Informed Consent
(Including an overview of policies, processes, practices, and fees)
(Including an overview of policies, processes, practices, and fees)
Welcome to my practice! This page contains important information about my professional counseling services and policies.
Together, we will review the key points in this informed consent at the start of our intake session; however, please carefully read the entirety of what is written below and feel free to ask any questions you have regarding its contents prior to, or during our initial session (and, of course, anytime thereafter)...
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The therapeutic relationship is unique in that it is exceptionally personal and at the same time, it is a contractual agreement between therapist and client. Because of this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect throughout our therapeutic adventure together...
Over the course of therapy, I will do my best to evaluate whether the services I am providing are beneficial to you. While I hope our work together will be effective, due to the varying nature and severity of presenting problems, as well as the individuality of each client, I cannot predict how long therapy services will be needed, and I cannot guarantee a specific outcome or result. However, I can promise to do my very best to empathize with you, to identify repeating patterns in your life and what may be driving them, to help you clarify what you want for yourself, and to support you in making useful and important changes. I will strive to provide you with a protected space where you can safely explore, process, and learn to cope with the feelings surrounding what you’ve encountered in life.
Participating in therapy can require significant courage as it may, at times, feel considerably uncomfortable; facing difficult truths, recalling unpleasant events and experiences, and developing a more conscious awareness of the emotions attached to those truths, events, and experiences, can elicit strong feelings. Therapy can be a challenging process, but fulfilling and empowering with a well matched therapist.
Participating in therapy may result in a number of benefits including, but not limited to: a reduction in stress and related symptoms; a decrease in negative thoughts and self-defeating behaviors; the ability to generate more balanced, realistic thoughts; recognition of personal values and how to make decisions based upon those values; improved interpersonal relationships; increased comfort in social settings; increased self-confidence; and paradigm shifts that allow you to experience new freedoms and possibilities. Attaining such benefits will likely require quite a bit of effort on your part, including consistent, active participation in the therapeutic process, and a willingness to change feelings, thoughts, and behaviors.
I will use an integrative approach, (typically consisting of attachment-based, strengths-based, cognitive-behavioral, acceptance and commitment, humanistic and occasionally Eye Movement Desensitization and Reprocessing interventions, as well as others) tailored to you and your needs. We will collaboratively address the issues you face in life. Positive outcomes are associated with a strong therapeutic alliance, so if at any time you feel we are misaligned or mismatched, please communicate this to me so that we can determine the most helpful path forward.
It is important that you feel comfortable talking with me about anything, and as a psychotherapy client, you have a right to confidentiality with respect to information related to our work together (see HIPAA, the Health Insurance Portability and Accountability Act, for more information). Outside of what you give me permission to disclose, information you share with me will generally remain confidential. There are, however, important exceptions to this rule. I am a mandated reporter and, in some situations, I am required by law and the guidelines of my profession to disclose information whether I want to or not, without your permission, and/or against your wishes…
▶ You tell me that you plan to kill yourself and I believe you have the intent and ability to do so in the very near future. In order to ensure your protection, I am required by law to report this disclosure and will inform your emergency contact and/or protective services. (Additionally, if I have concerns about suicide risk - or, your general safety, and I am unable to connect with you after you “no show” for a session, I may contact the police to request a welfare check at the address listed in this paperwork.)
▶ You tell me you plan to hurt or kill another identified party, and I believe you have the intent and ability to do so in the very near future. In order to ensure the protection of others, I am required by law to report this disclosure and will inform your emergency contact, school administration (when applicable), protective services, as well as the identified target whose well-being has been threatened.
▶ You plan to do something that could cause serious harm to yourself or someone else (even if unintentional). In these situations, I will use my professional judgment to decide whether your emergency contact, school administration (when applicable), and/or protective services should be informed.
▶ My personal safety is threatened; in the event that you or an individual associated with you threatens my safety and/or the security of my office, I hold the right to terminate services immediately and to notify law enforcement.
▶ I know or have a "reasonable suspicion" that you have shared or are in the possession of sexually explicit or exploitative images with or of minors (a minor is anyone under the age of 18) including electronically exchanged images (e.g. “sexting”) or otherwise, regardless of whether you are a minor yourself. In these situations, I am required to report this activity to protective services and/or to the police.
