Informed Consent for Psychotherapy
The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me.
We will be working together as a team to define your treatment goals ans the types of therapeutic interventions that will be most effective in helping you achieve those goals.
PATIENT RIGHTS:
1. You have the right to ask any questions about the procedures used in therapy. If you wish, I will explain the usual methods of practice to you.
2. You have the right to refuse the use of any therapeutic techniques.
3. You have the right to learn about alternative methods of treatment and your I will
gladly discuss these, at your request, during our work together.
4. You have the right to end your psychotherapy at any time without prejudice. If you wish, I will do my best to assist you in finding a referral to another practitioner.
CONFIDENTIALITY:
All information disclosed within sessions and the written records
pertaining to those sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law.
CONSULTATION:
From time to time, I may consult with other professionals in their areas of expertise in order to provide the best treatment for you. Each client's identity remains completely anonymous and confidentiality is fully maintained.
SOCIAL MEDIA AND PUBLIC INTERACTION:
To maintain confidentiality and an appropriate patient/therapist relationship, I
will not address you in public places (without you initiating contact), accept, or respond to any request on any and all social networking sites, or engage in any activities that are not of a therapeutic nature. Mental health professionals believe that adding clients as friends on these sites and/or communicating via such sites is likely to compromise their privacy and confidentiality. For this same reason, this provider requests that clients not communicate with with me via any interactive or social networking web sites.
WHEN DISCLOSURE IS REQUIRED OR MAY BE REQUIRED BY LAW:
Some of the circumstances where disclosure is required or may be required by law are: where there is a reasonable suspicion of child, dependent, or elder abuse or neglect; where a client presents a danger to self, to others, to property, or is gravely disabled; or when a client's family members communicate to your provider that the client presents a danger to others.
Disclosure may also be required pursuant to a legal proceeding by or against you. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by your provider.
In couple and family therapy, or when different family members are seen individually, even over a period of time, confidentiality and privilege do not apply between the couple or among family members, unless otherwise agreed upon. Your provider will use his/her clinical judgment when revealing such information. Your provider will not release records to any outside party
unless s/he is authorized to do so by all adult parties who were part of the family therapy, couple therapy or other treatment that involved more than one adult client.
E–MAILS, CELL PHONES, COMPUTERS, AND FAXES:
It is very important to be aware that computers and unencrypted e-mail, texts, and faxes communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. E-mails, texts, 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 e-mails, texts and faxes that go through them. E-mails and fax are not. It is always a possibility that faxes and email can be sent erroneously to the wrong address and computers. If you communicate confidential or private information via unencrypted e-mail, texts or fax or via phone messages, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and s/he will honor your desire to communicate on such matters.
Please do not use e-mail, voice mail, or faxes for emergencies. Your provider is not on-call for mental health emergencies, and you should contact 911 in mental or physical health emergencies.
EMERGENCY:
If there is an emergency during therapy, or in the future after termination,
where I become concerned about your personal safety, the possibility of you
injuring someone else, or about you receiving proper emergent care, I will do whatever I can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, I may also contact the person whose name you have provided on the biographical sheet.
If an emergency situation arises, indicate it clearly in your message (phone or email), (I do not accept text messages for emergency situations)
and if you need to talk to someone right away call the 24-hour Crisis Line at 988 or dial 911.