INFORMED CONSENT FOR PSYCHOTHERAPY AND PRACTICE POLICIES

THERAPY CONSENT, POLICIES, & AGREEMENT

PART I: THERAPEUTIC PROCESS

BENEFITS/OUTCOMES: The therapeutic process seeks to meet goals established by all persons involved, usually revolving around a specific complaint(s).  Participating in therapy may include benefits such as the resolution of presenting problems as well as improved intrapersonal and interpersonal relationships.  The therapeutic process may reduce distress, enhance stress management, and increase one’s ability to cope with problems related to work, family, personal, relational, etc.  Participating in therapy can lead to greater understanding of personal and relational goals and values.  This can increase relational harmony and lead to greater happiness.  Progress will be assessed on a regular basis and feedback from clients will be elicited to ensure the most effective therapeutic services are provided.  There can be no guarantees made regarding the ultimate outcome of therapy.

EXPECTATIONS: In order for clients to reach their therapeutic goals, it is essential they complete tasks assigned between sessions.  Therapy is not a quick fix.  It takes time and effort, and therefore, may move slower than your expectations.  During the therapy process, we identify goals, review progress, and modify the treatment plan as needed.

RISKS: In working to achieve therapeutic benefits, clients must take action to achieve desired results.  Although change is inevitable, it can be uncomfortable at times.  Resolving unpleasant events and making changes in relationship patterns may arouse unexpected emotional reactions.  Seeking to resolve problems can similarly lead to discomfort as well as relational changes that may not be originally intended.  We will work collaboratively toward a desirable outcome; however, it is possible that the goals of therapy may not be reached.

STRUCTURE OF THERAPY:

• Intake Phase – During the first session, therapeutic process, structure, policies and procedures will be discussed.  We will also explore your experiences surrounding the presenting problem(s).
• Assessment Phase – The initial evaluation may last 2-4 sessions.  During this assessment phase, I will be getting to know you.  I will ask questions to gain an understanding of your worldview, strengths, concerns, needs, relationship dynamics, etc.  During this relationship building process, I will be gathering a lot of information to aid in the therapeutic approach best suited for your needs and goals.  If it is determined that I am not the best fit for your therapeutic needs, I will provide referrals for more appropriate treatment.
• Goal Development/Treatment Planning – After gathering background information, we will collaborative identify your therapeutic goals.  If therapy is court ordered, goals will encompass your goals and court ordered treatment goals, based on documentation from the court (please provide any court documents).  Once each goal is reached, we will sign off on each goal and you will receive a copy.
• Intervention Phase – This phase occurs anywhere from session two until graduation/discharge/termination.  Each client must actively participate in therapy sessions, utilize solutions discussed, and complete assignments between sessions.  Progress will be reviewed and goals adjusted as needed.
• Graduation/Discharge/Termination – As you progress and get closer to completing goals, we will collaboratively discuss a transition plan for graduation/discharge/termination.

LENGTH OF THERAPY: Therapy sessions are typically weekly or biweekly for 30 to 60 minutes depending upon the nature of the presenting challenges and insurance authorizations.  It is difficult to initially predict how many sessions will be needed.  We will collaboratively discuss from session to session what the next steps are and how often therapy sessions will occur.

APPOINTMENTS AND CANCELLATIONS: You are responsible for attending each appointment and agree to adhere to the following policy: If you cannot keep the scheduled appointment, you MUST notify our office to cancel or reschedule the appointment within 48 hours of the scheduled appointment time.  If you cancel or rescheduled more than 3 times in a row, we may re-evaluate your needs, desires, and motivations for treatment at this time.  Each insurance panel has a different policy on whether clinicians can charge for missed appointment/s.  Check your provider’s policies regarding cancellations and/or no shows. At Dynamic Psychometrics LLC we charge a late fee of $50.00 for late cancelations/reschedules and $100.00 for no show. Your insurance policy is unlikely to cover this expense and you will be fully responsible to cover this cost.

Psychotherapy is a uniquely personal service; therefore, consultations may be briefly interrupted.  I may periodically take time off for vacation, seminars, and/or become ill.  Attempts will be made to give adequate notice of these events.  If I am unable to contact you directly, a colleague may contact you to cancel or reschedule an appointment.

