CHILD THERAPY CONTRACT
Prior to beginning treatment, it is important for you to understand the therapist’s approach to child therapy and agree to some rules about your child’s confidentiality during the course of his/her treatment. The information herein is in addition to the information contained in the Patient-Therapist Agreement. Under HIPAA and the APA Ethics Code, the therapist is legally and ethically responsible to provide you with informed consent. As your proceed, the therapist will try to notify and remind you of important issues as they arise.
One risk of child therapy involves disagreement among parents and/or disagreement between parents and therapist regarding the best interests of the child. If such disagreements occur, the theapist will strive to listen carefully so that they can understand your perspectives and fully explain their perspective. You may resolve such disagreements or agree to disagree, so long as this enables your child’s therapeutic progress. Ultimately, you will decide whether therapy will continue. If either of you decides that therapy should end, the therapist will honor that decision, however we ask that you allow the option of having a few closing sessions to appropriately end the treatment relationship.
Therapy is most effective when a trusting relationship exists between the therapist and the patient. Privacy is especially important in securing and maintaining that trust. One goal of treatment is to promote a stronger and better relationship between children and their parents. However, it is often necessary for children to develop a “zone of privacy” whereby they feel free to discuss personal matters with greater freedom. This is particularly true for adolescents who are naturally developing a greater sense of independence and autonomy. By signing this agreement, you will be waiving your right of access to your child’s treatment records.
It is our policy to provide you with general information about treatment status. The therapist will raise issues that may impact your child either inside or outside the home. If it is necessary to refer your child to another mental health professional with more specialized skills, the therapist will share that information with you. The therapist will not share with you what your child has disclosed without your child’s consent. The therapist will inform you if your child does not attend sessions. At the end of your child’s treatment, the therapist will provide you with a treatment summary that will describe what issues were discussed, what progress was made, and what areas are likely to require intervention in the future.
If your child is an adolescent, it is possible that he/she will reveal sensitive information regarding sexual contact, alcohol and drug use, or other potentially problematic behaviors. Sometimes these behaviors are within the range of normal adolescent experimentation, but at other times they may require parental intervention. Your and the therapist will carefully and directly discuss your feelings and opinions regarding acceptable behavior. If the therapist ever believes that your child is at serious risk of harming him/herself or another, your provider will inform you.
Although the therapist’s responsibility to your child may require their involvement in conflicts between the two of you, their involvement will be strictly limited to that which will benefit your child. This means, among other things, that you will treat anything that is said in session with the therapist as confidential. Neither of you will attempt to gain advantage in any legal proceeding between the two of you from the therapist’s involvement with your children. In particular, please agree that in any such proceedings, neither of you will ask your provider to testify in court, whether in person or by affidavit. You also agree to instruct your attorneys not to subpoena your provider or to refer in any court filing to anything the therapist has said or done.
Note that such agreement may not prevent a judge from requiring the therapist’s testimony, even though they will work to prevent such an event. If required to testify, they are ethically bound not to give their opinion about either parent’s custody or visitation suitability. If the court appoints a custody evaluator, guardian ad litem, or parenting coordinator, the therapist will provide information as needed (if appropriate releases are signed or a court order is provided), but will not make any recommendation about the final decision. Furthermore, if the therapist is required to appear as a witness, the party responsible for my participation agrees to reimburse the Clinic at the rate of $400 per hour for time spent traveling, preparing reports, testifying, being in attendance, and any other case-related costs.
CONFIDENTIALITY
Sessions with the therapist and the information discussed in them are confidential and are protected by state law and the ethical principles of your therapist’s profession. That is, the contents of a session, or even whether or not you attend, will not be revealed to outside sources unless you have provided written permission to do so, or as required by law.
There are several important circumstances under which confidentiality may not be legally and/or ethically guaranteed, and which may require your therapist to initiate hospitalization for you, notify the police or other government agency, or notify your family members to help protect you. Such circumstances include:
(1) when the therapist believes you intend to harm yourself or another person;
(2) when your therapist believes a child or elderly person or dependent person has been or is in danger of being abused or neglected;
(3) if we receive service of legal process seeking your mental health records; and
(4) if your therapist consults with another mental health professional regarding your case, in which case none of your personal identifying information will be used.
BILLING/INSURANCE REIMBURSEMENT
We do not accept insurance as payment. However, you may be able to receive reimbursement from your insurance company for seeing an “out of network provider.” It is your responsibility to determine whether or not your insurance company will reimburse you and to what extent you will be reimbursed. If you wish to seek reimbursement from your health insurance company, your therapist will complete any reasonable forms to enable you to do so. If required to provide clinical information, your provider will make every effort to release only the information about you that is necessary for the purposes requested. By signing this agreement, you agree that your therapist can provide required information to your insurance carrier in order to help you receive reimbursement. However, ultimately you are responsible for all incurred fees. If you have an outstanding balance for more than 2 months, we reserve the right to use legal matters including hiring a collection agency and/or using small claims court to receive payment. Should this occur, certain information pertaining to your treatment will be released. Your therapist reserves the right to terminate your treatment for nonpayment of incurred fees. In such a case, your provider will suggest alternative service providers as appropriate
CONTACTING YOUR THERAPIST
All calls to your therapist’s office number are routed to a confidential voice mailbox. Your therapist will check for messages frequently throughout the workday, and will make every effort to return your call within 48 hours, with the exception of weekends and holidays. Your therapist can also be reached by email. Email is the preferred method of communication for non-urgent logistical questions, such as those pertaining to scheduling. Email is not a secure form of communication and confidentiality cannot be guaranteed.
