This consent form contains important information about my professional services, business policies, and the Health Insurance Portability and Accountability Act (HIPAA). Under the HIPAA law, I am required to provide you with a Notice of Privacy Practices for use and disclosure of Protected Health Information (PHI). After reviewing both the consent for treatment and Notice of Privacy Practices forms, please sign below, which will then represent an agreement between us. You have the right to revoke this agreement at any time in writing. I will honor the revocation unless I have already acted upon your previous authorization, or if there are obligations imposed on me by your health insurer in order to process or substantiate claims, or if you have not satisfied any financial obligations you incurred from my services.
Psychological Services
The purpose of psychotherapy is to help clients address various problems or issues within a supportive environment. Successful psychotherapy requires clients to make an active effort. This entails working on issues that are talked about during sessions, outside the office during everyday activities.
Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings such as sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people, including better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience. During treatment, if you have questions regarding your treatment or my procedures, we should discuss them at that time. If at any time, you do not think we are a good fit, I will be happy to discuss your concerns and if you determine you would like to pursue other options, I will do my best to provide you with appropriate referrals. I also reserve the right to terminate treatment based on determining clinical benefit/necessity, adherence to ethical and legal guidelines, etc. This decision will be shared with you and attempts will be made to offer other options at that time.
The initial process of psychotherapy involves an evaluation of your needs which usually lasts for approximately 2-4 sessions. This period of time allows me to gain an understanding of your issues and how we can tailor treatment goals to address them most effectively.
Billing and Payment
My hourly fee is $201.25 for the initial session, $161 for 60 minute sessions, $143.75 for 45 minute sessions, $86.25 for 30 minute sessions, and $161 for 60 minute family sessions. You will be expected to pay for each session at the time services are rendered, unless we agree to other arrangements. I charge this amount for other professional services you may need, though I break down the hourly cost if I work for periods of less than one hour. Other services may include telephone conversations, consulting with other professionals with your permission, preparation of treatment summaries, and the time spent performing other services you may request of me.
Payment schedules for unusual financial hardship are available upon request. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure payment. In these situations, I only release the client’s name, nature of services provided, and the amount due.
If you have an insurance policy, it will usually provide some coverage for mental health services. Please note that we are unable to guarantee what your insurance will cover and it is important for you to understand your own mental health benefits. This information can be found in your insurance coverage booklet or by contacting your plan administrator. I will bill electronically for services rendered and be of whatever assistance I can to help you receive the benefits to which you are entitled; however, you are responsible for full payment of my fees. You should also be aware that the contract with your insurance company requires that you authorize me to provide it with information such as diagnostics, treatment plans, or copies of your Clinical Record. I attempt to release the minimum information necessary for the purpose requested. Some insurance companies will not allow me to provide services after your benefits have ended. In such cases, I will assist you in finding another provider who can help you continue your treatment.
You should also be aware that most insurance companies require that I provide them with your clinical diagnosis. Sometimes I have to provide additional clinical information, such as treatment plans, progress notes or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any records I submit, if you request it. You understand that, by using your insurance, you authorize me to release such information to your insurance company. I will try to keep that information limited to the minimum necessary.
Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above unless prohibited by the insurance contract.
Once an appointment is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation. There may be exceptions to this rule if we both agree that you were unable to attend due to circumstances beyond your control.
Confidentiality
In general, the law protects the privacy of all communications between a patient and psychologist. I can only release information about our work to others with your written permission. There are a few exceptions.
On occasion, I may wish to consult with other health/mental health professionals. During these consultations, I make every effort to avoid revealing the identity of my clients. The other professionals are legally bound to maintain confidentiality. If you do not object, I will not discuss these consultations with you unless I feel it is important to our work together. I will note all consultations in your Clinical Record.
In the event that I am involved in a legal proceeding, you have the right to prevent me from disclosing information regarding your treatment. However, there may be times when a judge orders my testimony when he or she deems it crucial to the situation. This may occur during proceedings involving child custody or your emotional condition.
If a government agency requests the information for health oversight activities, I may be required to provide it to them. Additionally, if a client files a complaint or lawsuit against me, I may disclose relevant information regarding the client in order to defend myself. Finally, if you file a worker’s compensation claim and I am rendering treatment in accordance with the provisions of Illinois Worker’s Compensation law, I must, upon appropriate request, provide a copy of your records to your employer or the appropriate designee.