▶ You tell me about a child, elder, or dependent adult being, or having been, abused (this includes physical, sexual, and emotional abuse, as well as neglect). In these situations, I am required by law to report abuse to protective services and/or to the police.
▶ You are involved in a court case and a request is made for information about your therapy services. If this happens, I will not disclose information without your (or your legal representative's) written agreement - unless the court orders me to do so.
▶ I may also collaborate with outside service providers working with you, if needed.
▶ I may participate in clinical, ethical, and/or legal consultation with appropriate professionals.
Due to the importance of confidentiality and clear boundaries, I do not accept friend requests/follows on social media from current or former clients on any social networking site. I will also take measures to protect your privacy should we encounter each other in public (i.e. I will not acknowledge you or expect you to acknowledge me, and we will not - at any time - have a relationship outside of the therapist-client relationship).
Please see this formal Notice of Privacy Practices for more specific information regarding how your health information may be used and disclosed, as well as how you can access your information.
For those under the age of 18: I may involve your parent(s)/guardian(s) in your treatment unless such involvement would be inappropriate; however, this would not give your parent(s)/guardian(s) rights to your confidential information. Except in situations such as those listed above, I will not discuss with your parent(s)/guardian(s) the specifics you share with me in our private therapy sessions without your permission. This includes activities and behavior that your parent(s)/guardian(s) may not approve of (or that they could be upset by). However, if your risk-taking behavior puts you in danger of harm, I may communicate this information to your parent(s)/guardian(s). You are always welcome to ask me questions about the type of information I would be required to disclose.
If I believe that it is important for your parent(s)/guardian(s) to be informed as to what is discussed in your therapy sessions, I would encourage you to talk with them and we would work together to find the best way to communicate your needs. If I were ever to meet with your parents, I may describe problems in general terms, in order to help them better understand your needs.
According to the Mental Health Services for At-Risk Youth Act (SB 543), minors over the age of 12, are able to consent to mental health treatment without permission from their parent(s)/guardian(s) as long as they are mature enough to intelligently participate in therapy services. If you consent to your own treatment, and can afford to pay session costs on your own, the law generally prohibits me from communicating with your parent(s)/guardian(s) without your written authorization - unless you are experiencing a crisis or other emergency circumstance that would require me to break confidentiality.
For those parent(s)/guardian(s) of minors receiving mental health services: if you give me consent to treat your minor child, I may provide you with general updates about their treatment. These updates may include your child’s diagnosis, treatment plan, progress in therapy, session attendance, or similar information. However, I generally do not share specific details about your child's treatment or what they have shared with me during sessions unless: 1) they give me permission to disclose such information and I believe the disclosure would be clinically appropriate; or 2) they are experiencing a crisis or other emergency circumstance that would require me to break confidentiality.
According to the Mental Health Services for At-Risk Youth Act (SB 543), minors over the age of 12, are able to consent to mental health treatment without permission from their parent(s)/guardian(s) as long as they are mature enough to intelligently participate in therapy services. If your child consents to their own treatment, and they can afford to pay session costs on their own, the law generally prohibits me from communicating with you without their written authorization - unless the minor is experiencing a crisis or other emergency circumstance that would authorize me to break confidentiality.
Please plan to remain in the waiting area or parking lot immediately outside the building in the event that you are needed in your minor child's session; also, please be aware that I cannot remain present with your child beyond their session time.
Please provide the phone numbers and email addresses for two emergency contacts whom I am authorized to contact and leave messages with if/when needed (e.g. if I cannot reach you and have safety concerns, or if you express risk for self-harm or suicide, etc.).
Please communicate with me through your Simple Practice Client Portal if you have questions about these policies or if you would like to discuss them further.
Though we will meet in person for weekly sessions, in the event that you are mildly ill and would like to meet for a session, we may opt to do so online as a “teletherapy” session. “Teletherapy” includes secure video conferencing, emails, telephone conversations, and psycho-education using interactive audio, video, and/or data communications. Teletherapy services furnished in the state of California are governed by the laws of California. Services provided are required by law to take place within the state of California, where I am licensed, with the exception of minimal urgent communication. If you are physically located outside of the state of California, you should notify me as soon as possible so that we can discuss alternative care options and strategies, as well as what you should do in the event of an emergency. You have the right to withdraw or withhold consent from teletherapy services at any time. I also have the right to terminate teletherapy treatment at any time.
