Informed Consent Form

Informed Consent for Participation in Treatment

This form outlines the policies, procedures, and expectations for your participation in treatment. It serves to inform you about the types of services offered, confidentiality guidelines, fees, and other important details to ensure a transparent and collaborative therapeutic process. Please review it carefully, as signing the form indicates your understanding and agreement to the terms.
Name*
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Address*

Street Address

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Date of Birth
Email
example@example.com
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Please read this consent form carefully, as it describes the policies and procedures followed by your psychologist. You will receive a copy of this form. The terms "psychologist" and "therapist" are used interchangeably below. Services will be conducted via telehealth if appropriate.

Types of Service Provided by Your Psychologist:

You will be interviewed and may be asked to fill out some questionnaires to assist your psychologist in determining how best to help you. Sometimes, additional psychological testing is conducted, and your psychologist will discuss with you the reasons for this if it is relevant. Treatment usually involves individual meetings with the therapist, but may also include group treatment and/or involving family members or significant others in some individual sessions. All treatment will be conducted only with your consent.

What You Can Expect from Treatment:

Your psychologist will work with you to develop a specific, individualized treatment plan tailored to your needs. This will include a written list of specific goals that you hope to achieve in treatment. You may be expected to work on specific tasks outside the therapy sessions. This "homework" will be decided by you and your therapist together, and might include thinking about a particular issue, reading some relevant material, writing down a log of feelings or behaviors or practicing a particular skill, for example. The duration of treatment is different for each person and can be difficult to estimate; your therapist will address any concerns that you have about this. If you are not feeling satisfied with your treatment for any reason, you are asked to discuss this directly with your therapist. The therapist will work with you to uncover what might be preventing progress, will modify goals with you if appropriate, and will make a referral for you to (an)other professional(s) if necessary, and/or at your request. Sometimes people find that they have a temporary increase in their level of distress when beginning psychotherapy, because the process of working on personal issues can be difficult. Please be aware of this.

Confidentiality:

What you discuss with your psychologist is kept confidential, or private, with some exceptions. Your therapist may share information about you for purposes of arranging vacation & leave time coverage. In this case, your therapist will discuss the need for coverage with you and will obtain your consent for sharing basic information with an alternate therapist should a therapeutic need arise in this therapist's absence. The Notice of Privacy Practices provides detailed information about how private information about your healthcare is protected and under what circumstances it may be shared.

Fees for Services:

Payments for services must be made prior to the beginning of each session. I do not accept insurance. I will provide you with a paid invoice that you may submit to your insurance company for possible reimbursement. The following fees are charged for services:

Initial Assessment Session = $225 per hour

Therapy Session = $225 per therapy hour

Cancellation policy:

You will be billed at the full out-of-pocket rate if you miss an appointment without providing at least 24 hours notice.
Please select one of the options below and then sign to indicate that you have read and understand (1) this Informed Consent form for participation in treatment, (2) the Notice of Privacy Practices form and how information about you may be used or disclosed, and (3) that you consent to treatment and the provisions in the Informed Consent and Notice of Privacy Practices form.*

I authorize my psychologist to release information about me as necessary to my insurance company for billing purposes. I understand that I am responsible for payment of any balance or co-pay not covered by my insurance.I do NOT authorize release of any information about me or my treatment to an insurance company. I will be responsible to pay all fees for treatment myself.
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Printed name of Parent or Legal Guardian or Personal Representative (if applicable).
Obtain evidence of legal authority of Legal Guardian or Personal Representative and file it with this form.
Should be Empty:

Informed Consent for Participation in Treatment

Types of Service Provided by Your Psychologist:

What You Can Expect from Treatment:

Confidentiality:

Fees for Services:

Cancellation policy: