2024 Psychotherapy Informed Consent

Psychotherapy Consent to Treat Document

Updated April 1, 2024

Name*

Date of Birth*

Gender Identity

Phone Number *

Address *

Email*

example@example.com

Responsible Person/Legal Gaurdian: (If this info is the same as patient, write "same as above")

Name

Relationship

Phone Number

Address

Email

example@example.com

For Clients Under Age 16

Please list all legal guardians and/or any adult that has the ability to consent for the minor or make medical decisions (if not listed above).

Name

Relationship

Phone Number

Name

Relationship

Phone Number

Consent for Treatment

By signing below, I voluntarily consent to assessment, treatment, and/or diagnostic procedures for myself and/or my family members. I understand that the purpose of these procedures will be explained to me upon my request and subject to my agreement. You also agree that you understand that no guarantee has been made regarding specific outcomes or efficacy for

Client Signature*

Date

Parent Guardian andor Legal Representative Signature (if applicable)

Date

Confidentiality

All information disclosed within sessions or consultations is held strictly confidential and may not be revealed to anyone without a written release of information, except where disclosure is permitted or required by law in the following circumstances:

1.When there is reasonable suspicion of child abuse or neglect, or abuse to a dependent or

2. When the client presents an imminent danger to self-and/or others 3. If a judge determines that your discussions are not confidential, a judge may request specific

4. If a therapist has concerns that a client is being abused by their romantic partner, they are not required to report their concerns to law enforcement but can do so at your request. They required by law to provide clients with resources and education regarding dating violence, and to report to police if they believe that the death of a victim may be related to domestic or

5. If the client is a minor, you acknowledge that your child's records are confidential except in

6. If receiving medication management at Hagan Health, therapists collaborate with prescriber(s) and supervisors in order to maintain a high standard of care.

Initial to confirm you have read the terms of confidentiality *

Therapy Process and Termination

Psychotherapy can result in a number of benefits to you, such as a decrease in psychological symptoms, improved relationships, and achievement of personal goals. However, the process of talking about painful memories, thoughts, and feelings can be difficult and can at times lead to a client feeling worse for a time. Please discuss with your therapist if you are feeling worse or are not feeling satisfied with the direction and pace of therapy. You are always free to terminate therapy at any time, and we are happy to provide you with referrals to other providers.

Initial to confirm you have read the terms of therapy process and termination*

Phone Contact

If you need to contact your therapist by phone-call or text, they may provide you with their office number, but are not required to do so. If they provide their contact information, they may set boundaries and expectations regarding when they will respond. Phone calls, text messages, and emails cannot be quaranteed the same level of confidentiality as face-to-face conversations, are not encrypted, and should be used primarily for housekeeping and scheduling concerns. Questions for other providers at Hagan Health need to be routed through the front office. Do not attempt to contact your therapist for emergency purposes; in the case of an emergency, please call 911. Therapists reserve the right to restrict or not provide phone communication if a client repeatedly crosses these boundaries and expectations.

Initial to confirm you have read the terms of phone contact *

Litigation Limitations

Due to the nature of the therapeutic process and the fact that it often involves disclosing personal and confidential natures, it shall be agreed that if there are legal proceedings involving the client, neither you, your attorney, or anyone acting on your behalf will call on your therapist to testify in court or at any other proceeding, nor will a release of psychotherapy records be requested.

Initial to confirm you have read the terms of litigation limitations*

Scope of Competency

Our therapists do not perform the following services: Custody evaluations or recommendations of custody, prescribing medication or making recommendations of medication, disability paperwork, divorce mediation.

Initial to confirm you have read the terms of scope of competency *

No Shows and Cancellations

Therapy cancellations must be made with a 24-hour advance notice or a $75 no-show fee will be charged. If something unexpected comes up, we are happy to switch your appointment to telehealth if it would help you avoid rescheduling. Hagan Health's policy states that a client may be discharged if they last-minute cancel 3 times in a 3 month period. If a client does not show up to the appointment with no notice 2 or more times in a 2 month period that client may be discharged. If this is the case, the client will receive a letter either via email or in the mail.

Initial to confirm you have read the terms of no shows and cancellations *

Session Structure

The therapeutic hour is approximately 50 minutes with the last 10 minutes reserved for documentation. If your therapist is running behind, they will adjust their schedule to give you your full 50 minutes. Unfortunately, if you are late, they cannot adjust their schedule as it will impact other clients. In these cases, sessions will still end at the 50-minute mark, so your session may be shorter.

Initial to confirm you have read the terms of session structure *

Supervision

Your therapist may be receiving clinical supervision. They are happy to provide contact information for their supervisors upon request. Your information will continue to be protected by HIPAA policies. The purpose of supervision is to ensure that all our clients receive the highest possible care.

Initial to confirm you have read the terms of supervision *

Requirements to Engage in Therapy via Telehealth (if applicable)

Psychotherapy at Hagan Health utilizes Zoom to conduct telehealth sessions. The day before or the morning of your appointment, you will be sent a link to your provider's virtual waiting room. If you do not receive a link, please be sure to check your spam folder. If your link is not in your spam folder, please contact the front desk.
Before you see your provider, a member of the front office staff will meet with you to ensure your information is still accurate and will collect your fee or copay. Hagan Health does not carry balances, so fees and copays must be paid at the time of your appointment.
Once the front office staff informs the provider that you are ready in the waiting room, your provider will begin your session.
At the time of your session you need to be stationary in a quiet and private place.
You CANNOT be driving, running errands, or in a public space during your appointment.
You need to be in a separate room or space where others will not interrupt your session.This is both to maintain your privacy and to ensure you can hear your therapist and your therapist can hear you.
If these conditions are not met, your therapist reserves the right to ask you to reschedule and you may be charged a no-show fee.
Standard no-show policies and no-show fees apply to telehealth sessions. Any cancellations or need to reschedule should be communicated to the office 24 hours in advance whenever possible.
Telehealth appointments will still only be scheduled within normal operating hours for Hagan Health.
Your therapist cannot provide technical support for Zoom, so it is recommended that you try logging in before your session to make sure everything is working correctly.

Initial to confirm you have read the terms of requirements to engage in telehealth *

By signing below, you are agreeing that you have read and understand the policies outlined in this informed consent document.

Client or Guardian Signature*

Date