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Office Policies, General Information, Agreement for Psychotherapy Services and Informed Consent
Confidentiality: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law.
When disclosure is required or may be required by law: Some of the circumstances where disclosure is required or may be required by law are: where there is a reasonable suspicion of child, dependent, or elder abuse or neglect; where a client presents a danger to self, to others, to property, or is gravely disabled; or when a client’s family members communicate that the client presents a danger to others. Disclosure may also be required pursuant to a legal proceeding by or against you. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records. In couple and family therapy, or when different family members are seen individually, even over a period of time, confidentiality and privilege do not apply between the couple or among family members, unless otherwise agreed upon. Your counselor will use her clinical judgment when revealing such information. She will not release records to any outside party unless she is authorized to do so by all adult parties who were part of the family therapy, couple therapy or other treatment that involved more than one adult client.
Emergency: If there is an emergency during therapy, or in the future after termination, where your provider becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, she will do whatever she can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, she may also contact the person whose name you have provided as an emergency contact.
Health Insurance & Confidentiality of Records: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. If you so instruct your provider, only the minimum necessary information will be communicated to the carrier. Your provider has no control over, or knowledge of, what insurance companies do with the information she submits or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy or to future capacity to obtain health or life insurance or even a job. The risk stems from the fact that mental health information is likely to be entered into big insurance company’s computers and is likely to be reported to the National Medical Data Bank. Accessibility to companies’ computers or to the National Medical Data Bank database is always in question as computers are inherently vulnerable to hacking and unauthorized access. Medical data has also been reported to have been legally accessed by law enforcement and other agencies, which also puts you in a vulnerable position.
LITIGATION LIMITATION: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that, should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you nor your attorney(s), nor anyone else acting on your behalf will call on your provider to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested unless otherwise agreed upon.
Supervision/consultation: Supervision is an important part of maintaining quality therapy. Your provider consults regularly with other professionals regarding her clients; however, each client’s identity remains completely anonymous and confidentiality is fully maintained.
E-Mails, Cell Phones, Computers and Faxes: It is very important to be aware that computers and unencrypted email, texts, and e-faxes communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. E-mails, texts, and e-faxes, in particular, are vulnerable to such unauthorized access due to the fact that servers or communication companies may have unlimited and direct access to all e-mails, texts, and e-faxes that go through them. While data on your provider’s laptop is encrypted, emails and e-faxes are not. It is always a possibility that e-faxes, texts, and e-mail can be sent erroneously to the wrong address and computers. Unencrypted email or text provides as much privacy as a postcard. You should not communicate any information with your health care provider that you would not want to be included on a postcard that is sent through the Post Office. Your provider’s laptop is equipped with a firewall, a virus protection and a password. Please notify her if you decide to avoid or limit, in any way, the use of e-mails, texts, cell phone calls, phone messages, or e-faxes. If you communicate confidential or private information via unencrypted e-mail, texts or e-fax or via phone messages, your provider will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and she will honor your desire to communicate on such matters. Please do not use texts, e-mail, voice mail, or faxes for emergencies.
Records and Your Right To Review Them: Both the law and the standards of your provider’s profession require that she keep treatment records for at least seven years. Unless otherwise agreed to be necessary, your provider retains clinical records only as long as is mandated by Illinois law. If you have concerns regarding the treatment records, please discuss them with your provider. As a client, you have the right to review or receive a summary of your records at any time, except in limited emergency circumstances or when your provider assesses that releasing such information might be harmful in any way. In such a case, your provider will provide the records to an appropriate and legitimate mental health professional of your choice. Considering all of the above exclusions, if it is still appropriate, and upon your request, your provider will release information to any agency/person you specify unless your provider assesses that releasing such information might be harmful in any way. When more than one client is involved in treatment, such as in cases of couple and family therapy, your provider will release records only with signed authorization from all adults (or all those who legally can authorize such a release) involved in the treatment.
Telephone & Emergency Procedures: If you need to contact your provider between sessions in a non-emergency situation, please leave a message at (217)546-4090 x55 and your call will be returned as soon as possible. Your provider checks her messages a few times during the daytime only, unless she is out of town. If an emergency situation arises, call 911. Please do not use e-mail, text, or faxes for emergencies. Your provider does not always check her email or faxes daily.