While teletherapy will be conducted primarily through secure and private videoconferencing, there are always some risks with teletherapy services including, but not limited to, the possibility that: the transmission of your medical information could be disrupted or distorted by technical failures; the transmission of your information could be intercepted by unauthorized persons, and/or the electronic storage of your medical information could be accessed by unauthorized persons.
At the start of each teletherapy session, please provide the physical address where you are located. We will identify an alternative communication method (most often, telephone) in the event that the videoconferencing tool fails.
You will be responsible for providing your own computer and/or necessary telecommunications equipment and internet access for your teletherapy sessions, as well as arranging a location with sufficient lighting and privacy that is free from distractions or intrusions (utilizing earbuds is also highly recommended). If I am concerned about your safety, if I lose contact with you, or if you fail to show up for a scheduled teletherapy session, I may contact you by phone to check on your well-being. In addition, if I have reason to believe that you may be in danger or that you may present a danger to others, I am required to contact the police to check on you and ensure your safety and the safety of others.
You may not record teletherapy sessions. You must be dressed as if you were attending an in-person face to face session.
I value your privacy and take appropriate steps to preserve the confidentiality of information shared between us. That said, I may need to communicate with you, your emergency contact, emergency services, and/or appropriate consultants by unsecured phone or text, internet correspondence, and/or by other means.
Potential risks of using electronic communication may include, but are not limited to inadvertent sending of an e-mail or text message containing confidential information to the wrong recipient; theft or loss of the computer, laptop, or mobile device storing confidential information; and interception by an unauthorized third party through an unsecured network. E-mail messages may contain viruses or other defects and it is your responsibility to ensure that messages are virus-free.
Due to these risks, text-based electronic communications should be limited to scheduling-related issues only and should not contain any information you would like or expect to have kept confidential.
If you wish to use out-of-network insurance coverage to pay for your sessions, I will be required to document your diagnosis and treatment information for your insurance provider. Weekly counseling notes are kept on an encrypted flash drive that only I have access to.
I do NOT provide letters or documentation for legal or evaluative purposes (such as custody evaluations, social security requests, emotional support animal recommendations, etc.).
"Under the law, health care providers must give clients who do not have insurance or who are not using insurance an estimate of the expected charges for any non-emergency healthcare services, including psychotherapy services. You can ask [me] for a Good Faith Estimate before you schedule a service. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill; make sure to save a copy or picture of the fees listed below. For questions or more information about your right to a Good Faith Estimate, please visit www.cms.gov/nosurprises."
▶ The fee for service is $154.25 per 55-minute individual therapy session
▶ Service fees may increase over time - you will be provided 3 months' notice before fee increases.
**You may be eligible for reimbursement if your insurance covers out-of-network services; to see if you qualify, please click HERE.**
**UCD Students, please inquire with Student Health and Counseling Services about the Health Equity Fund.**
***I cannot accept single case agreements that require me to submit bills to your insurance carrier (I can provide you with a superbill to submit to your insurance carrier so that you may seek reimbursement for therapy services)***
Fees are payable at or before the time services have been scheduled to take place (valid payment information must be kept on file). I accept payment in the form of cash, check, or card (through Ivy Pay*).
If you are a UC Davis student, please inquire with Student Health and Counseling Services about the Health Equity Fund. ("The UC Davis Health Equity Fund is available to help reimburse students who have experienced significant out-of-pocket expenses related to accessing physical or mental healthcare or to students who have a significant privacy concern as a dependent (e.g., sexual health services). Students can apply for financial assistance in the form of a grant for expenses between $50 and $2,500. Any funds you receive from the Health Equity Fund will be included on your 1098-T tax form. Please consult with a tax professional for any tax related questions.")
I currently accept Aetna and United Healthcare (Optum) insurance coverages; however, you are responsible for payment of scheduled services, even if you are relying on, or expecting your insurance company or another third-party payer to cover the costs of your treatment. I will notify you of any changes to fees or when other charges are to be applied. If you are experiencing financial difficulty, please let me know so we can discuss your options for care.
You may be eligible for reimbursement if your insurance covers out-of-network services; to see if you qualify, please click HERE. The amount of reimbursement depends on the requirements of your specific insurance plan. You are responsible for verifying and understanding the limits of your insurance coverage. Although I am happy to assist your efforts to seek insurance reimbursement, I am unable to guarantee that your insurance will provide payment for the services provided to you.
