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  • Contract for Professional Psychotherapy Services

  • Welcome to Insight Psychotherapy Group (“IPG”). Below is essential information about our policies that are designated to facilitate and optimize your treatment. Please read it carefully and ask your therapist any questions you might have so that you can be fully informed and prepared as you begin your treatment. When you sign this document, it will represent an agreement between you and IPG.

    Psychological Services

    Psychotherapy varies depending on the needs and personality of the client, the psychotherapist, and the problems you are experiencing. There are many different techniques that may be helpful in dealing with the problems that you hope to address.

    Psychotherapy calls for an active effort on your part both during and in between sessions. Psychotherapy can have benefits and risks since therapy often involves discussing difficult aspects of your life. As a result, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, resolutions to specific problems, and reductions in feelings of distress. However, there are no guarantees of what you will experience.

    Initial Visit

    Your first, and possibly second session, will involve an evaluation of your needs, at which time your therapist will discuss his/her treatment recommendations. During this time, you will have an opportunity to decide if your therapist is the best person to provide the services you need to meet your treatment goals. If psychotherapy is initiated, your therapist will usually schedule one 45-minute session per week. If you decide to discontinue your work with your therapist, he/she can help you secure an appropriate consultation with another qualified mental health professional at IPG.

    Confidentiality

    In general, the law protects the privacy of all communications between a patient and a therapist, and your therapist can only release information with your permission. However, there are a few exceptions in which your therapist is legally obligated to act to protect others from harm, even if it requires that your therapist reveal information about a client’s treatment.

    These exceptions include: 1) If you reveal information related to the abuse or neglect of a child, dependent adult, or elderly person, then the appropriate authorities may be contacted. 2) If you threaten bodily harm or death to yourself, your therapist may notify the appropriate authorities and appropriate others (e.g., family member, inpatient hospital staff). 3) If you threaten bodily harm or death to others, your therapist may notify the appropriate authorities and/or the intended victim. 4) If there is clear and imminent danger to you or the public, or there is probable cause to believe that a potential victim is likely to be in danger, your therapist may notify the appropriate authorities and/or the intended victim(s). In most legal proceedings, you have the right to prevent your therapist 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 subpoena the testimony of your therapist if he/she determines that the issues demand it. Your therapist may occasionally find it helpful to consult with other healthcare professionals about a case. During the consultation your therapist will make every effort to avoid revealing the identity of any patient details. The consultant is also legally bound to keep the information confidential.

    Confidentiality Issues with Children & Adolescents

    If you are a parent or guardian of a child or adolescent receiving psychotherapy, your therapist will involve you in helping your child to the fullest extent possible. However, the content of your child’s sessions must be confidential to enable your child to confide in your therapist and for therapy to be effective. In the treatment of adolescents, there are many issues that therapists have no opportunity to address unless the adolescents trust that communication in therapy will not be shared with parents or guardians. These issues may include the use of cigarettes, alcohol, drugs, sexual concerns or behavior, gang involvement, cutting classes or truancy, school failure, unauthorized time with peers, and/or criminal activity. As your adolescent’s therapist, he/she will work to help him or her behave in ways that are not self-destructive, and that do not limit his or her options for the future. If any of these issues rise to the level of serious, imminent danger to self or others, parents and/or the authorities will be notified.

    Professional Records

    The laws and standards of the mental health profession require that IPG maintain treatment records. Your records are stored on an offsite server that is HIPPA compliant. You are entitled to request a copy of your records unless your therapist believes that seeing them would be emotionally damaging, in which case your therapist will review them with you or send them to another mental health professional of your choice to allow you to review and discuss the contents.

    Fees & Insurance

    Your fee for psychotherapy will be agreed-upon prior to your first session. IPG is in-network with insurance companies. If you are utilizing your insurance, please be aware that all insurance companies require IPG to provide a clinical diagnosis. In some cases, we are required to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases), and said information will be on file with the insurance company. Although all insurance companies claim to keep such information confidential, IPG has no control over what they do with the information once the information has been released. Your therapist will inform you if any information beyond a diagnosis code is required.

    IPG will check your benefits and notify you of any co-pays, co-insurance or deductibles.  Please be aware that insurance companies often state "estimation of benefits is not a guarantee of payment", therefore, we will collect payment based upon the initial benefits check information but may need to readjust your payment after the Explanation of Benefits is received by IPG.

    Other services may include report writing, telephone conversations lasting longer than 15 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and time spent performing any other service you may request. If you become involved in legal proceedings that require your therapist’s participation, you will be expected to pay for your therapist’s time including preparation, transportation, and attendance costs.

