RISKS AND BENEFITS OF PSYCHOTHERAPY

Psychotherapy is a choice. Helping you define and achieve therapeutic goals is the purpose of our collaborative work. Psychotherapy often involves learning about yourself – how to recognize, tolerate and respond to your emotional needs – and about the way you relate to other people. Psychotherapy has both benefits and risks. The risks may include experiencing uncomfortable feelings such as sadness, anxiety, confusion or frustration. These feelings typically occur as a result of your discussing difficult aspects of your life, and they are a typical response to the process of therapy.

The benefits are that it often leads to significant reduction of distress, a stronger sense of who you are, enhancement of relationships, closure of un-mourned experiences, and resolution of conflicts. It does require consistent effort and a desire to change on your part. Your role will be to speak openly about your thoughts, feelings or symptoms at your own pace. I will be listening, asking questions, and offering new ways to look at or think about your experiences. If appropriate, I may also recommend that you seek additional services. For some people that means a consultation with a psychiatrist for medication, psychological testing, a visit to your primary care physician, or a support group.

You may end psychotherapy at any time, but I would like to encourage you to bring up any thoughts you might have about the future of our sessions anytime.

OUR FIRST SESSION: The first few sessions typically involve an evaluation of your needs through gathering detailed information. By the end of the evaluation, I will offer you some initial impressions of what our work will include. It is important for you to evaluate this information as well as your level of comfort in working with me. Therapy involves commitment of time, money and energy, so it is crucial that you select a therapist with whom you can connect. If, through this initial evaluation either of us feels that we are not the best match, or that you need another type of service, I will help you with referrals. 

LENGTH AND FREQUENCY OF OUR SESSIONS

The therapy schedule (the length and frequency of your sessions) will depend upon many factors, including your level of distress, individual preference, time limitations, and financial concerns. We will determine an initial plan and make adjustments as we go along, modifying the schedule as needed.

I offer 50-60 minute sessions on a twice-a-week, once-a-week, every-other-week, monthly or on "as needed" basis. I will discuss with you my treatment’s frequency recommendation. If you are late, we will end the session on time. If I am late, you will still receive 55 minutes of my time for the session. This may be provided during that same session period, or added to another session at a later date.

CONTACTING MY OFFICE

You may leave messages (voice or text) for me at any time at my office number:  619-797-6595. This is a Google Voice line that only I have access to but is subject to the interception of third parties. I will return your message as soon as possible within 24 hours of your call. I check my messages at the end of my working day during the weekdays and I return calls up until 6 p.m. Messages left after 6 p.m. Monday through Thursday are returned the following day, and those left after 4 p.m. on Friday are returned the following weekday.  It is important that you leave your phone number when you call as I may not have your number available at the time I respond to your message. It is also important that the phone message you leave is a discreet one in order to maintain your own confidentiality. If your message is urgent, please specify it.

EMERGENCY PROCEDURES

If you are experiencing an emergency please call 911 or go to the nearest emergency room hospital. If you experience a crisis call or text 988 or the San Diego Crisis line at 1.888.724.7240 at any time.

Please note that my office is not an emergency facility and my contact number is not designated to be used in the case of an emergency.

GOOD FAITH ESTIMATE

As of January 2022, health care providers need to make available to clients an estimate of the expected charges for medical services if they don’t have insurance, or choose not to use their insurance; this includes psychotherapy services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency health care services. Therefore, you can ask me for it any time during our treatment, and keep it in your records. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. For questions or more information about your rights to a Good Faith Estimate, visit www.cms.gov/nosurprises.

SESSION FEE

I offer a discounted rate of $180 for 50-60 minute sessions if you pay by cash, Zelle or Venmo. $200 if you pay by credit card, debit card or HSA card.

You are expected to pay the agreed fee on the day of your session, unless other payment arrangements have been made between us. 

