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Psychotherapy Informed Consent Form

It  is not easy to seek help with regard to mental health concerns.  The acceptance of the need for help must come from the person seeking counseling.  With this informed consent for psychotherapy, you will be able to address the concerns you are struggling with, understand more about what you are going through, and work towards healing your emotional pain.

The Therapist

I am a licensed clinical social worker specializing in mental health concerns (depression, anxiety, trauma, addiction, relationship and work challenges) for over 20 years.  I have been a certified EMDR therapist through the Eye Movement Desensitization and Reprocessing International Association for over 2 years.  During our session time, we will formulate a treatment plan and address your personalized healthcare goals.  Please note, you are voluntarily agreeing to therapy and may withdraw or terminate at any point.  Terminating before completing your treatment goals is better to discuss with your therapist so follow-up recommendations can be made.  The relationship between therapist and client is strictly professional.  Personal or business relationships are strictly forbidden by the Department of Health Professionals as these disrupt the effectiveness of treatment.  

Session Length/Billing/Cost

Sessions run from 45-55 minutes depending on your particular need each visit and can last over the time span of however long you need treatment.  Sometimes clients accomplish treatment goals quickly and other times clients need long-term therapy for issues like complex trauma.  I will bill your insurance company for each session, however, I cannot ensure payment.  You hold a contract through your insurance company so I encourage you to obtain specifics about coverage (deductible status, copays, mental health benefits) prior to your first appointment.  I bill the first intake session as a code 90791 at $200, a 55 minute session is code 90837 at $150, and a 45 minute session is code 90834, $125.  Private pay is charged at the same rate.  No-shows and cancellations less than 24 hours in advance are charged at at the same rate as above.  Cancelled checks/insufficient funds, $45.  Records requests,  $15 minimum.  Past Due accounts over 30 days,  $30 month, accounts open beyond 90 days are sent to collections.  Payment is due at the time of visit.  There are no exceptions to these rules. I have to reveal your diagnostic code, your date of service and sometimes routine progress notes to your insurance company to secure reimbursement.
 
Confidentiality

See the lengthier HIPPA (privacy)  form for a thorough outline of confidentiality, however, in brief, sessions between the therapist and client are strictly confidential.  Audio/visual recordings are never done without further consent processes.  All session notes are kept secure and not released unless the client signs a Release of Information form.  You may revoke any release of information as long as the request is in writing. Exceptions to certain limitations by law for release of records without client consent are as follows:
 

1. Abuse to a child, disabled, elderly, other people;
2. Serious threat to health or safety (suicidal / homicidal);

3. Criminal acts;

4. Sexual abuse;

5. Acts which may involve transmission of HIV/AIDS;
6. Any other instance when the therapist has a duty or she has a firm belief that there is a necessity to disclose.

All of these scenarios can be discussed anytime with your therapist.

Risks/Advantages

Growth cannot happen unless certain uncomfortable feelings, thought, or behaviors are confronted.  All of this takes place in a safe therapeutic environment.  Clients are encouraged to bring up any threats to their safety at any point during therapy.  Sometimes clients experience discomfort during or after a session is over but the therapist helps prepare clients for this potentiality.  Feelings are transient and will come and go.  The tolerance of a wide range of affect and the transformation of uncomfortable affective states is the goal of therapy.  Therapy allows clients to expand awareness, develop insight, and change dysfunctional behaviors and relationships.  Many clients report feeling better after therapy, having more ability to cope with life’s challenges, and a resolution of trauma and old pain.  

Court Proceedings/Disability

The therapist is not available to appear in court proceedings (custody, divorce, injuries, or any other lawsuits) or determine disability status. If I get subpoenaed nonetheless, my charge is $150 per hour for preparation, travel time, court appearance and / or missed time from work.

Consent

I have read the contents of this form and fully understand the contents indicated within.

Initial ___________________

I understand the confidentiality that is required by the therapist to perform, as well as the limitations by which the therapist has to abide by the requirements of her license and the law.

Initial ___________________

I understand my psychotherapist’s responsibilities as well as my own as a client working towards definitive treatment goals

Initial _______________________

I understand and agree with the information about insurance, billing, court, fees and no-shows/cancellations.

Initial___________________

I understand I can end psychotherapy or request a referral to someone else at any time.

Initial _______________________
I understand my therapist can terminate therapy with me if she feels she cannot treat me for any reason.
Initial _______________________
Consenting Age

I am above 18 and I hereby voluntarily give informed consent to this agreement with full knowledge of my rights.

Client Signature:

______________________________________________________________

Date:  ____________________


As a therapist I have explained to the client the relevant information contained in this informed consent.  I have given him/her opportunity to ask questions and have answered the already asked questions to his/her satisfaction.

Therapist Signature:

__________________________________________________________________

Date: ______________________
Click on the PDF icon below to open a printable copy of the "Informed Consent" form.
Click on the Word icon below to open a printable copy of the "Informed Consent" form.
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