FEES: The fee for each Initial session is $200.00. 53–60-minute therapy session is $180.00 and 38-52 min therapy session is $120.00. Payment is due at the time of service.  Acceptable forms of payment are: exact-amount cash, check (insufficient-funds checks will be returned upon full payment of the original amount plus $30.00 for any returned check), or credit/debit card.  In the event that a scheduled appointment time is missed or cancelled less than 48 hours, please refer to the “Appointments and Cancellations” policy above.

The clinician reserves the right to terminate the counseling relationship if more than three sessions are missed without proper notification.

The clinician charges his/her hourly rate in quarter hours (15 minutes interval) for phone calls over 10 minutes in length, email correspondence, reading assessments or evaluations, writing assessments or letters, and collaborating with necessary professionals (with your permission) for continuity of care.  All costs for services outside of session will be billed at $30.00 per 15 minutes. Many of these services are not covered by medical insurance and you will be responsible for complete payment.

TRIAL, COURT ORDERED APPEARANCES, LITIGATION: Rarely, but on occasion, a court will order a therapist to testify, be deposed, or appear in court for a matter relating to your treatment or case.  In order to protect your confidentiality, I strongly suggest not being involved in the court.  If I get called into court by you or your attorney, you will be charged a fee of $1,500.00 door to door or $250.00 per hour to include travel time, court time, preparing documents, waiting time, phone hearing, etc. whatever is less.

COMPLETING MEDICAL RECORDS OR FORMS: Should you request a form to be completed, or any additional medical records to be completed, the cost is 25 for 1-3 pages, and 50 for more than 3 pages. This include, but not limited to forms such as for disability and FMLA.

COPIES OF MEDICAL RECORDS: Should you request a copy of your medical records, the cost is $5.00 per page up to $30.00.  Payment for your medical records will be due prior or upon receipt and records can be picked up at the office or sent through fax. You may choose to have your records send and a release of information will be required. Please allow at least 2 weeks to prepare medical records.

PHONE CONTACTS AND EMERGENCIES: Office hours are from 9:00am to 5:00pm, Monday through Friday.  If you need to contact the clinician for any reason please call 727-279-5878, leave a voicemail, and a return call will be made within 24 hours during business hours.  You can access emergency assistance by calling the DIAL 2-1-1 or 988 for confidential crisis counseling, along with information and referrals to a crisis center service and other community resources through Crisis Center of Tampa Bay in Brandon. Inpatient services are available at North Tampa Behavioral Health Hospital in Wesley Chapel at (855) 527-2918.

PART II: CONFIDENTIALITY**:****

Anything said in therapy is confidential and may not be revealed to a third party without written authorization, except for the following limitations:

