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 _____________________________________