Informed Consent and Service Agreement
This document contains important information about my professional services and business policies. It also contains summary information about confidentiality. At our first session, I will give you a paper copy of this agreement to take home and read.
When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign it or at any time in the future.
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 therapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights, which I will touch on below.
Goals of Therapy
There can be many goals for the therapy relationship. Some possibilities are improving the quality of your life, learning to live with mindfulness, healing from trauma, and self-actualization. Others could be decreasing anxiety and depression symptoms, developing healthy relationships, or changing problem behaviors. As a client in therapy, you choose your goals and the focus of our work together. I may make suggestions on how to reach your goals but you decide where you want to go.
Risks/Benefits of Therapy
There are many benefits to therapy. Therapy can help you develop coping skills, make behavioral changes, reduce symptoms of mental health disorders, improve the quality of your relationships, learn to manage emotions, and learn to live in the present.
Therapy is an intensely personal process, which can bring unpleasant memories or emotions to the surface. There are no guarantees that therapy will work for you. Though I will make all efforts to help, it is possible that you may not reach your goals. Progress may happen quickly or more slowly than desired. When positive change happens, some clients find that others in their life react. This is usually positive, but that is not guaranteed.
Appointments will ordinarily be 50 minutes in duration, scheduled regularly at a time of our agreement. Sessions may be more or less frequent as needed. Initial Assessments may take longer.
The time scheduled for your appointment is assigned to you. If you need to cancel or reschedule a session, please let me know as soon as possible. If you miss a session with less than 24 hours’ notice, you agree to a $75 late cancellation fee. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. You are responsible for paying at the time of your session.
Regular sessions (in office or remote) - $180
Initial Assessment - $200
Preparation of written reports (i.e. for advocacy or legal purposes) that are not required by your insurance company will be billed at the regular session rate in 20-minute increments.
Telephone calls (for other than scheduling or new client consultations) $2.50/minute.
Requests for sliding scale rates are handled on a case-by-case basis and will require you to substantiate financial hardship.
Attendance at Meetings or Legal Proceedings
If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you share confidential information with me. If you are seeing me for couple therapy or family therapy, I will ask you to sign a declaration that you will not try to use the content of sessions in an adversarial contest. In the event my services are required at a school meeting, court proceeding, or other location outside our normal office visits, you will be expected to pay for the professional time required at the normal hourly rate ($150 per hour), billed in 20-minute increments, as well as parking and bridge or tunnel tolls as appropriate. Insurance may not cover services delivered for these purposes.
I will make every effort to keep your personal information private. If you wish to have information released, you will be required to sign a consent form before such information will be released. There are some limitations to confidentiality of which you need to be aware. I may consult with a supervisor or other professional therapist to give you the best service. If I consult with another therapist, no identifying information such as your name would be released. As a mandated reporter, law requires me to release information when the client poses a risk to themselves or others and in cases of abuse to children or the elderly. If I receive a court order or subpoena, I may be required to release some information. In such a case, I would release only what is necessary by law. If a client refuses to pay for services in a timely manner, therapists may use the courts or a collection agency to secure payment.
Confidentiality and Group Therapy
The nature of group therapy makes it difficult to maintain confidentiality. If you choose to participate in group therapy, be aware that I cannot guarantee that other group members will maintain your confidentiality. However, I will make every effort to maintain your confidentiality by reminding group members frequently of the importance of keeping what is said in group confidential. I also reserve the right to remove any group member from the group should I discover that a group member has violated confidentiality.
Confidentiality and Technology
Some clients may choose to use technology to communicate with their therapist. This includes but is not limited to telephone, video conference, and text. Due to the nature of technology, there is always the possibility that unauthorized persons may attempt to discover your personal information. I will take every precaution to safeguard your information in keeping with HIPAA requirements, but cannot guarantee that unauthorized access to electronic communications could not occur. Please be advised to take precautions regarding authorized and unauthorized access to any technology used. Be aware of any friends, family members, significant others or co-workers who may have access to your computer, phone or other technology used to communicate with me.
If you will be using health insurance, the insurance company determines your share of cost (co-pay or deductible) and my rate of reimbursement. They do not reimburse for missed sessions or telephone calls. You will bear responsibility for payment for sessions missed in violation of the cancellation policy, as well as telephone calls or services not covered by insurance.
If you have a health insurance policy, it will usually provide some coverage for mental health treatment. With your permission, I will assist you to the extent possible in filing claims and ascertaining information about your coverage, but you are responsible for knowing your coverage and for letting me know if/when your coverage changes. You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. This will label you as having a mental illness. With some exceptions, I do not use the medical model for assessing clients or determining treatment, but I am qualified to provide a diagnosis if required. Sometimes I must provide additional clinical information, which will become part of the insurance company files. Your confidentiality is extended to anyone with access to your insurance records. By signing this Agreement, you agree that I can provide requested information to your carrier if you plan to pay with insurance.
In addition, if you plan to use your insurance, authorization from the insurance company may be required before they will cover therapy fees. If you did not obtain authorization and it is required, you may be responsible for full payment of the fee. Most policies leave a percentage of the fee (co-pay) to be covered by the client. Either amount is to be paid at the time of the visit by check, cash, or credit card. In addition, some insurance companies also have a deductible, which is an out-of-pocket amount that must be paid by the client before the insurance companies are willing to begin paying any amount for services. Depending upon your insurance plan, your insurance may cover a limited number of sessions per year.
Out of Network
If I am not a participating provider for your insurance plan, I will supply you with a receipt of payment for services, which you can submit to your insurance company for reimbursement. Please note that not all insurance companies reimburse for out-of-network providers. If you prefer to use a participating provider, I will try to refer you to a colleague.
If you do choose to see me out of network and your insurance company reimburses you, there may be a deductible. In some cases, the copay is less if you file out of network, so your cost may be less than with a participating provider.
Contact Between Sessions
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 you feel you cannot wait for a return call or it is an emergency situation, go to your local hospital or call 911.
As a psychotherapy client you have a right to:
a confidential relationship with your therapist;
discuss your therapy with anyone;
receive respectful treatment;
proceed with the therapeutic process at a pace that feels safe and comfortable;
end therapy at any time and for any reason;
a clear understanding of session times, fees, policies and goals;
know whether your therapist will discuss your case with others (e.g. supervisors, consultants, insurance companies, or students);
be informed of your therapist’s experience and training beyond formal education and to ask whether your therapist has ever been in therapy;
know whether your therapist is a member of any professional associations which set ethical standards;
a therapist who strives to understand how oppressive forces in society might affect her or his clients;
a therapist who monitors boundaries and addresses boundary issues if they occur.