INFORMED CONSENT & OFFICE POLICIES
This document contains important information about my professional services and business policies. Please read it carefully. When you sign this document, it will represent an agreement between us.
The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by signing at the end of this document.
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to address. There are many different methods I may use to deal with those problems. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.
Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But, there are no guarantees as to what you will experience.
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 about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and, if so, I will give you referrals to other practitioners whom I believe are better suited to help you. If you or your child are receiving a psychological evaluation, this will include a diagnostic interview followed by one or more multi-hour face-to-face testing sessions, and a feedback session scheduled several weeks later to review the results, which will allow proper time to interpret the results and prepare an evaluation report. The feedback session will not be scheduled until all forms are completed and returned to me.
Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. 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.
I normally conduct an evaluation that will last from 2 to 4 sessions. 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 we agree to begin psychotherapy, I typically schedule one 45-minute session (one appointment hour of 45 minutes duration) per week, at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to attend unless you provide 24 hours advance notice of cancellation. If it is possible, I will try to find another time to reschedule the appointment. Please see late cancelations/no-show policy for more information.
RATES & INSURANCE
The following fees are self-pay rates for services. If I am an in-network provider for your insurance plan, rates are determined per contract for each plan. If your insurance company does not pay the full amount of this rate based on your coverage benefits, you will be responsible for the remainder of the rate.
45 minute therapy session (38-52 minutes): $130
60 minute therapy session (53 - 60 minutes): $150
60 minute intake session (53-60 minutes): $165
Psychological/Psychoeducational Testing: $150 per hour administration, test scoring/interpretation, and evaluation report writing.
Career/Vocational Assessment: $150 per hour for administration, test scoring/interpretation, and evaluation report writing.
*Payment for fee-for-service/self-pay evaluations is due in full at the end of the first
testing session in order to schedule remaining testing appointment(s). You must notify
me of any cancelations within 48 hours prior to your testing appointment, otherwise you
will be charged the cancelation fee. (See the Cancelations, no-show policies for more
Legal Proceedings: $250 per hour (including travel, preparation, and attendance paid in full prior to court appearance)
Phone consultations with patients or other care providers for more than 15 minutes: $35 per additional 15 minute increment
Preparation of documents (treatment summaries, letters, forms) = $25 per 15 minute increment (15 minute minimum)
Returned Check Fee = $20
Records request: 10 cents per page
*Please note: I am not a forensic psychologist and I do not typically participate in client legal matters; however, if you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party. Payment is due in full 48 hours prior to the court appearance, or I will not be able to appear. Hourly charges are based on 4 - hour increments (1 increment minimum), due to the necessity of clearing large portions of my schedule.
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 that requires another arrangement. Payment schedules for other professional services will be agreed to when such services are requested.
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 the payment. This may involve hiring a collection agency or going through small claims court. In most collection situations, the only information I will release regarding a patient’s treatment is his/her name, the dates, times, and nature of services provided, and the amount due.
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. I will fill out forms and provide you with whatever assistance I 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. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If necessary, I am willing to call the insurance company on your behalf to obtain clarification.
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 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. Though 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 me to provide services to you once your benefits end. If this is the case, I will try to assist you in finding another provider who will help you continue your psychotherapy.
You should also be aware that most insurance companies require that I provide them with your clinical diagnosis. Sometimes I have to provide additional clinical information, such as treatment plans, progress notes or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files. Though all insurance companies claim to keep such information confidential, I 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. I will provide you with a copy of any records I submit, if you request it. You understand that, by using your insurance, you authorize me to release such information to your insurance company. I will try to keep that information limited to the minimum necessary.
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 my services yourself to avoid the problems described above unless prohibited by the insurance contract.
NO - SHOWS and LATE CANCELLATIONS:
Please provide at least 24 HOURS ADVANE NOTICE OF THERAPY SESSION CANCELLATIONS or you will be subject to a charge unless we both agree that circumstances were out of your control. This is necessary because a time commitment is made to you and is held exclusively for you. If it is possible, I will try to find another time to reschedule the appointment that same week.