WHAT TO DO IN A PSYCHIATRIC EMERGENCY
Sometimes people experience an emotional crisis that requires immediate attention. In such a case, you may call the office first to see if an emergency appointment can be arranged. Please note that we do NOT provide emergency services. Your provider may not be immediately available during the day, evenings, or on weekends. However, your provider will return your call as soon as possible, usually on the same business day. Often, an appointment can be made on short notice, but this cannot be guaranteed. If you feel you cannot wait, or if it is outside office hours, you should contact your family physician, or go to the Emergency Department of your nearest hospital and ask for the psychiatrist on call.
FEES
The therapy hour involves fifty minutes of direct contact, with the remaining ten minutes being used for notes, reports, and treatment planning. There is usually no charge for: (i) treatment planning outside the session; (ii) brief telephone contacts (15 min. or less) with you, family members where appropriate, and other professionals; and (iii) other brief and incidental involvements of your provider’s time. However, when tasks and consultation require considerable time, fees may be charged. Administrative fees will be charged for requests for file notes (for time and duplication costs), reviewing files/notes and writing reports.
Payment for therapy is normally expected at each session (check, Visa, MasterCard, PayPal, or American Express). Receipts or superbills can be sent to you at the end of each month upon request. Please retain these receipts for your insurance or income tax claims, if applicable.
PROVIDER INVOLVEMENT IN LEGAL PROCEEDINGS
In the event you should require your provider’s testimony or involvement in legal or court proceedings, client consent will be required. Your provider will be unable to disclose any information pertaining to other family members or parties in counseling without each person’s specific consent. Court appearances, either requested or subpoenaed, as well as depositions and settlement conferences are billed at an hourly rate of $400.00. These rates will be charged at a minimum of four hours which includes time spent on preparation, travel, waiting, and testimony. The initial minimum four-hour charge of $1600 is due at the time of the subpoena. These charges are not allowable charges for insurance and are the sole responsibility of the client. Because it is often difficult to accurately determine the time needed to appear in court, there is a need for the therapist to clear his or her appointment schedule for the entire day. Such scheduling makes it necessary to charge in this manner.
RECORD KEEPING
Your provider’s profession requires that treatment records be maintained after discontinuation of treatment. You may submit a request in writing to receive a copy of your records. Your provider will honor your request, unless your provider considers your records to be potentially dangerous, in which case we will forward them to another mental health provider of your choice.
THE THERAPY PROCESS
Your provider will conduct an initial comprehensive evaluation, and use an approach that your provider believes will be most effective in attaining the goals that you both have established. It is crucial for you to actively participate in this process by attending regular sessions, preparing for them, and practicing any between session exercises. Your input is essential in establishing treatment goals, issues, risks and benefits of change, the time commitment involved, costs, and other pertinent aspects of your situation. Periodically, you and your provider will evaluate your progress and, if necessary, redesign the treatment plan, goals, and/or methods.
As with any successful intervention, there are both benefits and risks associated with psychotherapy. Risks may include experiencing uncomfortable levels of feelings such as sadness, guilt, shame, anxiety, anger, frustration or conflicts with other people. Some changes may lead to feeling worse in the short run. However, long term benefits may include improvement in mood and distress, better relationships, and solutions to personal problems.
Evaluations and therapy are completely voluntarily. You may discontinue treatment at any time. However, it is important to discuss terminating treatment with your provider and to make subsequent plans for referral or discontinuation of treatment.
TELEHEALTH (REMOTE SERVICES)
“Telehealth” involves consultation, treatment, transfer of medical data, emails, telephone conversations, and education using interactive video, audio, or voice communications.
1. Unless we explicitly agree otherwise, our telehealth exchange is confidential. The same regulations governing face-to-face interactions remain in effect for telehealth.
2. Regardless of your location, our telehealth occurs in the state of California, and is governed by the laws of that state. In a manner of speaking, you use this modality to visit our office in California.
3. You understand that telehealth is neither a universal substitute, nor the same as, face-to-face psychotherapy treatment. You accept the distinctions made using telehealth vs. face-to-face psychotherapy. In particular, you accept that telehealth does not provide emergency services. Your signature indicates that you understand that you may choose to engage in telehealth at your own discretion.
4. You are responsible for information security on your computer. If you decide to keep copies of our emails or communication on your computer, it is up to you to keep that information secure.
5. The risks involved with telehealth include the potential release of private information due to the complexities and abnormalities involved with the Internet. Viruses, Trojans, and other involuntary intrusions have the ability to grab and released information you may desire to keep private. Furthermore, there is the risk of being overhead by anyone near you if you do not place yourself in a private area and open to other’s intrusion.
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