There are also some situations where I am legally obligated to take actions which I believe are necessary to protect others from harm. In these situations, I may reveal information about a client’s treatment. For example, if I believe that a child, disabled, or elderly person is being abused, I must file a report with the appropriate state agency. Another example, if I believe that a client is threatening serious bodily harm to another, I am required to take protective actions. This may involve notifying the potential victim, contacting the police, and/or seeking hospitalization for the client. If the client threatens to harm him/herself, I am obligated to seek hospitalization for him/her or contact others who can provide protection. I will make every effort to fully discuss the situation with you before taking action.
Following the enactment of Public Act 098-0063, the Illinois Firearm Concealed and Carry Law, all physicians, clinical psychologists, and qualified examiners are required to notify the Department of Human Services (DHS) within 24 hours of determining a person to be “a clear and present danger” to themselves or others, Developmentally Disabled, or Intellectually Disabled.
Electronic Communication & Social Media
In order to maintain clarity regarding our use of electronic modes of communication during your treatment, I have prepared the following policy. This is because the use of various types of electronic communications is common in our society, and many individuals believe this is the preferred method of communication with others, whether their relationships are social or professional. Many of these common modes of communication, however, put your privacy at risk and can be inconsistent with the law and with the standards of my profession. Consequently, this policy has been prepared to assure the security and confidentiality of your treatment and to assure that it is consistent with ethics and the law.
Social Media: I do not accept contact requests from current or former clients on any social networking site. I believe that adding clients as friends or contacts on these sites can compromise our confidentiality and our respective privacy. It may also blur the professional boundaries of our relationship. You are welcome to follow or “like” my posts on social media but please be aware I will not respond to any of your responses as it could potentially compromise confidentiality. If you have any questions about this, feel free to bring it up so we can discuss it further.
Email/Texts: I use email communication and texting only with your permission and for administrative purposes unless we have made another agreement. Please note that I cannot guarantee that texts and emails are secure. That means that email and text exchanges with my office should be limited to things like setting and changing appointments, minor billing matters and other administrative issues unless we have made other arrangements.
At the outset of our work together, we can discuss your preferred method for communicating in between sessions after you fully understand risks associated with each format. It is always best that we discuss clinical issues during sessions as this allows for processing, dialogue, and is most secure. However, there may be times when you’d like to reach out in between sessions for various reasons.
Please be advised that all emails are retained in the logs of your and my Internet Service Provider. You should also know that any emails/texts I receive from you and any responses that I send to you become a part of your legal record. There may be times when you request I communicate with other individuals (i.e. members of your treatment team or family members) in regard to your treatment. If you give me permission to do so electronically (text or email), please remember that I cannot guarantee these communications are confidential or secure.
Email and texting should also not be used to communicate with me in an emergency situation. I make every effort to respond to emails and texts and phone calls within 24 hours, except on weekends and holidays. In case of an emergency, please call our office at 866-220-8371. If I am not immediately available by phone, please call 911, contact local crisis services at 988, or go to the nearest emergency room.
Web Reviews: Recently it has become common for clients to review their health care provider on various websites. However, mental health professionals cannot respond to such comments because of confidentiality restrictions. It is also generally preferable for clients to discuss their concerns directly with their health care provider. If you have concerns or questions about any aspect of our work together or about any previously posted online reviews of my practice, please let me know so that we can discuss them. I recommend that you do not rate my work with you on any website for several reasons. If you rate my work on a website while you are in treatment with me, it has the potential to affect our therapeutic relationship. If you choose to post an online review about me or another health care provider either while you are in treatment or afterwards, please keep in mind that you may be revealing confidential information about your treatment. Thank you for keeping this policy in mind and for letting me know of any concerns.
No Recording of Therapy Sessions. Illinois law (720 ILCS 5/14-2) prohibits the recording of all or any portion of a private conversation or private electronic communication without the consent of all parties to the private conversation or private electronic communication. For the privacy of our clients and therapists, therapy sessions shall not be recorded.
