Informed Consent to Treatment Form:
The therapeutic relationship is unique in that it is highly personal and, at the same time, a contractual agreement. 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.
What is therapy?
Therapy is a relatively structured psychological investigation of your thoughts, feelings, and behaviors in the service of identifying and practicing techniques to help you make changes that you want to make, as well as better understanding some of the blocks that might be getting in the way of these changes. This investigation is accomplished through discussion during therapy sessions and through the completion of various assignments I might sometimes give you between sessions.
Does therapy always help?
No. Some people experience no benefit from therapy. Also, even in cases where changes do occur, improvement can be minor/temporary and symptoms can remain. I cannot guarantee you any type of result.
At certain points therapy is not easy. You may find yourself discussing very personal information. You could find those conversations difficult and painful, and you might be very anxious during and after these conversations. As you learn more about yourself, you might encounter increased conflict with friends, co-workers, and family members. Also, sometimes therapy requires trying new ways of doing things outside sessions. This can also be uncomfortable. You will always be free to move at your own pace. You should always tell me if something we discuss or that you are asked to do for homework makes you feel uncomfortable.
I will indicate to you if I think that you are not being well served by participating in therapy with me. It is very helpful if you directly mention any concerns you have about your progress as well so that we can discuss them.
How long does therapy last?
The duration of an episode of therapy generally depends on the nature of the matter(s) you want to work on. Some matters can benefit from a relatively short course of therapy while others take much longer. In general, I have found that most people do not realize significant benefit from therapy until they have participated regularly in it for at least three months.
How often do I come in for therapy?
In my experience, in most cases, therapy is more effective if the client comes in at least once per week. In many cases, twice per week will yield a more effective, more involved therapy. Some clients can benefit from once every two weeks, but I typically do not schedule clients once every two weeks to start. Towards the end of a therapy, I usually titrate session frequency down to every other week or every four weeks before the last session.
Are there rules about attendance?
Yes. Regular attendance is really important. Attendance problems are an indication that I am not helping you sufficiently and/or that you are not in a position to engage in therapy in an effective manner at this time. Addressing attendance problems is a core issue therapists need to manage, should they emerge. What follows is how I have come to manage them.
- Non-emergency no-shows and cancellations with less than 24 hours notice are subject to a charge of $35. (If you have Medicaid, there is no charge for no-shows or late cancels. This is a CMS regulation and no Colorado provider should be charging a Medicaid patient for no-shows or late cancels.)
- Patients who no-show more than three times are immediately discharged at that point. That is, if you no-show a fourth time your case will be discharged.
- If you no-show, I shall reach out to you by phone or text to note the missed appointment and see what is the matter. If you do not respond to the text or voicemail within 5 days, that is your communication to me that you are no longer interested in therapy with me and you will be discharged at that point without further communication about it from me. Any remaining scheduled appointments will be taken off the schedule. I will charge any remaining balance to the credit card I have on file for you and email you the paid invoice. You are certainly free to call me at any time after that to discuss the possibility of resuming therapy if that is something you desire.
- If for any reason I have reached out to you about scheduling a subsequent appointment and I do not hear back from you within 5 days, that is your communication to me that you are no longer interested in therapy with me and you will be discharged at that point without further communication about it from me. Any remaining scheduled appointments will be taken off the schedule. I will charge any remaining balance to the credit card I have on file for you and email you the paid invoice. You are certainly free to call me at any time after that to see if the possibility exists of resuming therapy.
- Arriving to appointments consistently late is not helpful for your progress. If you tend to arrive significantly late (more than 10 minutes), I will discuss that with you. If you are still not able to arrive timely, I will need to consider discharging your case.
- In general, I see patients at the same time and on the same day(s) each week. This is easier for me and it is easier for most patients to have a set time each week. When you start work with me, we will agree on your time and that time is yours going forward. You will need to make approximately 80% (8 out of 10) of your appointments over time to hold on to your spot. If you are not able to do this, it is likely that you will lose your time slot. If this happens, we can try to schedule as openings arise in the schedule. Alternatively, I may decide to discharge your case for inconsistent attendance.
What are the fees?
The fee for a 45 minute session is $120. The fee for a 60 minute session is $150. The fee for a 90 minute session is $200. (Most sessions of this length are couples sessions or EMDR sessions). Any session shorter than 45 minutes is billed at $100. The clock starts running when I ask you to come in the office. (That means if I am running late, you are not charged for that time.) If you use an insurance policy in which I participate, my office will submit claims for you. It is your responsibility to be aware of and pay any deductible or copayment that might be a part of their plan. Please contact your insurance company’s Member Services department to ascertain if you have a copayment or deductible. If you use an insurance plan, I charge your credit card and email you a receipt for these copayments and deductibles at the time the insurance claim is processed. If you are self-pay, I generally charge your card the day of service. There is a $30 charge for any returned checks.
Is therapy confidential?
Not entirely. Under various state laws and professional ethics codes, I am mandated to report/disclose information regarding certain material as noted below:
- If a client makes a credible threat of suicide or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm. If such a situation arises, I make a 911 call.
- If a client makes a credible threat of bodily harm or death to another person. If such a situation arises, I make a 911 call.
- If the therapist has a reasonable suspicion that a client or other named person known to the therapist is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years. Reports involving physical or emotional abuse are made to Child Protective Services. Reports involving sexual abuse are made to law enforcement.
- Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
- Suspected neglect of a child or elder.
- If a court of law issues a legitimate subpoena for information stated on the subpoena.
- If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.
- Please note that insurance companies are now more frequently requiring clinicians to submit progress notes to them. This is even the case if you are using out of network benefits. If you are using out of network benefits and are receiving reimbursement from your insurer, it is possible that they may require records from me, determine treatment to not be medically necessary, and recoup from you money they have paid you.
From time to time I participate in a consultation group of local mental health colleagues. I may present your case in the context of this group to help me provide the best treatment for you. Information that could identify you in this setting is omitted (like your name, where you live, occupation, people related to you, etc.,).
If you are being treated by another clinician, HIPAA rules allow me to discuss your case with them without receiving your express permission. In most cases I will let you know that I am planning to speak with the other provider. An example of this would be me talking to your primary care provider about whether the psychiatric medications they are prescribing you appear to be effective or not.
Additionally, I do communicate basic information to your insurance company for billing purposes if you use insurance. By signing this form you are consenting to my releasing this information to your insurance company.
If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you if that seems like what you want to do at that time.