INSURANCE

If you are utilizing insurance to pay for your treatment, you are responsible for any applicable deductibles, co-shares and co-payments at the time of service. By signing this contract, you agree that if you have obtained all necessary authorizations from your insurance. If you are using your health insurance: co-payments and co-insurances are also due on the day of your session. Many plans have high deductible rates, meaning the insurance will only cover the cost of the session once the deductible has been met, until then you will pay me my negotiated rate with the insurance company (typically between $120-$180 depending on the insurance) until you reach your deductible allowance. 

You should also be aware that insurance companies require you to authorize me to provide them with a clinical diagnosis.  Sometimes I have to provide additional clinical information such as treatment plans or summaries.  This information will become part of the insurance company files and will probably be stored in a computer.   I will provide your insurance company with only the information required in order to meet their administrative needs.  If you don’t want a diagnosis sent to the insurance company, you can chose to pay for sessions out of pocket. 

By signing this consent form, you agree that if your insurance payment is denied for any reason you are responsible for the payment of therapist’s full fee, even if the insurance determination is made after the services are rendered. If payments are not made, I reserve the right to utilize a collections agency for the means of collecting the payment. In the event of a returned check for insufficient funds, you will be charged $20 in addition to the amount of the check to cover banking fees. Please do not hesitate to notify me if any problem arises during the course of therapy regarding your ability to make timely payments. It is essential that financial difficulties not prevent you from obtaining the help you need. Although I provide a portion of my work at a reduced fee, these arrangements are in high demand. If I am unable to accommodate your financial limitations, I will assist you in finding alternatives for the continuity of your mental health treatment.

CANCELLATION POLICY 

When client and therapist decide to work together they both commit to that appointment time. That means that I will reserve that portion of my limited working hours exclusively for you. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation (unless we both agree that you were unable to attend due to circumstances beyond your control). 

Please note that 24 hrs in advance does not include Holidays or weekends as I don't check my work messages on those days and I can't try to fill that spot. If it is possible, I will try to find another time to reschedule the appointment. If we can’t reschedule for the same week, the full session fee will be charged. 

It is important to note that insurance companies do not provide reimbursement for cancelled sessions.  

PHONE CALLS TO CLIENT OR COLLATERAL CONTACTS

If you have a quick question you can call me and I will be available to speak for a maximum of 10 minutes. Calls over 10 minutes will be charged $10 per every 5 additional minutes. If more time is needed to discuss the issues presented, an additional session might need to be scheduled. The fee for this meeting will be the same as your psychotherapy fee.

TELEHEALTH

Online teletherapy includes consultation, treatment, transfer of medical data, emails, telephone conversations and education using interactive audio, video, or data communications. Teletherapy also involves the communication of medical/mental information, both orally and visually.

The laws that protect the confidentiality of your medical information also apply to teletherapy. Information disclosed during the course of teletherapy is generally confidential, however, there are limits and exceptions to confidentiality just as there are with in person sessions.

Potential risks and limitations of telehealth may include: technical failures; interruption by unauthorized persons; unauthorized access to transmitted and/or stored confidential information; and decreased availability of the therapist in the event of a crisis.

I am currently using a HIPAA compliant platform that requires Google Chrome or Safari browsers. Client will provide the necessary computer, telecommunications equipment and internet access for teletherapy sessions and will arrange a location with sufficient lighting and privacy that is free from distractions or intrusions.

Teletherapy based services and care may not be as complete as face-to-face services. Teletherapy does not provide emergency services. If you are experiencing an emergency situation, please call 911; or proceed to the nearest hospital emergency room for help. Please call 988 for free 24 hour mental health support. 

TREATMENT SUMMARIES

The writing of simple treatment summaries for individual or conjoint treatment will include solely the information regarding number of session attended, frequency of sessions, current treatment goals and treatment progress. The fee is: $120 paid in advance.

LITIGATION LIMITATION

Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to the many matters which may be confidential, it is agreed that should there be legal proceedings (for example, divorce custody disputes, lawsuits, injuries, divorce, etc.), neither yourself, nor your attorney, nor anyone else acting on your behalf will call me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.