1st Occurrence late cancellation/no-show for therapy: no charge
2nd Occurrence late cancellation/no-show for therapy: half session charge
3rd Occurrence late cancellation/no-show for therapy: full session charge
You must provide 48 HOURS ADVANCE NOTICE OF TESTING APPOINTMENT CANCELLATIONS or you will be subject to a half session charge (i.e., half of the charge for a multi-hour appointment) unless we both agree that circumstances were out of your control.
If you begin to cancel appointments regularly or no-show more than 2 consecutive times, we will need to discuss your ability to commit to therapy and consider discontinuing services depending on the circumstances.
If you will be late, please call or email your likely arrival time. You will only have the remaining time available for your scheduled appointment once you arrive. If you are later than 20 minutes, I will assume you are not coming and will try to reach out to you.
I am often not immediately available by telephone due to being in session with a client. I am usually in my office between 9 AM and 5 PM on Tuesdays through Thursday. When I am unavailable, please leave a message on my voice mail that I monitor frequently. I will make every effort to return your call on the same day you make it, if requested, or within 48 hours when I am in the office, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. If I am absent from the office for an extended time, I will attempt to inform you ahead of time or my voice message will state when I plan to return. I am not available to speak about clinical matters during non-office hours.
There could be circumstances (i.e., illness, emergencies, weather conditions) when I need to unexpectedly cancel appointments with you. If this occurs, I will try to reach you the best I can to reschedule your appointment. I will also put a message in my voicemail stating the terms of my absence.
In the case of an emergency:
If you are unable to reach me and feel that you cannot wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. You can also go directly to psychiatric emergency departments including the following:
For Adults (ages 18 or older):
Memorial Hospital of Jacksonville
3625 University Blvd., S.
Jacksonville, FL 32216
Behavioral Health/Emergency evaluation: #904-702-6600
For Children/Teens/Adults (ages 6 and older):
Baptist Medical Center Jacksonville (Downtown)
800 Prudential Drive
Jacksonville, FL 32207
24- Hour Crisis Line: 904-202-7900
Patient Coordinator: 904-376-3800
I use a secure, confidential online client portal for message exchanges related to setting/changing appointments, billing matters, or receiving confidential clinical information from clients (i.e., intake paperwork, evaluations, treatment records). If you need to discuss a clinical matter at length, please call to request a time to discuss it or wait until your next appointment to share it in session unless we have made another arrangement.
I use email communication only with your permission and only for administrative purposes unless we have made another agreement. That means that email exchanges through the email@example.com email address with my office should be limited to things like setting and changing appointments, billing matters and other related issues; however, the secure client portal is still a preferred method of contact. Please do not email me about clinical matters because email is not a secure way to contact me, nor is it HIPAA compliant. Clinical information sent by email will be discussed during session times. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies. If you need to discuss a clinical matter with me, please feel free to call me so we can discuss it on the phone or wait so we can discuss it during your therapy session. The telephone or face-to-face context simply is much more secure as a mode of communication. Please note, all email and messages sent to me will become part of the medical record.
Because text messaging is a very unsecure and impersonal mode of communication, I do not text message to nor do I respond to text messages from anyone in treatment with me.
Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I do not communicate with, or contact, any of my clients through social media platforms like Twitter and Facebook. In addition, if I discover that I have accidentally established an online relationship with you, I will cancel that relationship. This is because these types of casual social contacts can create significant security risks for you.
I participate on various social networks, but not in my professional capacity. The Facebook company business page is only used for marketing purposes and offering useful mental health articles or information. If you have an online presence, there is a possibility that you may encounter me by accident. If that occurs, please discuss it with me during our time together. I believe that any communications with clients online have a high potential to compromise the professional relationship. In addition, please do not try to contact me in this way. I will not respond and will terminate any online contact no matter how accidental.
I will not use web searches to gather information about you without your permission. I believe that this violates your privacy rights; however, I understand that you might choose to gather information about me in this way. In this day and age there is an incredible amount of information available about individuals on the internet, much of which may actually be known to that person and some of which may be inaccurate or unknown. If you encounter any information about me through web searches, or in any other fashion for that matter, please discuss this with me during our time together so that we can deal with it and its potential impact on your treatment.
