This consent form contains important information about my professional services, business policies, and the Health Insurance Portability and Accountability Act (HIPAA). Under the HIPAA law, I am required to provide you with a Notice of Privacy Practices for use and disclosure of Protected Health Information (PHI). After reviewing both the consent for treatment and Notice of Privacy Practices forms, please sign below, which will then represent an agreement between us. You have the right to revoke this agreement at any time in writing. I will honor the revocation unless I have already acted upon your previous authorization, or if there are obligations imposed on me by your health insurer in order to process or substantiate claims, or if you have not satisfied any financial obligations you incurred from my services.
The purpose of psychotherapy is to help clients address various problems or issues within a supportive environment. Successful psychotherapy requires clients to make an active effort. This entails working on issues that are talked about during sessions, outside the office during everyday activities.
Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings such as sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people, including better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience. During treatment, if you have questions regarding your treatment or my procedures, we should discuss them at that time.
The initial process of psychotherapy involves an evaluation which usually lasts for approximately 2-4 sessions. This period of time allows me to gain an understanding of your issues and how we can tailor treatment goals to address them most effectively.
Billing and Payment
My hourly fee is $175 for the initial session, $150 for 60 minute sessions, $135 for 45 minute sessions, $90 for 30 minute sessions, and $150 for 45 minute family sessions. You will be expected to pay for each session at the time services are rendered, unless we agree to other arrangements. I charge this amount for other professional services you may need, though I break down the hourly cost if I work for periods of less than one hour. Other services may include telephone conversations, consulting with other professionals with your permission, preparation of treatment summaries, and the time spent performing other services you may request of me.
Payment schedules for unusual financial hardship are available upon request. 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 payment. In these situations, I only release the client’s name, nature of services provided, and the amount due.
If you have an insurance policy, it will usually provide some coverage for mental health services. I will bill electronically for services rendered and be of whatever assistance I can to help you receive the benefits to which you are entitled; however, you are responsible for full payment of my fees. You should also be aware that the contract with your insurance company requires that you authorize me to provide it with information such as diagnostics, treatment plans, or copies of your Clinical Record. I attempt to release the minimum information necessary for the purpose requested. Some insurance companies will not allow me to provide services after your benefits have ended. In such cases, I will assist you in finding another provider who can help you continue your treatment.
Once an appointment is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation. There may be exceptions to this rule if we both agree that you were unable to attend due to circumstances beyond your control.
In general, the law protects the privacy of all communications between a patient and psychologist. I can only release information about our work to others with your written permission. There are a few exceptions.
On occasion, I may wish to consult with other health/mental health professionals. During these consultations, I make every effort to avoid revealing the identity of my clients. The other professionals are legally bound to maintain confidentiality. If you do not object, I will not discuss these consultations with you unless I feel it is important to our work together. I will note all consultations in your Clinical Record.
In the event that I am involved in a legal proceeding, you have the right to prevent me from disclosing information regarding your treatment. However, there may be times when a judge orders my testimony when he or she deems it crucial to the situation. This may occur during proceedings involving child custody or your emotional condition.
If a government agency requests the information for health oversight activities, I may be required to provide it to them. Additionally, if a client files a complaint or lawsuit against me, I may disclose relevant information regarding the client in order to defend myself. Finally, if you file a worker’s compensation claim and I am rendering treatment in accordance with the provisions of Illinois Worker’s Compensation law, I must, upon appropriate request, provide a copy of your records to your employer or the appropriate designee.
There are also some situations where I am legally obligated to take actions which I believe are necessary to protect others from harm. In these situations, I may reveal information about a client’s treatment. For example, if I believe that a child, disabled, or elderly person is being abused, I must file a report with the appropriate state agency. Another example, if I believe that a client is threatening serious bodily harm to another, I am required to take protective actions. This may involve notifying the potential victim, contacting the police, and/or seeking hospitalization for the client. If the client threatens to harm him/herself, I am obligated to seek hospitalization for him/her or contact others who can provide protection. I will make every effort to fully discuss the situation with you before taking action.