Professional Records
I am required by law and the standards of my profession to maintain Clinical Records, which contain Protected Health Information. These records include information about your reasons for seeking treatment, a description of ways your problem impacts your life, your diagnosis, treatment goals, progress towards goals, medical and social history, treatment history, past treatment records I receive from other providers, billing records, and reports to others such as your insurance carrier. Additionally, I also keep a separate file containing Psychotherapy Notes. These notes aid me in providing you with effective treatment and may include sensitive information that is unnecessary to be included in your Clinical Record. Insurance companies do not have access to Psychotherapy Notes without your authorization and cannot require you to provide such authorization as a condition of coverage or penalize you for your refusal.
You may access your records by submitting a request in writing. Due to the professional nature of your treatment records, the contents may be misinterpreted or upsetting to untrained readers. To address this, my general policy is to prepare a treatment summary and recommend you review your summary/records in my presence so we can discuss the contents. If you choose, I can also send them to another mental health professional of your choice.
Client Rights
Under HIPAA provisions, you are entitled to several rights. These rights include requesting I amend your record, requesting restrictions on what information from your Clinical Record is disclosed to others, requesting an accounting of most disclosures of Protected Health Information you have neither consented to nor authorized, determining the location to which protected information disclosures are sent, and having any complaints you make about my policies and procedures recorded in your records.
Confidentiality for Couples and Families
Partners and family members may attend a counseling session together (conjoint session). Depending on therapist’s boundaries and structures, individual members may also attend private sessions alone as deemed necessary. Please review the parameters around confidentiality with your couples/family therapist so you are aware of the boundaries and what information may or may not be shared with others involved in treatment.
Confidentiality and Consents Regarding Minors and Parents
If you are under twelve years of age, the law provides your parents with the right to examine your treatment records. For those clients between the ages of twelve and eighteen, parents cannot examine records unless their child provides consent and/or if I find no compelling reason for denying access. Since parental involvement is often crucial to the success of treatment, it is my policy to request an agreement from parents and children allowing parents access to certain information. This includes general information about the progress of treatment and attendance. Any other communication requires your consent unless I feel there is high risk that you will seriously harm yourself or others. Prior to giving them any information, I will discuss the matter with you and if possible, do my best to handle any objections you may have to what I am prepared to discuss.
Parent Authorization for Minor’s Mental Health Treatment
In order to authorize mental health treatment for your child, you must have either sole or joint legal custody of your child. If you are separated or divorced from the other parent of your child, please notify me immediately. I will ask you to provide me with a copy of the most recent custody decree that establishes custody rights of you and the other parent or otherwise demonstrates that you have the right to authorize treatment for your child.
If you are separated or divorced from the child’s other parent, please be aware that it is my policy to notify the other parent that I am meeting with your child. I believe it is important that all parents have the right to know, unless there are truly exceptional circumstances, that their child is receiving mental health evaluation or treatment.
One risk of child therapy involves disagreement among parents and/or disagreement between parents and the therapist regarding the child’s treatment. If such disagreements occur, I will strive to listen carefully so that I can understand your perspectives and fully explain my perspective. We can resolve such disagreements or we can agree to disagree, so long as this enables your child’s therapeutic progress. Ultimately, parents decide whether therapy will continue. If either parent decides that therapy should end, I will honor that decision, unless there are extraordinary circumstances. However, in most cases, I will ask that you allow me the option of having a few closing sessions with your child to appropriately end the treatment relationship.
Individual Parent/Guardian Communications with Me
In the course of my treatment of your child, I may meet with the child’s parents/guardians either separately or together. Please be aware, however, that, at all times, my patient is your child – not the parents/guardians nor any siblings or other family members of the child. If I meet with you or other family members in the course of your child’s treatment, I will make notes of that meeting in your child’s treatment records. Please be aware that those notes will be available to any person or entity that has legal access to your child’s treatment record.
Mandatory Disclosures of Treatment Information
In some situations, I am required by law or by the guidelines of my profession to disclose information, whether or not I have your or your child’s permission. I have listed some of these situations below.
Confidentiality cannot be maintained when:
•Child patients tell me they plan to cause serious harm or death to themselves, and I believe they have the intent and ability to carry out this threat in the very near future. I must take steps to inform a parent or guardian or others of what the child has told me and how serious I believe this threat to be and to try to prevent the occurrence of such harm.
•Child patients tell me they plan to cause serious harm or death to someone else, and I believe they have the intent and ability to carry out this threat in the very near future. In this situation, I must inform a parent or guardian or others, and I may be required to inform the person who is the target of the threatened harm and the police.
