Informed Consent Form
Welcome to our practice. Thank you for trusting us to assist you with your personal concerns. Please take the time to read and understand this document and ask us about any portions which may be unclear to you.
This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides new privacy protections and new client rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices. The accompanying Notice of Privacy Practices explains HIPAA and its application to your PHI in greater detail. The law requires that we obtain your signature acknowledging that we have provided you with this information before we provide any services. You may revoke this Agreement in writing at any time.
Services
We provide individual, couples, and family psychotherapy. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the therapist and client, and the particular problems you are experiencing. There are many different methods we may use to deal with the problems that you hope to address. Psychotherapy calls for an active effort on your part. In order for therapy to be most successful, you will have to work on things we talk about both during sessions and at home.
Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings. On the other hand, psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, but there are no guarantees of what you will experience.
In your first session, we will offer you some sense of what therapy will entail and how we propose we address your concerns. You should evaluate this information and whether you feel comfortable working with us. If you have questions about our procedures, please discuss them with us whenever they arise. You have the right to ask for the rationale for any aspect of your treatment or to decline any part of your treatment. You also have the right to request another therapist. While we encourage you to discuss your concerns with us in order to explore why things may not be working out, you are under no obligation to do so.
Policies Regarding Appointments
Individual and couples therapy appointments are generally for 45 minutes and are typically scheduled once per week at a time we agree on. That appointment time may be reserved as a standing time each week if you so indicate. . If you cannot make a scheduled appointment, it is your responsibility to call our office to cancel at least 24 hours in advance. If you forget an appointment or fail to provide 24 hours advance notice of a cancelation, you will be charged $75. If you miss your appointment and do not call to reschedule, your standing appointment time will not be held for you. You will need to pay for missed appointments prior to scheduling another appointment.
Please note that email is not a secure form of communication and is not recommended as a means of contacting us for any treatment-related concerns. If you choose to contact us via email, we recommend you limit the contact to pertinent information only. Details can then be shared with us once we talk in person or on the phone.
Professional Fees
Our fee for the first session is $210 and $150 for subsequent sessions. We do cooperate with insurance companies and have a sliding scale for those that do not have insurance and are in hardship. In addition to session fees, there may be charges for other professional services you may need, including, but not limited to, report writing, telephone conversations lasting longer than 15 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of us. If you become involved in legal proceedings that require our participation, you will be expected to pay for our professional time even if we end up not being called to testify. Because of the difficulty of legal involvement, we charge $200 per hour for preparation and all time in attendance at any legal proceeding.
Billing and Payments
You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage which requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, we may be willing to negotiate a fee adjustment or payment installment plan.
If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information we release regarding a client’s treatment is his/her name, the nature of services provided, and the amount due. We will make reasonable attempts to contact you prior to taking legal action.
Insurance Reimbursement
In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. We will fill out forms and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers.
You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. We will provide you with an insurance pre-authorization form which may make this process easier and clearer. We will be happy to help you in understanding the information you receive from your insurance company.
Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow us to provide services to you once your benefits end. If this is the case, we will do our best to find another provider who will help you continue your psychotherapy.
You should also be aware that most insurance companies require you to authorize us to provide them with a clinical diagnosis. Sometimes we have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, we have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. We will provide you with a copy of any report we submit, if you request it.
Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for our services yourself to avoid the problems described above [unless prohibited by contract].
Contacting Me
We are often not immediately available by telephone. When we are unavailable, our telephones are answered by voice mail that we monitor frequently. We will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform us of some times when you will be available. If you are unable to reach us and feel that you can’t wait for us to return your call, contact your family physician or the nearest emergency room and ask for the psychologist [psychiatrist] on call. If you are experiencing suicidal thoughts, thoughts of wanting to hurt someone else, or thoughts of committing dangerous acts, call 911 or proceed to the nearest emergency room. If we will be unavailable for an extended time, we will provide you with the name of a colleague to contact, if necessary.
Professional Records
The laws and standards of our profession require that we keep treatment records. You are entitled to receive a copy of the records unless we believe that seeing them would be emotionally damaging, in which case we will be happy to send them to a mental health professional of your choice. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. We recommend that you review them in our presence so that we can discuss the contents. Clients will be charged an appropriate fee for any time spent in preparing information requests.
Minors
If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is our policy to request an agreement from parents that they agree to give up access to your records. If they agree, we will provide them only with general information about our work together, unless we feel there is a high risk that you will seriously harm yourself or someone else. In this case, we will notify them of our concern. We will also provide them with a summary of your treatment when it is complete. Before giving them any information, we will discuss the matter with you, if possible, and do our best to handle any objections you may have with what we are prepared to discuss.
Limits of Confidentiality
In general, the privacy of all communications between a client and a psychologist is protected by law, and we can only release information about our work to others with your written permission. But there are a few exceptions.
There are some situations where we are permitted or required to disclose information either with or without your consent or authorization:
• If you are involved in a court proceeding and a request is made for information concerning your treatment, we cannot provide such information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order your therapist to disclose information.
• If a government agency is requesting the information for health oversight activities, we may be required to provide it for them.
• If you file a complaint or lawsuit against us as your therapist, we may legally disclose relevant information regarding our work together in order to defend ourselves.
• If you file a worker’s compensation claim, we must, upon appropriate request, provide a copy of your record or a report of your treatment.
There are some situations in which we are legally obligated to take actions to protect others from harm, and we may have to reveal some information about your treatment. If such a situation arises, we will make every effort to fully discuss it with you before taking any action and will limit disclosure to what is necessary.
• If we have reason to believe that a child, senior citizen, or vulnerable adult is being neglected or abused, the law requires that the situation be reported to the appropriate state agency.
• If we believe you present a clear and substantial danger of harm to yourself or another/others, we will take protective actions. These may include contacting family members, seeking hospitalization for you, notifying any potential victim(s), and notifying the police.
While this summary is designed to provide an overview of confidentiality and its limits, it is important that you read our Notice of Privacy Practices for more detailed explanations, and discuss any questions or concerns you may have.
I have been provided the Notice of Privacy Practices and information about the Health Insurance Portability and Accountability Act (HIPAA). ___________(initials)
I consent to my therapist discussing my presenting symptoms and diagnosis with my primary care physician, _______________________________(name). ________________( number) ______ (intl)
I consent to my therapist discussing my presenting symptoms and diagnosis with my pastor/ minister/priest,________________________________(name). _______________(number) ______(intl)
Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.
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Printed Name
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Signature Therapist Signature