Transformative Therapy LA

Jacqueline Bocian, M.A., L.C.S.W., License #80469

 

INFORMED CONSENT FOR PSYCHOTHERAPY TREATMENT

Welcome:

Welcome to Transformative Therapy LA. This document contains important information about the psychotherapeutic process, my professional services, and my business practices. Please read it carefully before you sign it. We can discuss any questions you might have before you sign, or anytime during our therapeutic relationship.

Nature of Psychotherapy:

Psychotherapy is a collaborative process. My personal commitment to you is that I will make every effort to provide you with a safe, nonjudgmental, caring interaction each session. Together, we will explore the thoughts, emotions, and behaviors that may be causing you distress, or which you hope to change. Our primary goal will be to help you progress toward living a fulfilled and meaningful life. A key factor in psychotherapy is the nature of the relationship between therapist and client. I will seek to build an interpersonal relationship with you in which you are at ease discussing your innermost thoughts, feelings, and your behaviors in an open and honest manner. My role will be to offer you my knowledge, the benefits of my training, my emotional support, positive regard, encouragement, and guidance.

Psychotherapy has both benefits and risks. Risks may include temporarily experiencing an increase in uncomfortable feelings. This may occur because the process of psychotherapy often requires discussing the unpleasant or previously unexamined aspects of your life. During evaluation or therapy, remembering or talking about distressing events, feelings, or thoughts can result in your experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, anxiety, depression, insomnia, etc. However, psychotherapy has been shown to yield benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress, and resolutions to specific problems. But, there are no guarantees about what you will experience. I am always open to discussing your feelings and thoughts about the process of therapy. If at any time you feel that I am unable to help you, or that you would prefer working with another psychotherapist, please feel free to discuss these feelings openly with me, and together, we will find a resolution.

Process of Psychotherapy:

During our first few sessions, I will be gathering information about you, your family, the reasons for which you are seeking therapy, and assessing your needs and your strengths. By filling out the initial Intake Form in as complete a manner as possible, you will help us move more efficiently into the core issues. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and behavior. To be most successful, you should dedicate yourself to working outside of sessions on issues we discuss during our sessions. I will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you  to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it may be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results.

During the course of therapy, I am likely to draw on various psychological approaches according to the problem that is being treated and my assessment of what will best benefit you. These approaches include, but are not limited to: somatic, cognitive-behavioral, existential, gestalt, psychodynamic, or psycho-educational.

Confidentiality:

In general, the privacy of all communications between a patient and a psychotherapist is protected by law. The session content and all materials relevant to your treatment will be held confidential unless you request in writing to have all or portions of such content released to a specifically named person/persons But there are legally imposed limitations on the privilege of confidentiality accorded the client. These are itemized below:

1. If a client threatens or attempts to commit suicide or otherwise conducts him/herself in a manner in which there is a substantial risk of incurring serious bodily harm;

2. If a client threatens grave bodily harm or death to another person;

3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years;

4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses;

5. Suspected neglect of the parties named in items #3 and # 4;

6. If a court of law issues a legitimate subpoena for information stated on the subpoena;

7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

Occasionally, I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name or other identifying information.

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it is most appropriate not to engage in any lengthy discussions in public or outside of the therapy office. I will not refer to our therapeutic relationship if I am ever asked by others as to how I know you.

I do not accept friend requests from current or former clients on social networking sites such as Facebook or LinkedIn. I believe that adding clients as friends on these sites and/or communicating via such sites can compromise their privacy and confidentiality. For this same reason, I request that clients not communicate with me via any interactive or social networking websites.