Recently it has become more common for clients to review their health care provider on various websites. Unfortunately, mental health professionals cannot respond to such comments and related errors because of confidentiality restrictions. If you encounter such reviews of me or any professional with whom you are working, please share it with me so we can discuss it and its potential impact on your therapy. Please do not rate my work with you while we are in treatment together on any of these websites. This is because it has a significant potential to damage our ability to work together.
Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.
If you begin to cancel appointments regularly or no-show more than 2 consecutive times, we will need to discuss your ability to commit to therapy and consider discontinuing services depending on the circumstances.
CONFIDENTIALITY (ADULT CLIENTS)
In general, the privacy of all communications between a patient and a psychologist 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.
1) In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some legal proceedings, a judge may order my testimony if he/she determines that the issues demand it, and I must comply with that court order.
2) 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 believe that a child or elderly person or disabled person is being abused or neglected or has been abused or neglected, I must make a report to the appropriate state agency.
3) If I believe that a patient is threatening serious bodily harm to another, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient.
4) If the patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. If a similar situation occurs in the course of our work together, I will attempt to fully discuss it with you before taking any action.
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. Ordinarily, I will not tell you about these consultations unless I believe that it is important to our work together.
Although this written summary of exceptions to confidentiality is intended to inform you about potential issues that could arise, it is important that we discuss any questions or concerns that you may have at our next meeting. I will be happy to discuss these issues with you and provide clarification when possible. However, if you need specific clarification or advice I am unable to provide, formal legal advice may be needed, as the laws governing confidentiality are quite complex and I am not an attorney. If you request, I will provide you with relevant portions or summaries of the state laws regarding these issues.
Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.
PATIENT SIGNATURE ________________________________ DATE _________________
Parent Authorization for Minor’s Mental Health Treatment
In order to authorize mental health treatment for your child, you must have either sole or joint legal custody of your child. If you are separated or divorced from the other parent of your child, please notify me immediately. I will ask you to provide me with a copy of the most recent custody decree that establishes custody rights of you and the other parent or otherwise demonstrates that you have the right to authorize treatment for your child.
If you are separated or divorced from the child’s other parent, please be aware that it is my policy to notify the other parent that I am meeting with your child. I believe it is important that all parents have the right to know, unless there are truly exceptional circumstances, that their child is receiving mental health evaluation or treatment.
One risk of child therapy involves disagreement among parents and/or disagreement between parents and the therapist regarding the child’s treatment. If such disagreements occur, I will strive to listen carefully so that I can understand your perspectives and fully explain my perspective. We can resolve such disagreements or we can agree to disagree, so long as this enables your child’s therapeutic progress. Ultimately, parents decide whether therapy will continue. If either parent decides that therapy should end, I will honor that decision, unless there are extraordinary circumstances. However, in most cases, I will ask that you allow me the option of having a few closing sessions with your child to appropriately end the treatment relationship.
Individual Parent/Guardian Communications with Me
In the course of my treatment of your child, I may meet with the child’s parents/guardians either separately or together. Please be aware, however, that, at all times, my patient is your child – not the parents/guardians nor any siblings or other family members of the child.
If I meet with you or other family members in the course of your child’s treatment, I will make notes of that meeting in your child’s treatment records. Please be aware that those notes will be available to any person or entity that has legal access to your child’s treatment record.
Mandatory Disclosures of Treatment Information
In some situations, I am required by law or by the guidelines of my profession to disclose information, whether or not I have your or your child’s permission. I have listed some of these situations below.
Confidentiality cannot be maintained when:
Child patients tell me they plan to cause serious harm or death to themselves, and I believe they have the intent and ability to carry out this threat in the very near future. I must take steps to inform a parent or guardian or others of what the child has told me and how serious I believe this threat to be and to try to prevent the occurrence of such harm.
Child patients tell me they plan to cause serious harm or death to someone else, and I believe they have the intent and ability to carry out this threat in the very near future. In this situation, I must inform a parent or guardian or others, and I may be required to inform the person who is the target of the threatened harm and the police.