FEES FOR DEPOSITIONS, COURT APPEARANCES OR OTHER TESTIMONY: 

In the case of depositions, court appearances or testimony by the therapist in proceedings, whether requested by you or others, will accrue the following fees:  

1.  $800 (eight hundred dollars), for up to four hours of the therapist’s time in preparing for the deposition, court appearances or testimony, which fee shall be paid at least two weeks in advance of the appearance date.
2.  $800 (eight hundred dollars), for up to four hours of the therapist’s time in attending or testifying in person at a Deposition or court appearance, which fee shall be paid at least two weeks in advance of the appearance datE.
3. $200 (two hundred dollars) for up to one hour of the therapist’s time in being available on call or testifying by telephone, which fee shall be paid at least two weeks in advance of the appearance date.
4. Time expended by the therapist in excess of the above, shall accrue fees of $200 (two hundred dollars) per hour or fraction of it.
5. All fees shall be earned regardless of whether the therapist is actually called to testify or whether the Deposition or Court proceeding is cancelled or rescheduled.

PREPARATION OF WRITTEN DOCUMENTS IN ANY LEGAL PROCEEDINGS

Any written reports or other documents that I as the therapist am required to prepare in connection with proceedings regarding yourself, whether requested by you or others, will accrue the following fees:

1. $400 (four hundred and fifty dollars) for up to two hours of the therapist’s time in preparing the report, which shall be paid in advance.
2. Time expended by the therapist in excess of the above, shall accrue fees of $200 (two hundred and sixty dollars) per hour or fraction of it.
3.  All fees shall be earned regardless of whether the request for the report is later cancelled or whether the report is used.

ELETRONIC COMMUNICATION

The U.S. Department of Health and Human Services (HHS) Office for Civil Rights announces a final rule that implements a number of provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009, to strengthen the privacy and security protections for health information established under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

HIPAA Omnibus Rulemaking: (page 5634) —  We clarify that covered entities are permitted to send individuals unencrypted emails if they have advised the individual of the risk, and the individual still prefers the unencrypted email… If individuals are notified of the risks and still prefer unencrypted email, the individual has the right to receive protected health information in that way, and covered entities are not responsible for unauthorized access of protected health information while in transmission to the individual based on the individual’s request. Further, covered entities are not responsible for safeguarding information once delivered to the individual.

I inform that in my private practice I use an email system, Gmail, which is considered by HIPAA regulations as not secure.  Often my clients, or their legal representatives and I also communicate by text messaging - which is also considered by HIPAA as a not secure means of communication. I inform you that by using these means of communication, despite my email accounts and office cell phone being confidential and password protected, there may be some risk that the information shared by email or text message could be read by a third party. If you wish to communicate with me by electronic means, please be advised of the risks involved. By signing this document, you accept the risks explained and give Shirla de Magalhães, permission to communicate with you by email and text messages. Please indicate in written if you wish to not utilize electronic means of communication.

TERMINATION OF TREATMENT

As a therapist, I reserve the right to end therapy at my professional discretion. Reasons for termination include, but are not limited to, untimely payment of fees, failure to comply with treatment recommendations, conflicts of interest, failure to participate in therapy, multiple session cancellations, when client’s needs are outside my scope of competence or practice, or when a client is not making adequate progress in treatment.

Clients have the right to terminate therapy at their discretion at any time. Upon either party’s decision to terminate therapy, I will generally recommend that you participate in one, or possibly more, termination sessions. These sessions are aimed at facilitating positive closure and give both parties an opportunity to reflect on the work that has been done. At that juncture, I will also attempt to ensure a smooth transition to another therapist by offering referrals.