Electronic Media:

It is very important to be aware that computers and unencrypted email, texts, voicemails, and faxes can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. Emails, texts, voicemails, and faxes, in particular, are vulnerable to such unauthorized access due to the fact that servers or communication companies may have unlimited and direct access to all emails, texts, voicemails and faxes that go through them. While data on my laptop is encrypted, emails, texts and faxes are not. It is always a possibility that faxes, texts, and email can be sent erroneously to the wrong address. My laptop is equipped with a firewall, virus protection and a password, and I back up all confidential information from my computer on a regular basis onto an encrypted hard drive. However, my voicemails are not encrypted. Please notify me if you decide to avoid or limit, in any way, the use of email, texts, cell phone calls, phone messages, or faxes. If you communicate confidential or private information via unencrypted email, texts or fax or voicemail messages, I will assume that you have made an informed decision, and will view it as your agreement to take the risk that such communication may be intercepted.

Right to Review Records:

Both California law and the standards of the psychotherapy profession require that I keep treatment records for at least seven years after the end of treatment. Please note that clinically relevant information from emails, texts, and faxes are part of the clinical records. Unless otherwise agreed to be necessary, I retain clinical records only as long as is mandated by California law. If you have any concerns regarding your treatment records, please discuss them with me. As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when I assess that releasing such information might be harmful in any way. In such a case, I will provide the records to an appropriate and legitimate mental health professional of your choice.

Termination of Treatment:

Ideally, therapy ends when we agree that your treatment goals have been achieved. If you do not believe that you are receiving benefit from therapy, you have the right to terminate your therapy at any time, for any reason, without legal or financial obligation (except for fees already incurred). Other situations that warrant termination include: regularly becoming enraged or threatening during a session; bringing a weapon onto the premises; persistent drug abuse; arriving under the influence of drugs or alcohol; disclosing illegal intentions or actions.

Fees and Forms of Payment:

My fee is $250.00 per 50-minute session. I do not take insurance; therefore, you are responsible for paying the full fee at the end of each session, unless an arrangement for monthly billing has been made. You may pay via cash, check, Zelle, PayPal, or credit card. You may also choose to authorize me to charge your credit card automatically at the end of each session. If you choose this option, please complete and submit to me the form on my website entitled “Authorization for Payment by Credit Card for Psychotherapy Services.”

Insurance Reimbursement:

Many insurance plans offer coverage for psychotherapy services. If yours does, upon request I will be happy to provide you with a monthly statement that you can submit to your insurance company for reimbursement purposes. If you do choose to submit claims to your insurance company, they will most likely require you to authorize me to provide a clinical diagnosis and other ongoing treatment information such as treatment notes or summaries of treatment. There is no guarantee that your insurance company will keep such information completely confidential once they receive it from me. If you do decide to use your insurance, you are hereby authorizing me to release requested information to your insurance company.

Mediation and Arbitration:

All disputes arising out of, or in relation to, this agreement to provide psychotherapy services shall preferably first be referred to mediation before the initiation of arbitration or litigation. The mediator shall be a neutral third party chosen by agreement of the client(s) and myself. The cost of such mediation, if any, shall be split equally, unless otherwise agreed upon. In the event that mediation is unsuccessful or not an agreed-upon option, any unresolved controversy related to this agreement should preferably be submitted to and settled by binding arbitration, in accordance with the rules of the American Arbitration Association that are in effect at the time the request for arbitration is filed. Please note that neither mediation or arbitration is mandatory.

How to Reach Me:

The best way to reach me is to send me a text or leave a message on my voicemail at (310) 597-0387. I will do my very best to respond to you within a 24-hour period. Messages left on weekends or holidays may not be responded to until the next business day.

Emergencies:

If you are unable to reach me and feel that you cannot wait for me to return your call, please contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, such as on a vacation or at a professional conference, I will provide you with the name of a colleague to contact, if necessary.

Scheduling and Cancellations:

You are responsible for coming to your session on time and at the scheduled time. Sessions last for 50 minutes. If you are late, we will still have to send on time and not run over into the next client’s session. If you miss a session without canceling, or cancel with less twenty-four (24) hours’ notice, you will be charged for that session, unless we both agree that the session was cancelled due to circumstances beyond your control.

I have read the Informed Consent for Psychotherapy Treatment carefully. I understand what / read, and agree to comply with all terms of this agreement.