Child patients are doing things that could cause serious harm to them or someone else, even if they do not intend to harm themselves or another person. In these situations, I will need to use my professional judgment to decide whether a parent or guardian should be informed.
Child patients tell me, or I otherwise learn that, it appears that a child is being neglected or abused--physically, sexually or emotionally--or that it appears that they have been neglected or abused in the past. In this situation, I am required by law to report the alleged abuse to the appropriate state child-protective agency.
I am ordered by a court to disclose information.
Disclosure of Minor’s Treatment Information to Parents
Therapy is most effective when a trusting relationship exists between the psychologist and the patient. Privacy is especially important in earning and keeping that trust. As a result, it is important for children to have a “zone of privacy” where children feel free to discuss personal matters without fear that their thoughts and feelings will be immediately communicated to their parents. This is particularly true for adolescents who are naturally developing a greater sense of independence and autonomy.
It is my policy to provide you with general information about your child’s treatment, but NOT to share specific information your child has disclosed to me without your child’s agreement. This includes activities and behavior that you would not approve of — or might be upset by — but that do not put your child at risk of serious and immediate harm. However, if your child’s risk-taking behavior becomes more serious, then I will need to use my professional judgment to decide whether your child is in serious and immediate danger of harm. If I feel that your child is in such danger, I will communicate this information to you.
Even when we have agreed to keep your child’s treatment information confidential from you, I may believe that it is important for you to know about a particular situation that is going on in your child’s life. In these situations, I will encourage your child to tell you, and I will help your child find the best way to do so. Also, when meeting with you, I may sometimes describe your child’s problems in general terms, without using specifics, in order to help you know how to be more helpful to your child.
Disclosure of Minor’s Treatment Records to Parents
Although the laws of Florida may give parents the right to see any written records I keep about your child’s treatment, by signing this agreement, you are agreeing that your child or teen should have a “zone of privacy” in their meetings with me, and you agree not to request access to your child’s written treatment records.
Parent/Guardian Agreement Not to Use Minor’s Therapy Information/Records in Custody Litigation
When a family is in conflict, particularly conflict due to parental separation or divorce, it is very difficult for everyone, particularly for children. Although my responsibility to your child may require my helping to address conflicts between the child’s parents, my role will be strictly limited to providing treatment to your child. You agree that in any child custody/visitation proceedings, neither of you will seek to subpoena my records or ask me to testify in court, whether in person or by affidavit, or to provide letters or documentation expressing my opinion about parental fitness or custody/visitation arrangements.
Please note that your agreement may not prevent a judge from requiring my testimony, even though I will not do so unless legally compelled. If I am required to testify, I am ethically bound not to give my opinion about either parent’s custody, visitation suitability, or fitness. If the court appoints a custody evaluator, guardian ad litem, or parenting coordinator, I will provide information as needed, if appropriate releases are signed or a court order is provided, but I will not make any recommendation about the final decision(s). Furthermore, if I am required to appear as a witness or to otherwise perform work related to any legal matter, the party responsible for my participation agrees to reimburse me at the rate of $250 per hour for time spent traveling, speaking with attorneys, reviewing and preparing documents, testifying, being in attendance, and any other case-related costs.
By signing below, you show that you have read and understood the policies described above. If you have any questions as we progress with therapy, you can ask me at any time.
Minor’s Signature* _______________________________________ Date___________________
Parent/Guardian of Minor Patient:
Please initial after each line and sign below, indicating your agreement to respect your child’s privacy:
I will refrain from requesting detailed information about individual therapy sessions with my child. I understand that I will be provided with periodic updates about general progress, and/or may be asked to participate in therapy sessions as needed. ________ ________
Although I may have the legal right to request written records/session notes since my child is a minor, I agree NOT to request these records in order to respect the confidentiality of my child’s/adolescent’s treatment. ________ ________
I understand that I will be informed about situations that could endanger my child. I know this decision to breach confidentiality in these circumstances is up to the therapist’s professional judgment, unless otherwise noted above. ________ ________
Parent/Guardian Signature ________________________________________ Date__________
Parent/Guardian Signature ________________________________________ Date__________
* For very young children, the child’s signature is not necessary