PROFESSIONAL RECORDS AND CONFIDENTIALITY

The laws of California and the standards of my profession require that I keep treatment records.  The information in your medical record may include your personal history, reasons you are seeking treatment, problems, complaints, symptoms or needs, diagnoses and treatment plan. Progress Notes – after each session I write down how you are doing, observations and things you tell me as well as records provided to me from others who have treated or evaluated you such as psychological evaluations and any other information provided to me including information about medications taken, legal matters and billing and insurance information. Process Notes includes pictures of sandtrays, art or play that I have taken during or after session, as well as notes to myself to test hypothesis, help me recall content, etc. Process notes can rarely be accessed by other parties, it requires my permission, which I would only give if I felt it wouldn’t be detrimental to the therapeutic relationship and confidentiality of the client. A separate signed authorization from you would also be required.

When you understand what is in your record and what it is used for, you can make better decisions about who, when and why others should have this information.

I use the information given to me to plan your treatment and keep a record of the significant issues that we address in treatment. I also use the information to coordinate your treatment with other professionals or to provide information to significant others or family members; information is only provided to those that you have given me permission in writing to communicate with regarding your treatment.  You have the right to limit which kind of information I share with others. I will keep our agreement except if it is against the law, or an emergency.

I will maintain treatment records for ten years following termination of treatment.  After ten years treatment records will be destroyed in a manner that preserves confidentiality.

EXCEPTIONS TO CONFIDENTIALITY

Legal exceptions to confidentiality include the following: 

1. When there is risk of imminent danger to you or your child or another person, I am required to take the necessary steps to prevent such danger. e.g.; imminent risk of suicide or violence to others, destruction of property that could endanger others, and grave disability e.g.: inability to provide for one’s own food, shelter, and clothing, or to obtain this help from others.In case of a serious threat of violence, I must also attempt to warn intended victims.
2. When there is reasonable suspicion that a child, elder (65+) or disabled adult has been neglected, sexually or physically abused or is at risk of abuse, I am mandated to report to Child Protection, and/or law enforcement based on information provided by the client or collateral sources. This also includes child behavior suggesting exposure to inappropriate sexual material or activity and exposure to addictive drugs at birth.
3. Sexual intercourse involving a minor is reported to authorities when a minor is under 14 and another party is 14 or older, or if a minor is under 16 and another party is over 21.
4. Emotional abuse and exposure of children to domestic violence may also be reported.
5. Past physical abuse or sexual abuse of the child must be reported.
6. I am also obligated under the law to report to the appropriate authorities any instance where a client discloses that she/he has accessed, streamed, or downloaded material where a child is engaged in an obscene sexual act.  I must also report electronic images of children that depict obscene sexual conduct.   

Psychotherapists often consult with other professionals on cases, but disguise identifying information when doing so, to protect client’s confidentiality. Please indicate in writting if you wish to make restrictions on consultation.

OTHER EXCEPTIONS TO CONFIDENTIALITY

Some exceptions to confidentiality include billing account management, managed care, worker’s compensation claims, and disclosure to insurance and collection agencies. If you plan to bill health insurance to reimburse you for your therapy, please be aware that many companies require private information about you, such as diagnosis, symptoms, treatment and response to treatment. This carries a certain amount of risk to privacy and to future capacity to obtain health or life insurance.

Another exception to confidentiality is if the client is involved in a litigation process. These situations are rare in my practice, but I want you to be aware that if your records are ever requested by the court, you will be notified, and I will claim privilege on your (client’s) behalf. However, if a valid Court order is issued for release of health records I am bound by law to comply with such request.  In this case, only the essential information will be disclosed. It is important for you to know that if you place your mental status issue in a litigation process initiated by you, the defendant may have the right to obtain your therapy records as well, and/or my testimony.

Emergency situations may also be an exception to confidentiality. If there is an emergency with you or your child during our work together where I become concerned about your personal safety, I may contact the person whose name you have provided as the Emergency Contact on my caregiver’s information form.

If a situation occurs that requires that I share information without your written permission, I will make every effort to fully discuss it with you before taking any action.  In most situations, in order to release any information to another party, I will ask that you sign an Authorization to Release Information. You may revoke your authorization at any time.

