Informed Consent for Psychotherapy

This agreement is intended to provide you with important information regarding the practices, policies and procedures of Waxhaw Anxiety Care and to clarify the terms of the professional therapeutic relationship between you and your therapist. Any questions or concerns regarding the contents of this agreement may be discussed with your therapist prior to signing this agreement.  

Waxhaw Anxiety Care is owned and operated by M. William Futtersak, Ph.D., a clinical psychologist licensed in New York (Lic. # 010017) and in North Carolina (Lic. # 5382).  Dr. Futtersak earned his doctorate in psychology from S.U.N.Y. Stony Brook and completed his clinical internship at the Veterans Administration Medical Center in Northport, NY.. He is a member in good standing of The National Register of Healthcare Psychologists. Dr. Futtersak's practice focuses mainly on the treatment of adults and adolescents with anxiety disorders, however, his training and experience qualifies him to treat a wide range of psychological and behavioral problems. You have the right to inquire about any of Dr. Futtersak's credentials, education, and experience.

Psychotherapy is a process in which you and your therapist will discuss a variety of issues, events, experiences and memories for the purpose of creating positive change. Keep in mind, Psychotherapy is a joint effort between you and your therapist and progress and success may vary.   

Participating in therapy may result in a number of benefits to you, including, but not limited to reduced stress and anxiety, improved interpersonal relationships, increased comfort in social, work, and family settings, and increased self-confidence. Such benefits require effort on your part, including an active participation in the therapeutic process. There is no guarantee that therapy will yield any or all of the above benefits.

Participating in therapy may also involve some discomfort including remembering and discussing unpleasant events, feelings and experiences.  During the therapeutic process, some clients find that they feel temporarily worse before they feel better. This is generally a normal course of events. Your therapist will work with you to provide the most effective treatment possible.  Dr. Futtersak is committed to working with you in your best interest to facilitate your positive growth and increased functioning.

I understand that, as a client of Waxhaw Anxiety Care, I have the following rights and responsibilities.

• I have the right to psychotherapeutic treatment that is deemed effective, culturally competent, and respectful of my dignity and my privacy.
• I have the right to receive or refuse treatment services without fear of discrimination, abuse, or exploitation.  
• I have the right to participate in the development of an individualized treatment plan and the right to request access to my clinical record.
• I understand that Dr. Futtersak and Waxhaw Anxiety Care is committed both ethically and legally to protecting children's emotional and physical safety by reporting suspected child abuse or neglect.
• I understand that, for my treatment to be most effective, I need to be an active participant in my psychotherapy.  It is my responsibility to attend treatment sessions consistently, report my personal information accurately and honestly, and make efforts to remain open to treatment recommendations and therapeutic homework assignments.
• I understand that Dr. Futtersak will make other treatment recommendations to me if services offered at Waxhaw Anxiety Care are not my best option for care.
• I have the right to address, either verbally or in writing, any concerns or dissatisfactions that I might have with services at Waxhaw Anxiety Care directly to Dr. Futtersak or to any other staff member at Waxhaw Anxiety Care.  All concerns will be addressed in a direct, non-judgmental, and timely manner.
• I understand that I am encouraged to make inquiry to my therapist of any questions and concerns regarding my care as they arise.

Information disclosed by you in the course of psychotherapy is confidential and will not be released to any third party without your written authorization, except where required or permitted by law.

Exceptions to confidentiality, include, but are not limited to the following:

(a) there is reasonable suspicion of past or present child, dependent adult, or elder abuse,

(b) when a client makes a serious threat of violence towards a reasonably identifiable person or entity 

(c) when a client expresses serious intent to harm him/her self

(d) another health care provider is providing emergency services

*Please, note that some Protected Health Information (PHI) may be disclosed for billing purposes such as when you ask Waxhaw Anxiety Care to process payment for your treatment through your health insurance carrier.

Court Procedings: Waxhaw Anxiety Care does not seek to become involved in legal/court procedings of any type.  However, please, be aware that should a subpoena or other court order be received by Waxhaw Anxiety Care, our staff will likely be subject to the stipulations of that legal request.

I understand that I have the following rights with respect to telemedicine:

1. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.

2. I understand that Waxhaw Anxiety Care, making use of the most secure electronic means available, will make every effort to protect my confidentiality and privacy of my therapy sessions conducted on line by either telephone or video communication.  However, I understand that information disclosed by video, telephone, or text may be subject to unintended disruption outside the control of Dr. Futtersak and Waxhaw Anxiety Care.  I will make every effort to communicate  with Waxhaw Anxiety Carei nformation that I deem sensitive only via electronic means recommended to me by Dr. Futtersak and his staff.

2. The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.