Therapy is an investment of time, energy, and money. Being financially invested in your treatment can help you remain committed and focused when making efforts to improve your mental health becomes difficult. Additionally, not seeking reimbursement through insurance allows for more freedom in determining the scope and quality of your treatment, giving you more control over your services. Operating outside of the insurance system is also more protective of your privacy as I would not be required to attach a diagnosis or share any other personal information in order to receive payment for services.
*Ivy Pay (terms of service) is a credit card processing service where I am able to charge you for sessions without swiping your card at every appointment. Ivy Pay is secure and compliant with HIPAA standards. Your credit or debit card information is stored in Ivy Pay; I do not have access to your stored payment information. Using this payment method, you would provide me with a phone number, which I would enter into the Ivy Pay app along with the fee for session. Ivy Pay then sends you a text message with a secure link where you enter valid credit or debit information and approve the first charge; following sessions will charge your stored credit or debit card. You do not need to download the app and you can change or remove your card information at any time.
When possible, we will typically schedule sessions to occur once per week on the same day and at the same time. I may suggest a different number or frequency of therapy sessions depending on the nature and severity of your concerns. Your consistent attendance can greatly contribute to a successful therapy outcome. In order to ensure all clients are seen at their appointment time, I must end sessions on time. This may require us to wrap up even if we are in the middle of something important. If you arrive to a session late, we can still meet for the session; however, you will forfeit the time missed.
To cancel or reschedule (depending on availability) an appointment, please notify me as soon as possible - preferably at least 24 hours in advance of your appointment. You will be charged $100 for cancellations made within 24 hours of your scheduled appointment time.
If you "no show" (i.e. you do not attend your scheduled session), approximately ten minutes into your appointment time, I will text you to check in at the phone number provided and you will be charged the full session fee for the missed appointment.
Fees for missed sessions are necessary because I make a time commitment to you and hold that time exclusively for you. If you are being reimbursed for out-of-network coverage, please be aware that your insurance company will not pay for missed or canceled sessions; you will be responsible for covering the cost of missed sessions and sessions canceled within 24 hours of your scheduled session.
If I am unable to make contact with you and you no show for two consecutive appointments, unless other arrangements have been made, I must consider the professional relationship discontinued.
The above fees may be waived twice per calendar year in the event that session must be canceled within 24 hours due to illness or another urgent/unavoidable event (this waiver does not apply to “no shows” unless you were experiencing an unforeseeable emergency).
Pausing or ending the therapeutic relationship can be difficult. However each of us has the right to discontinue treatment at any time, though services are typically discontinued when you and/or I decide that our collaborative work is ready to end. Scheduled sessions may taper down and we will discuss your graduation from therapy services. I will not unilaterally end the therapeutic relationship without first exploring the reason and purpose of discontinuing services. If I determine that the psychotherapy provided is not effective, or if you default on payment, we will discuss this and I will provide you with a list of resources to help you access therapy services outside of my care.
Assuming no conflict of interest, safety concern, or personal threat has been made, after completing services, you are welcome to contact me any time to inquire about resuming psychotherapy sessions.
▶ I do NOT provide emergency services. If you are experiencing an emergency, please call 911 or proceed to the nearest emergency room for help. If you are having suicidal thoughts or making plans to harm yourself, you may call the National Suicide Prevention Lifeline by dialing 988, or 1-800-273-TALK (8255), for free, 24-hour hotline support.
▶ Therapy Never Includes Sexual Behavior.
▶ My office is on the second floor of 423 F Street and there is no elevator in this building. If this impacts your ability to receive services with me, and you would like to schedule an appointment, please contact me at psychotherapy@kateabellorentzen.com to discuss options for treatment.
▶ Please no food or drink in the therapy office (water is okay), and please plan to silence your phone during sessions.
▶ Non-human animals (aside from trained and certified service dogs required to support those with a disability) are not permitted in the building.
▶ As a psychotherapist, I cannot accept gifts or tips as it may put stress on the therapeutic relationship and harm the therapeutic process.
▶ If you wish to seek services with another provider, please search Psychology Today to find an alternative therapist.
▶ The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of (marriage and family therapists, educational psychologists, clinical social workers, or professional clinical counselors). You may contact the board online at www.bbs.ca.gov, or by calling (916) 574-7830.
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