•Child patients are doing things that could cause serious harm to them or someone else, even if they do not intend to harm themselves or another person. Examples include if client patients are at serious risk of legal issues and/or police involvement or at risk for or has engaged in destruction of property. In these situations, I will need to use my professional judgment to decide whether a parent or guardian should be informed.
•Child patients tell me, or I otherwise learn that, it appears that a child is being neglected or abused (physically, sexually or emotionally) or that it appears that they have been neglected or abused in the past. In this situation, I am [may be] required by law to report the alleged abuse to the appropriate state child-protective agency.
•I am ordered by a court to disclose information.
Disclosure of Minor’s Treatment Information to Parents
Therapy is most effective when a trusting relationship exists between the psychologist and the patient. Privacy is especially important in earning and keeping that trust. As a result, it is important for children to have a “zone of privacy” where children feel free to discuss personal matters without fear that their thoughts and feelings will be immediately communicated to their parents. This is particularly true for adolescents who are naturally developing a greater sense of independence and autonomy.
It is my policy to provide you with general information about your child’s treatment, but NOT to share specific information your child has disclosed to me without your child’s agreement. This includes activities and behavior that you would not approve of — or might be upset by — but that do not put your child at risk of serious and immediate harm. However, if your child’s risk-taking behavior becomes more serious, then I will need to use my professional judgment to decide whether your child is in serious and immediate danger of harm. If I feel that your child is in such danger, I will communicate this information to you.
Example: If your child tells me that they have tried alcohol at a few parties, I would keep this information confidential. If your child tells me that they are drinking and driving or is a passenger in a car with a driver who is drunk, I would not keep this information confidential from you. If your child tells me, or if I believe based on things I learn about your child, that your child is addicted to drugs or alcohol, I would not keep that information confidential.
Example: If your child tells me that they are having voluntary, protected sex with a peer, I would keep this information confidential. If your child tells me that, on several occasions, the child has engaged in unprotected sex with strangers or in unsafe situations, I will not keep this information confidential.
You can always ask me questions about the types of information I would disclose. You can ask in the form of “hypothetical situations,” such as: “If a child told you that they were doing ________, would you tell the parents?”
Even when we have agreed to keep your child’s treatment information confidential from you, I may believe that it is important for you to know about a particular situation that is going on in your child’s life. In these situations, I will encourage your child to tell you, and I will help your child find the best way to do so.
Also, when meeting with you, I may sometimes describe your child’s problems in general terms, without using specifics, in order to help you know how to be more helpful to your child.
Disclosure of Minor’s Treatment Records to Parents
Although the laws of Illinois may give parents the right to see any written records I keep about your child’s treatment, by signing this agreement, you are agreeing that your child or teen should have a “zone of privacy” in their meetings with me, and you agree not to request access to your child’s written treatment records.
Parent/Guardian Agreement Not to Use Minor’s Therapy Information/Records in Custody Litigation
When a family is in conflict, particularly conflict due to parental separation or divorce, it is very difficult for everyone, particularly for children. Although my responsibility to your child may require my helping to address conflicts between the child’s parents, my role will be strictly limited to providing treatment to your child. You agree that in any child custody/visitation proceedings, neither of you will seek to subpoena my records or ask me to testify in court, whether in person or by affidavit, or to provide letters or documentation expressing my opinion about parental fitness or custody/visitation arrangements.
Please note that your agreement may not prevent a judge from requiring my testimony, even though I will not do so unless legally compelled. If I am required to testify, I am ethically bound not to give my opinion about either parent’s custody, visitation suitability, or fitness. If the court appoints a custody evaluator, guardian ad litem, or parenting coordinator, I will provide information as needed, if appropriate releases are signed or a court order is provided, but I will not make any recommendation about the final decision(s). Furthermore, if I am required to appear as a witness or to otherwise perform work related to any legal matter, the party responsible for my participation agrees to reimburse me at my hourly rate for time spent traveling, speaking with attorneys, reviewing and preparing documents, testifying, being in attendance, and any other case-related costs.
Your signature below indicates you read the information in this contract and agree to abide by its terms during our professional relationship. It also serves as an acknowledgement you received the HIPAA Notice form described above.