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INFORMED CONSENT FOR PSYCHOTHERAPY

Overview

Professional ethical practice requires that you be given, in writing, certain information. That information is stated below, and this is your opportunity to receive therapy & counseling services based on that information.

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.

Fee For Services

  • $100.00 – 50 minutes

  • Negotiable sliding scale

  • Insurance accepted: Aetna, Apostrophe, BCBS-TX, Cigna, United Health Care

  • Please also know that my fee for written or verbal communication with anyone will be prorated at $100.00/Hour. This does not apply to transmitting information from your Client Record to you. 

The Therapeutic Process
  • You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in emotional and/or thinking discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can be challenging. I will provide “tools” for you to help keep this to a minimum. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I promise to support you and do my very best to understand you and your repeating patterns. I can help you clarify what you want for yourself and provide ways to achieve that. Please also see: How We Will Work Together 

Confidentiality
  • The session content and all relevant materials to your treatment will be held confidential unless you request, in writing, to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

  1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.

    If a client threatens grave bodily harm or death to another person.

  2. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional, or sexual abuse of children under the age of 18 years.

  3. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

  4. Suspected neglect of the parties named in items #3 and # 4.

    If a court of law issues a legitimate subpoena for information stated on the subpoena.

  5. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney. Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

  6. For the complete document regarding privacy/confidentiality, please see the Notice of Privacy Practices Act 

Risks and Benefits

The risks and benefits are a natural consequence of this process because change will occur. Your perceptions will play a major role in whether these consequences are a risk or a benefit. Sometimes someone important to you may be very upset that you are changing in a way that is beneficial to you and they don’t know how to handle that.

Both risks and benefits involve a relationship change – a change in your relationship with yourself, others, and your world and so it will depend on whether you perceive these changes as a risk or as a benefit. Without having developed certain skills, these may be a risk, but with the skills, a benefit.

Risks:

  1. Telemental Health services can be impacted by technical failures, may introduce risks to your privacy, and may reduce your service provider’s ability to directly intervene in crisis or emergencies. 

  2. Internet connections and cloud services could cease working or become too unstable to use

  3. Computer or smartphone hardware can have sudden failures or run out of power, or local power services could go out

  4. There is a slight chance that malicious actors (hackers) may have the ability to access your private information that is transmitted or stored in the process of telemental health-based service delivery

  5. If I don’t have access to a reliable contact person, I may not be able to quickly provide the help you need

  6. It may be a challenge for you to find privacy in your residence

Benefits:

  1. Telemental health services can be more convenient, given the convenience of the internet

  2. Generally speaking, telemental health delivery (video) can be as effective as in-person delivery

  3. Services may be available at times or places where the service may not otherwise be available

  4. It may provide the space you need to just be yourself

Complaints

I foster a counseling/psychotherapy practice of self-empowerment, self-respect and optimism to promote resilience during and following our time together. However, if you are unhappy with the way our work together is proceeding, I hope you will talk to me about it so I can respond to your concerns directly. I will take such concerns seriously and meet them with care and respect. If you believe that I have been unwilling to listen and respond, or that I have behaved unethically, you can register a complaint with the following:

 

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