Payments & Insurance Reimbursement: Payment of session fees, insurance co-payment, coinsurance and deductible, or other charges are due at the time of service unless prior arrangements have been made with the provider. As always, verification of insurance coverage and referrals remains the responsibility of the client. Telephone conversations, site visits, writing and reading of reports, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the standard rate, unless indicated and agreed upon otherwise. Insurance may not cover these charges. Please notify your provider if any problems arise during the course of therapy regarding your ability to make timely payments. If you cannot pay for services as agreed, no further services will be provided until your account has been brought current. If your account is overdue (unpaid) and there is no written agreement on a payment plan, your provider can use legal or other means (courts, collection agencies, etc.) to obtain payment. You will be responsible for any fees incurred from returned checks. If your account, after insurance reimbursement, is 90 in arrears, a 9% per annum service charge will be added to your bill. If your account is turned over to a licensed collection agency, an additional fee of 40% of the unpaid balance will be added to your unpaid balance. You will be responsible for the unpaid balance as well as any fees associated with the collection process. These fees can include but are not limited to any additional agency fees, attorney fees, and court fees. You agree, in order for us to service our account or to collect any amounts you may owe, we may contact you by telephone at any telephone number associated with our account, including sending text messages or e-mails, using any e-mail address you provide to us. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable.
The process of therapy/evaluation and scope of practice: Participation in therapy can result in a number of benefits to you, including improving personal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. Your provider will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. Your provider may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, your provider is likely to draw on various psychological approaches according, in part, to the problem that is being treated and her assessment of what will best benefit you. These approaches include, but are not limited to, behavioral, cognitive-behavioral, cognitive, psychodynamic, existential, system/family, developmental (adult, child, family), humanistic or psycho-educational. Your provider provides neither custody evaluation recommendations nor medication, nor prescription recommendations nor legal advice, as these activities do not fall within her scope of practice.
Treatment Plans: Within a reasonable period of time after the initiation of treatment, your provider will discuss with you her working understanding of the problem, treatment plan, therapeutic objectives, and her view of the possible outcome of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, your provider’s expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits.
Termination: As set forth above, after the first couple of meetings, your provider will assess if she can be of benefit to you. Your provider does not work with clients who, in her opinion, she cannot help. In such a case, if appropriate, she will give you referrals that you can contact. If at any point during psychotherapy your provider either assesses that she is not effective in helping you reach the therapeutic goals or perceived you as non-compliant or non-responsive, and if you are available and/or it is possible and appropriate to do, she will discuss with you the termination of treatment and conduct pre-termination counseling. In such a case, if appropriate and/or necessary, she would give you a couple of referrals that may be of help to you. If you request it and authorize it in writing, your provider will talk to the psychotherapist of your choice in order to help with the transition. If at any time you want another professional’s opinion or wish to consult with another therapist, your provider will give you a couple of referrals that you may want to contact, and if she has your written consent, she will provide her or him with the essential information needed. You have the right to terminate therapy and communication at any time. If you choose to do so, upon your request and if appropriate and possible, your provider will provide you with names of other qualified professionals whose services you might prefer.
Dual Relationships: Despite a popular perception, not all dual or multiple relationships are unethical or avoidable. Therapy never involves sexual or any other dual relationship that impairs your provider’s objectivity, clinical judgment or can be exploitative in nature. Your provider will assess carefully before entering into non-sexual and non-exploitative dual relationships with clients. It is important to realize that in some communities, particularly small towns, military bases, university campus, etc., multiple relationships are either unavoidable or expected. Your provider will never acknowledge working with anyone without his/her written permission. Many clients have chosen your provider as their therapist because they knew her before they entered therapy with her, and/or are personally aware of her professional work and achievements. Nevertheless, your provider will discuss with you the often-existing complexities, potential benefits and difficulties that may be involved in dual or multiple relationships. Dual or multiple relationships can enhance trust and therapeutic effectiveness but can also detract from it and often it is impossible to know which ahead of time. It is your responsibility to advice your provider if the dual or multiple relationships becomes uncomfortable for you in any way. Your provider will always listen carefully and respond to your feedback and will discontinue the dual relationship if she finds it interfering with the effectiveness of the therapy or your welfare and, of course, you can do the same at any time.
Social Networking and Internet Searches: I do not accept friend requests from current or former clients on social networking sites such as Facebook. I believe that adding clients as friends on these sites and/or communicating via such sites is likely to compromise their privacy and confidentiality. For this same reason, I request that clients not communicate with me via any interactive or social networking web sites.
Cancellation: Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours (1 day) notice is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification. Most insurance companies do not reimburse for missed sessions.
I have read the above Office Policies and General information, Agreement for Psychotherapy Services; and Informed Consent for Psychotherapy carefully. I understand and agree to comply with them.
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