No Secrets Policy: In Family Therapy, or when different family members are seen individually by the same therapist, confidentiality and privilege do not apply between the parties.

In the event of my incapacitation, disability or death, I have authorized my colleague, Isabelle George, LMFT to have access to my client files and my appointment book.  As a licensed marriage and family therapist, she is bound by confidentiality as well. Ms. George can be reached at 619-784-3884

OUR PROFESSIONAL RELATIONSHIP AND SOCIAL MEDIA

Our relationship is professional and therapeutic. In order to preserve this relationship, it is imperative that we not have any other type of relationship. If I encounter you in a public setting, in order not to reveal your identity, I will not acknowledge your presence unless addressed by you first.

I do not accept friend or contact requests from current or former clients on any social media site. Adding clients as friends or contacts on these sites can compromise confidentiality and privacy of both the therapist and the client and can blur the boundaries of the professional relationship.

PROFESSIONAL RECORDS

You are entitled to receive a copy of your medical record unless I believe that receiving that information would be emotionally damaging.  Because these are professional records, they can be misinterpreted or upsetting to untrained readers.  If you wish to see your records or receive a copy of your records, I require written notice to that effect, and I would expect to discuss your request with you in person.  I typically provide a treatment summary when there is a request for records. 

If I deny you access to your records, you can request to speak with an independent mental health professional about the situation.  Your request for independent review of your original request for records should also be made in writing.  If you are provided with a copy of your medical record information, I may charge a fee for any costs associated with that request.

If you believe that the information I have about you is incorrect or incomplete, you may ask me to amend that information.  It is my practice to accept this sort of request in writing, and that any information you may wish to add to your record also be provided to me in written form.  

You have the right to request a restriction or limitation on the health information I disclose about you for treatment, payment, or health care operations. As noted above, I will not release your confidential information without your written permission. Any restrictions to your Authorization To Release Information should be specified on the Authorization. 

You have the right to request that I communicate with you only in certain ways.  For example, you can ask that I not leave a telephone message for you, or that I only contact you at work or by mail.

You have the right to a paper copy of this document. I reserve the right to change my policies as outlined in this document-if they change you will be informed of that change and will be provided with a copy of the updated form.

MEDIATION & ARBITRATION

By signing this office policy contract, you are agreeing that all disputes arising or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by our mutual agreement, and the costs of such mediation shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in San Diego County, California in accordance with the rules of the American Arbitration Association which is in effect at the time the demand for arbitration is filed. Lawsuits are something that no one anticipates and everyone hopes to avoid.

The method of resolving disputes by arbitration is one of the fairest systems for both parties and psychotherapists. Arbitration agreements between health care providers and their patients have long been recognized and approved by the California Courts. You may still call witnesses and present evidence. Each party selects one arbitrator, who then select a third, neutral arbitrator. These three arbitrators hear the case. This agreement typically helps to limit the legal costs for both parties and psychotherapists. Further, both parties are spared some of the rigors of trial and the publicity that may accompany judicial proceedings. My goal, of course, is to provide psychotherapy care in such a way as to avoid any such dispute. I know most problems begin with communication. Therefore, if you have any questions about your care, please ask.

QUESTIONS OR COMPLAINTS

The Board of Behavioral Sciences receives and responds to complaints
regarding services provided within the scope of practice of (marriage and family therapists, licensed educational psychologists, clinical social workers, or
professional clinical counselors). You may contact the board online at
www.bbs.ca.gov, or by calling (916) 574-7830.

Please feel free to ask me any questions you have before signing below. Your signature indicates that you have fully read and understood the information listed on the Informed Consent, Office Policy and Legal Engagement for Shirla de Magalhães, LMFT, you agree to abide by its terms during our professional relationship and thereafter, and that you authorize Ms. Magalhães to provide assessment, evaluation and treatment for yourself.

Acknowledgement

I have reviewed this Informed Consent, Office Policy and Legal Engagement. I likewise understand my Client's Rights set in this form.

I accept this agreement and consent to therapeutic services.