For individuals residing in a nursing or residential home, this consent permits me to consult with those directly involved in your care (i.e. attending physician, facility staff, etc.). These disclosures ensure comprehensive care and safety. I will note these disclosures in your Clinical Record.
Following the enactment of Public Act 098-0063, the Illinois Firearm Concealed and Carry Law, all physicians, clinical psychologists, and qualified examiners are required to notify the Department of Human Services (DHS) within 24 hours of determining a person to be “a clear and present danger” to themselves or others, Developmentally Disabled, or Intellectually Disabled.
Confidentiality for Couples and Families
Partners and family members may attend a counseling session together (conjoint session). If requested, individual members may also attend private sessions alone. Whenever a member attends a private session, his or her disclosures are respected as confidential and every effort will be made by your counselor to keep confidentiality during subsequent conjoint sessions. However, keep in mind that inadvertent breeches in this type of confidentiality are possible during conjoint sessions and that you agree to the risk.
Electronic Communication & Social Media
Social Media: I do not accept contact requests from current or former clients on any social networking site. I believe that adding clients as friends or contacts on these sites can compromise our confidentiality and our respective privacy. It may also blur the professional boundaries of our relationship. You are welcome to follow or “like” my posts on social media but please be aware I will not respond to any of your responses as it could potentially compromise confidentiality. If you have any questions about this, feel free to bring it up so we can discuss it further.
Email/Texts: Outside of our sessions, I prefer to interact via telephone. Please do not contact me by email/texts as it not completely secure or confidential. If you do email/text me for any reason, please be advised that all emails are retained in the logs of your and my Internet Service Provider. You should also know that any emails/texts I receive from you and any responses that I send to you become a part of your legal record. There may be times when you request I communicate with other individuals (i.e. members of your treatment team or family members) in regard to your treatment. If you give me permission to do so electronically or by text, please remember that I cannot guarantee these communications are confidential or secure.
I am required by law and the standards of my profession to maintain Clinical Records, which contain Protected Health Information. These records include information about your reasons for seeking treatment, a description of ways your problem impacts your life, your diagnosis, treatment goals, progress towards goals, medical and social history, treatment history, past treatment records I receive from other providers, billing records, and reports to others such as your insurance carrier. Additionally, I also keep a separate file containing Psychotherapy Notes. These notes aid me in providing you with effective treatment and may include sensitive information that is unnecessary to be included in your Clinical Record. Insurance companies do not have access to Psychotherapy Notes without your authorization and cannot require you to provide such authorization as a condition of coverage or penalize you for your refusal.
You may access your records by submitting a request in writing. Due to the professional nature of your treatment records, the contents may be misinterpreted or upsetting to untrained readers. To address this, my general policy is to prepare a treatment summary and recommend you review your summary/records in my presence so we can discuss the contents. If you choose, I can also send to them to another mental health professional of your choice.
Under HIPAA provisions, you are entitled to several rights. These rights include requesting I amend your record, requesting restrictions on what information from your Clinical Record is disclosed to others, requesting an accounting of most disclosures of Protected Health Information you have neither consented to nor authorized, determining the location to which protected information disclosures are sent, and having any complaints you make about my policies and procedures recorded in your records.
Minors and Parents
If you are under twelve years of age, the law provides your parents with the right to examine your treatment records. For those clients between the ages of twelve and eighteen, parents cannot examine records unless their child provides consent and/or if I find no compelling reason for denying access. Since parental involvement is often crucial to the success of treatment, it is my policy to request an agreement from parents and children allowing parents access to certain information. This includes general information about the progress of treatment and attendance. Any other communication requires your consent unless I feel there is high risk that you will seriously harm yourself or others. Prior to giving them any information, I will discuss the matter with you and if possible, do my best to handle any objections you may have to what I am prepared to discuss.
Your signature below indicates you read the information in this contract and agree to abide by its terms during our professional relationship. It also serves as an acknowledgement you received the HIPAA Notice form described above.