Individual Informed Consent

Welcome to my practice.  This document contains important information about my professional services and business policies.  Please read it carefully and jot down any questions you might have so that we can discuss them when we meet.  When you sign this document, it will represent an agreement between us.

THERAPY SERVICES

Our first few sessions will involve an evaluation of your needs.  By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy.  You should evaluate this information along with your own opinions of whether you feel comfortable working with me.  Therapy involves a commitment of time, money and energy, so you should be very careful about the therapist you select.  If you have any 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.

Therapy can have benefits and risks.  Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings such as sadness, guilt, anger, frustration, loneliness and helplessness.  Psychotherapy has been shown to have benefits for people who go through it.  Therapy often leads to better relationships, improved self-esteem, solutions to specific problems and significant reductions in feelings of distress.  But there are no guarantees of what you will experience.

MEETINGS

I normally conduct an evaluation that will last from 2-4 sessions. With individuals and couples, I require the first session to be 75 minutes. Often, with couples, after the initial session, I request an individual 50-minute session with each partner. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals.  If therapy commences, I will usually schedule one 50-minute session (one appointment lasting 50 minutes) per week at a time we agree on, although some sessions may be longer or more frequent.  Once any appointment is scheduled, you will be expected to pay for it unless you provide 48 hours advance notice of rescheduling/cancellation.

PROFESSIONAL FEES

My fee is $225.00 per 50-minute session for individuals and $337.50 per 75-minute session for individuals, couples and families.  In addition to weekly appointments, I charge this amount for other professional services you may need, though I will break down the cost if I work for periods less than 50 minutes.  Other services include telephone conversations lasting longer than 10 minutes, report writing, 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 me.  If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party.  (Because of the difficulty of legal involvement, I charge $250 per hour for preparation and attendance at any legal proceeding.)

BILLING AND PAYMENTS

You will be expected to pay for each session before the time it is held (unless otherwise mutually agreed upon in advance.)  I accept cash, checks, credit cards, Venmo and Zelle. A fee of $8.50 per 50-minute session and $12.85 per 75-minute session will be added for credit card payments. Payment schedules for other professional services will be agreed to when they are requested.

I do not provide any direct insurance billing.  However, I can provide you with a standardized receipt (“superbill”) for reimbursement purposes that some insurance companies accept for reimbursement.  My superbill includes name, social security number, types of services provided, diagnosis, dates of service and fees paid.  I do not provide any other services for billing nor reimbursement.  If you plan on submitting a superbill to your insurance company, please be advised that each coverage is different, and that it is advisable to check with your insurance company prior to seeking reimbursement.

If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure 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.)

CONTACTING ME

I am often not immediately available by telephone. My telephone is answered by voicemail that I monitor frequently.  I will make every effort to return your call by the next business day, with the exception of holidays.  If you are difficult to reach, please inform me of some times when you will be available.  In life threatening emergencies always dial 911.  If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the therapist/psychiatrist on call.  If I will be unavailable for an extended period of time, I will provide you with the name of a trusted colleague to contact, if necessary.

PROFESSIONAL RECORDS

The laws and standards of my profession require that I keep treatment records.  You are entitled to receive a copy of the records unless I believe that seeing them would be damaging, in which case I will be happy to send them to a mental health professional of your choice.  I may also exercise the option to provide a treatment summary. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers.  I recommend that you review documents in my presence so that we can discuss the contents.  Patients will be charged an appropriate fee for any time spent in preparing information requests.

CONFIDENTIALITY

In general, the privacy of all communications between a patient and a therapist is protected by law, and I can only release information about our work to others with your written permission.  But there are a few exceptions that I need to inform you about, even though they rarely occur in my practice.

In most legal proceedings, you have the right to prevent me from providing any information about your treatment.  In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it.

There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a patient’s treatment.  For example, if I suspect that a child, elderly person, or disabled person is being abused, I am required by law to file a report with the appropriate agency.

If I believe a patient is threatening serious bodily harm to another, I am required to take protective actions.  These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient.  If the patient threatens harm to himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection.

I may occasionally find it helpful to consult other professionals about a case.  During a consultation, I make every effort to avoid revealing the identity of my patient.  The consultant is also legally bound to keep the information confidential.  If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have when we meet.  I will be happy to discuss these issues with you if you need specific advice, but formal legal advice may be needed because the laws governing confidentiality are quite complex, and I am not an attorney.

Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.