advance, either through your consent at the onset of our relationship (by signing the attached general consent form), or through your written authorization at the time the need for disclosure arises. You may revoke your permission, in writing, at any time, by contacting me.
II. “Limits of Confidentiality”
Possible Uses and Disclosures of Mental Health Records without Consent or Authorization
There are some important exceptions to this rule of confidentiality – some exceptions created voluntarily by my own choice, and some required by law. If you wish to receive mental health services from me, you must sign the attached form indicating that you understand and accept my policies about confidentiality and its limits. We will discuss these issues now, but you may reopen the conversation at any time during our work together.
I may use or disclose records or other information about you without your consent or authorization in the following circumstances, either by policy, or because legally required:
· Emergency: If you are involved in a life-threatening emergency and I cannot ask your permission, I will share information if I believe you would have wanted me to do so, or if I believe it will be helpful to you.
· Child Abuse Reporting: If I have reason to suspect that a child is abused or neglected, I am required by New York law to report the matter immediately to the New York Department of Social Services.
· Adult Abuse Reporting: If I have reason to suspect that an elderly or incapacitated adult is abused, neglected or exploited, I am required by New York law to immediately make a report and provide relevant information to the New York Department of Welfare or Social Services.
· Health Oversight: New York law requires that licensed counselors report misconduct by a health care provider of their own profession. By policy, I also reserve the right to report misconduct by health care providers of other professions. By law, if you describe unprofessional conduct by another mental health provider of any profession, I am required to explain to you how to make such a report. If you are yourself a health care provider, I am required by law to report to your licensing board that you are in treatment with me if I believe your condition places the public at risk. New York Licensing Boards have the power, when necessary, to subpoena relevant records in investigating a complaint of provider incompetence or misconduct.
· Court Proceedings: If you are involved in a court preceding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and I will not release information unless you provide written authorization or a judge issues a court order. If I receive a subpoena for records or testimony, I will notify you so you can file a motion to quash (block) the subpoena. However, while awaiting the judge’s decision, I am required to place said records in a sealed envelope and provide them to the Clerk of Court. In New York civil court cases, therapy information is not protected by patient-therapist privilege in child abuse cases, in cases in which your mental health is an issue, or in any case in which the judge deems the information to be “necessary for the proper administration of justice.” In criminal cases, New York has no statute granting therapist-patient privilege, although records can sometimes be protected on another basis. Protections of privilege may not apply if I do an evaluation for a third party or where the evaluation is court-ordered. You will be informed in advance if this is the case.
· Serious Threat to Health or Safety: Under New York law, if I am engaged in my professional duties and you communicate to me a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and I believe you have the intent and ability to carry out that threat immediately or imminently, I am legally required to take steps to protect third parties. These precautions may include 1) warning the potential victim(s), or the parent or guardian of the potential victim(s), if under 18, 2) notifying a law enforcement officer, or 3) seeking your hospitalization. By my own policy, I may also use and disclose medical information about you when necessary to prevent an immediate, serious threat to your own health and safety. If you become a party in a civil commitment hearing, I can be required to provide your records to the magistrate, your attorney or guardian ad litem, a CSB evaluator, or a law enforcement officer, whether you are a minor or an adult.
· Workers Compensation: If you file a worker’s compensation claim, I am required by law, upon request, to submit your relevant mental health information to you, your employer, the insurer, or a certified rehabilitation provider.
· Records of Minors: New York has a number of laws that limit the confidentiality of the records of minors. For example, parents, regardless of custody, may not be denied access to their child’s records; and CSB evaluators in civil commitment cases have legal access to therapy records without notification or consent of parents or child. Other circumstances may also apply, and we will discuss these in detail if I provide services to minors.
Other uses and disclosures of information not covered by this notice or by the laws that apply to me will be made only with your written permission.
III. Patient’s Rights and Provider’s Duties:
· Right to Request Restrictions-You have the right to request restrictions on certain uses and disclosures of protected health information about you. You also have the right to request a limit on the medical information I disclose about you to someone who is involved in your care or the payment for your care. If you ask me to disclose information to another party, you may request that I limit the information I disclose. However, I am not required to agree to a restriction you request. To request restrictions, you must make your request in writing, and tell me: 1) what information you want to limit; 2) whether you want to limit my use, disclosure or both; and 3) to whom you want the limits to apply.
· Right to Receive Confidential Communications by Alternative Means and at Alternative Locations — You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send your bills to another address. You may also request that I contact you only at work, or that I do not leave voice mail messages.) To request alternative communication, you must make your request in writing, specifying how or where you wish to be contacted.
· Right to an Accounting of Disclosures – You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in section III of this Notice). On your written request, I will discuss with you the details of the accounting process
. · Right to Inspect and Copy – In most cases, you have the right to inspect and copy your medical and billing records. To do this, you must submit your request in writing. If you request a copy of the information, I may charge a fee for costs of copying and mailing. I may deny your request to inspect and copy in some circumstances. I may refuse to provide you access to certain psychotherapy notes or to information compiled in reasonable anticipation of, or use in, a civil criminal, or administrative proceeding.
· Right to Amend – If you feel that protected health information I have about you is incorrect or incomplete, you may ask me to amend the information. To request an amendment, your request must be made in writing, and submitted to me. In addition, you must provide a reason that supports your request. I may deny your request if you ask me to amend information that: 1) was not created by me; I will add your request to the information record; 2) is not part of the medical information kept by me; 3) is not part of the information which you would be permitted to inspect and copy; 4) is accurate and complete.
· Right to a copy of this notice – You have the right to a paper copy of this notice. You may ask me to give you a copy of this notice at any time. Changes to this notice: I reserve the right to change my policies and/or to change this notice, and to make the changed notice effective for medical information I already have about you as well as any information I receive in the future. The notice will contain the effective date . A new copy will be given to you or posted in the waiting room. I will have copies of the current notice available on request.
Complaints: If you believe your privacy rights have been violated, you may file a complaint. To do this, you must submit your request in writing to my office. You may also send a written complaint to the U.S. Department of Health and Human Services.
EFFECTIVE DATE: _________________
=========================================================================Heather Henry Rawlins, LMHC
Buffalo, NY
(716) 218-8255
hhenryrawlins@gmail.com
**Patient’s Acknowledgement of receipt of Notice of Privacy Practices**
Please sign, print your name, and date this acknowledgement form.
I have been provided a copy of Heather Henry Rawlins’s Notice of Privacy Practices.
I understand that I may ask questions about them at any time in the future.
I consent to accept these policies as a condition of receiving mental health services.
Signature: _____________________________________________________Printed Name: _____________________________________________________
Date: ______________________