• Child Abuse: Child abuse and/or neglect, which include but are not limited to domestic violence in the presence of a child, child on child sexual acting out/abuse, physical abuse, etc.  If you reveal information about child abuse or child neglect, I am required by law to report this to the appropriate authority.
• Vulnerable Adult Abuse: Vulnerable adult abuse or neglect.  If information is revealed about vulnerable adult or elder abuse, I am required by law to report this to the appropriate authority.
• Self-Harm: Threats, plans or attempts to harm oneself.  I am permitted to take steps to protect the client’s safety, which may include disclosure of confidential information.
• Harm to Others: Threats regarding harm to another person.  If you threaten bodily harm or death to another person, I am required by law to report this to the appropriate authority.
• Court Orders & Legal Issued Subpoenas: If I receive a subpoena for your records, I will contact you so you may take whatever steps you deem necessary to prevent the release of your confidential information.  I will contact you twice by phone.  If I cannot get in touch with you by phone, I will send you written correspondence.  If a court of law issues a legitimate court order, I am required by law to provide the information specifically described in the order.  Despite any attempts to contact you and keep your records confidential, I am required to comply with a court order.
• Law Enforcement and Public health: A public health authority that is authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability; to a health oversight agency for oversight activities authorized by law, including audits; civil, administrative, or criminal investigations; inspections; licensure or disciplinary actions; civil, administrative, or criminal proceedings or action; limited information (such as name, address DOB, dates of treatment, etc.) to a law enforcement official for the purpose of identifying or locating a suspect, fugitive, material witness, or missing person; and information that your clinician believes in good faith establishes that a crime has been committed on the premises.
• Governmental Oversight Activities: To an appropriate agency information directly relating to the receipt of health care, claim for public benefits related to mental health, or qualification for, or receipt of, public benefits or services when a your mental health is integral to the claim for benefits or services, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.
• Upon Your Death: To a law enforcement official for the purpose of alerting of your death if the there is a suspicion that such death may have resulted from criminal conduct;  to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death, or other duties as authorized by law.
• Victim of a Crime: Limited information, in response to a law enforcement official’s request for information about an you if you are suspected to be a victim of a crime; however, except in limited circumstances, we will attempt to get your permission to release information first.
• Court Ordered Therapy: If therapy is court ordered, the court may request records or documentation of participation in services.  I will discuss the information and/or documentation with you in session prior to sending it to the court.
• Written Request: Clients must sign a release of information form before any information may be sent to a third party.  A summary of visits may be given in lieu of actual “psychotherapy/process notes”, except if the third party is part of the medical team.  If therapy sessions involve more than one person, each person over the age of 18 MUST sign the release of information before information is released.
• Fee Disputes: In the case of a credit card dispute, I reserve the right to provide the necessary documentation (i.e. your signature on the “Therapy Consent & Agreement” that covers the cancellation policy to your bank or credit card company should a dispute of a charge occur.  If there is a financial balance on account, a bill will be sent to the home address on the intake form unless otherwise noted.
• Couples Counseling & “No Secret” Policy: When working with couples, all laws of confidentiality exist.  I request that neither partner attempt to triangulate your provider into keeping a “secret” that is detrimental to couple’s therapy goal.  If one partner requests that I keep a “secret” in confidence, I may choose to end the therapeutic relationship and give referrals for other therapists as our work and your goals then become counter-productive.  However, if one party requests a copy of couples or family therapy records in which they participated, an authorization from each participant (or their representatives and/or guardians) in the sessions before the records can be released.
• Dual Relationships & Public: Our relationship is strictly professional.  In order to preserve this relationship, it is imperative that there is no relationship outside of the counseling relationship (ie: social, business, or friendship).  If we run into each other in a public setting, I will not acknowledge you as this would jeopardize confidentiality.  If you were to acknowledge me, your confidentiality could be at risk.
• Social Media: No friend requests on our personal social media outlets (Facebook, LinkedIn, Pinterest, Instagram, Twitter, etc.) will be accepted from current or former clients.  If you choose to comment on our professional social media pages or posts, you do so at your own risk and may breach confidentiality.  I cannot be held liable if someone identifies you as a client.  Posts and information on social media are meant to be educational and should not replace therapy.  Please do not contact provider through any social media site or platform.  They are not confidential, nor are they monitored, and may become part of medical record.
• Electronic Communication: If you need to contact provider outside of our sessions, please do so via phone.

o   Clients often use text or email as a convenient way to communicate in their personal lives.  However, texting introduces unique challenges into the therapist–client relationship.  Texting is not a substitute for sessions.  Texting is not confidential.  Phones can be lost or stolen.  DO NOT communicate sensitive information over text.  The identity of the person texting is unknown as someone else may have possession of the client’s phone.

o   Do not use e-mail for emergencies.  In the case of an emergency call 911, your local emergency hotline or go to the nearest emergency room.  Additionally, e-mail is not a substitute for sessions.  If you need to be seen, please call to book an appointment.  E-mail is not confidential.  Do not communicate sensitive medical or mental health information via email.  Furthermore, if you send email from a work computer, your employer has the legal right to read it.  E-mail is a part of your medical record.

o   Simple Practice Messaging: You will be given a portal where you can access your sessions, make appointment online, access documents and inventories. The system provides with a secure messaging service where sensitive information can be shared. Texting is not a substitute for sessions. Messaging is not monitored 24/7 and should not be used to communicate emergencies. Messages will remain as part of your electronic health record.

• Sessions Outside the Office: From time to time, clients like to meet in an alternate location (i.e. their home, in public, or somewhere more conducive for them).  We may be able to accommodate this request, however, this can put your confidentiality at risk.

PART III: TELEHEALTH CONSULTATION BY SIMPLE PRACTICE*

1. I understand that my health care provider wishes me to engage in a telehealth consultation.
2. I understand that video conferencing is not the same as face to face in that I will not be in the same room with the provider. Telehealth is a proven effective technological method for provision of mental health services.
3. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
5. If there is any failure in connectivity, interrupting the normal flow of the session, a phone call will be used to complete the session if possible.
6. I should treat these sessions just like regular mental health sessions with my provider. I should be on time and adequate clothing is required.
7. My environment is only able to be controlled by me. I should make sure to ensure I am in a private setting and that there will be no to minimal interruptions. Dynamic Psychometrics encourage you to use an independent room with door.
8. I understand I will have the opportunity to have a direct conversation with my provider, during which I will have the opportunity to ask questions regarding this procedure.