    Sessions are payable by cash, check or credit card. If a check is returned unpaid you will be responsible for the returned check fee of $25.00, and any bills that are 90 days past due may be turned over to a collection agency. Your therapist will inform you before IPG takes this measure so that you will have the opportunity to resolve your outstanding balance.

    Inasmuch as IPG offers an affordable sliding scale fee, there is the possibility that psychotherapy session fees will be raised to keep up with rising inflation and other administrative costs of doing business.  If and when this does occur, you will be provided with 30 days notice.

     

  • For all services provided by IPG, payment is due at the time service is rendered unless prior arrangements have been made. ​The agreed upon fee is 

  • Cancellation Policy

    Once an appointment is scheduled you will be expected to pay for it unless you provide at least 24 hours’ advance notice of cancellation. ​If you must cancel and wish to reschedule your therapist will attempt to find another time to reschedule your appointment. However, there are certain circumstances in which notice is not possible, such as a medical emergency, inclement weather, or a natural disaster. Missed appointments for non-emergency reasons will result in a cancellation fee. In the case of utilizing insurance, ​please keep in mind insurance companies will not reimburse for no shows or late cancellations. As a result you are financially responsible for paying the full fee for each missed session​.

    Contacting Your Therapist

    Your therapist is often not immediately available by telephone. When your therapist is unavailable calls are answered by a confidential voicemail that your therapist monitors frequently during business hours. Your therapist will make every effort to return your call on the same day, except for weekends and holidays. If your therapist will be unavailable for an extended period, he/she will provide you with the name of a colleague to contact if you need immediate assistance. If you are unable to reach your therapist and it is an emergency dial 911 or go to the nearest emergency room.

    E-mail and Texting

    E-mail and text messages can be useful in addressing non-urgent matters, such as re-scheduling appointments. However, these forms of communication and their responses may be delayed, inadvertently missed, or not received due to technical issues. Additionally, e-mails and texts can also be misinterpreted because we are unable to see one another’s expressions or gestures. Furthermore, messages on your smartphone, tablet and computer have inherent privacy risks due to a lack of encryption. ​Should the exchange of information via e-mail, iMessage, text (SMS) message or another electronic method be initiated, you acknowledge that these forms of communication are not fully secure.

    Social Media

    Due to concerns about confidentiality and privacy, your therapist will not accept friend or contact requests from current or former clients on social networking sites. Because social networking sites, including Facebook, Instagram, SnapChat, Twitter, and LinkedIn are not secure, your therapist will not respond to messaging or wall postings from clients on these sites to maintain your confidentiality as well as your therapist’s individual privacy.

    Freedom to Withdraw

    You have the right to end therapy at any time. If desired your therapist can provide you with the names of other qualified psychotherapists at IPG.

    Litigation Limitation

    Due to the nature of the therapeutic process, and the fact that it often involves making a full disclosure with regard to many matters that may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to, divorce and custody disputes, injuries, lawsuits, etc.), neither you (the patient) nor your attorney, nor anyone else acting on your behalf will call on IPG to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested. If, however, you become involved in legal proceedings that require your therapist’s participation, you will be expected to pay for all professional time, including preparation and transportation costs, even if your therapist is called to testify by another party. Because of the difficulty of legal involvement, IPG will assess an hourly charge of $250 for preparation, travel, and attendance at any legal proceeding.

    Consent

    I authorize and request that my therapist carry out psychological examinations, treatment procedures, which now or during my care as a patient are advisable. I understand that I can ask questions regarding the purpose of these procedures and that I have the right to be aware of all aspects of the working relationship. I understand that I have the right to participate actively in all aspects of treatment planning and that I can discontinue treatment at any time. I also understand that while the course of therapy is designed to be helpful, it may at times be difficult and uncomfortable.

    Notice to Consumers

    The California Board of Behavioral Sciences receives and responds to questions and complaints regarding the practice of psychotherapy. If you have questions or complaints you may contact the Board at www.bbs.ca.gov, by calling 916-574-7830, or writing to the following address: Board of Behavioral Sciences, 1625 N, Market Blvd., Suite S-200, Sacramento, CA 95834.

    I have read IPG’s Contract for Professional Psychotherapy and understand my rights and responsibilities. I consent and agree to participate in psychotherapy. I understand that my participation is voluntary and can be discontinued at any time.

  • Therapist Name:

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  • If client is under 18 years of age:

  • Clear
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