Telehealth by SimplePractice is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:

1. Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911 or go to my nearest emergency care unit.
2. Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical services or advice including, but not limited to, emergency or urgent medical services.
3. The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any medical advice or care.
4. I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service.
5. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

PART IV: HEALTH INSURANCE

YOUR INSURANCE COMPANY: By using insurance, I am required to give a mental health disorder diagnosis that goes in your medical record.  The clinical diagnosis is based on your current symptoms even though you may have been previously diagnosed.  We will discuss your diagnosis during session.  Your insurance company will know the times and dates of services provided.  They may request further information to authorize additional services regarding treatment.

IMPORTANT: Some psychiatric diagnoses are not eligible for reimbursement (ie: marriage/couples therapy).  In the event of non-coverage or denial of payment, you will be responsible to pay for services provided.  Dynamic Psychometrics LLC reserves the right to seek payment of unpaid balances by collection agency or legal recourse after reasonable notice to the client.

PRE-AUTHORIZATION & REDUCED CONFIDENTIALITY: When visits are authorized, usually only a few sessions are granted at a time.  When these sessions are complete, we may need to justify the need for continued service, potentially causing a delay in treatment.  If insurance is requesting information for continued services, confidentiality cannot be guaranteed.  Sometimes, additional sessions are not authorized, leading to an end of the therapeutic relationship even if therapeutic goals are not met.

POTENTIAL NEGATIVE IMPACTS OF A DIAGNOSIS: Insurance companies require clinicians to give a mental health diagnosis (i.e., “major depression” or “obsessive-compulsive disorder”) for reimbursement.  Psychiatric diagnoses may negatively impact you in the following ways:

1. Denial of insurance when applying for disability or life insurance;
2. Company (mis)control of information when claims are processed;
3. Loss of confidentiality due to the increased number of persons handling claims;
4. Loss of employment and/or repercussions of a diagnosis in situations where you may be required to reveal a mental health disorder diagnosis on your record.  This includes but is not limited to: applying for a job, financial aid, and/or concealed weapons permits.
5. A psychiatric diagnosis can be brought into a court case (ie: divorce court, family law, criminal, etc.).

It is important that you’re an informed consumer.  This allows you to take charge regarding your health and medical record.  At times, having a diagnosis can be helpful (ie: child needing extra services in the school system or a person being able to receive disability).

Why Clinicians Do Not Take Insurance:  These involve enhanced quality of care and other advantages:

1. You are in control of your care, including choosing your therapist, length of treatment, etc.
2. Increased privacy and confidentiality (except for limits of confidentiality).
3. Not having a mental health disorder diagnosis on your medical record.
4. Consulting with your provider on non-psychiatric issues that are important to you that aren’t billable by insurance, such as learning how to cope with life changes, gaining more effective communication techniques for your relationships, increasing personal insight, and developing healthy new skills.

PART V: CONSENT

1. I have read and understand the information contained in the Therapy Agreement, Policies and Consent.  I have discussed any questions that I have regarding this information with Dynamic Psychometrics LLC.  My signature below indicates that I am voluntarily giving my informed consent to receive counseling services and agree to abide by the agreement and policies listed in this consent.  I authorize Dynamic Psychometrics LLC to provide counseling services that are considered necessary and advisable.
2. I authorize the release of treatment and diagnosis information (as described in Part III, above) necessary to process bills for services to my insurance company, and request payment of benefits to Dynamic Psychometrics LLC.  I acknowledge that I am financially responsible for payment whether or not covered by insurance.  I understand, in the event that fees are not covered by insurance, Dynamic Psychometrics LLC may utilize payment recovery procedures after reasonable notice to me, including a collection company or collection attorney.
3. Consent to Treatment of Minor Child(ren): I hereby certify that I have the legal right to seek counseling treatment for minor(s) in my custody and give permission to Dynamic Psychometrics LLC to provide treatment to my minor child(ren). If I have unilateral decision-making capacity to obtain counseling services for my minor, I will provide the appropriate court documentation to Dynamic Psychometrics LLC prior to or at the initial session.  Otherwise, I will have the other legal parent/guardian sign this consent for treatment prior to the initial session.