CLIENT CONSENT to PSYCHOTHERAPY
Important Information for You to Know when Consenting to Treatment
A therapeutic relationship of trust and understanding is the most important aspect of counseling. In the first session we will determine whether I can assist you, whether you are comfortable with me, and the plan for treatment. There are different methods that I may use in this process and this won’t be a passive process, it calls for an active effort from you.
Due to the nature of the therapeutic process (often involving full disclosure of confidential information), you agree that neither you, your attorney, nor anyone else acting on your behalf will call on me to testify in court or at any other legal proceeding. This includes, but is not limited to, divorce and custody disputes, injuries, and lawsuits. You also agree to not request a disclosure of the psychotherapy records.
Everything you say will be kept confidential with the following exceptions:
- You are a danger to yourself
- You are a danger to others
- A court order
In couple and family therapy, or when different family members are seen individually, confidentiality does not apply between the couple or among family members. I will use my clinical judgment when revealing such information.
I may occasionally find it helpful to consult other professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The consultant is also legally bound to keep the information confidential.
The fee for a 53-minute intake (first session) is $200 and for a 53-minute regular session is $175. Payment is expected at the time of service. In the event that you will not keep an appointment, you will be expected to notify me 24 hours in advance or full payment will be due unless we both agree that you were unable to attend due to circumstances beyond your control. Special reports will be billed at the standard hourly rate. Outstanding fees 90 days past due will be submitted to a collection agency.
Use of Insurance
If you have a health insurance policy that covers mental health treatment, it is important that you find out exactly what services it covers because not all treatment is reimbursed. Also, we may not be in-network providers for all insurance companies.
Be aware that most insurance companies require a diagnosis for treatment. Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company’s 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 many cases, they share the information with a national medical information databank (MIB Group, mib.com) and this information may show up when you apply for life and health insurance. People have been denied insurance because of a diagnosis.
I can help you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. Many people choose to pay for my services themselves to avoid the problems described above.
If I do not answer the phone when you call, please leave me a message in my voicemail and I will attempt to return your call within 24 business hours.
In the event of an emergency, you may contact me by calling the office (484-353-6544) and using the emergency number provided. You may also utilize your family doctor, the local Crisis Intervention service, the police, 911, or the hospital emergency room.
Electronic Communication Policy
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.
Email Communications & Text Messaging
I use email communication and text messaging only with your permission and only for administrative purposes unless we have made another agreement. That means that email exchanges and text messages with my office should be limited to things like setting and changing appointments, billing matters and other related issues. Please do not email me about clinical matters because email is not a secure way to contact me. If you need to discuss a clinical matter with me, please feel free to call me so we can discuss it on the phone or wait so we can discuss it during your therapy session.
I may participate on various social networks. If you have an online presence, there is a possibility that you may encounter me. If that occurs, please discuss it with me during our time together. I do not communicate with, or contact, any of my clients through social media platforms like Twitter and Facebook. In addition, if I discover that I have accidentally established an online relationship with you, I will cancel that relationship. This is because these types of casual social contacts can create significant confidentiality risks for you.
I have a website that you are free to access. I use it for professional reasons to provide information to others about me and my practice. You are welcome to access and review the information that I have on my website and, if you have questions about it, we should discuss this during your therapy sessions.
I will not use web searches to gather information about you without your permission. I believe that this violates your privacy rights; however, I understand that you might choose to gather information about me in this way. In this day and age there is an incredible amount of information available about individuals on the internet, much of which may actually be known to that person and some of which may be inaccurate or unknown. If you encounter any information about me through web searches, or in any other fashion for that matter, please discuss this with me during our time together so that we can deal with it and its potential impact on your treatment.
Recently it has become fashionable for clients to review their health care provider on various websites. Unfortunately, mental health professionals cannot respond to such comments and related errors because of confidentiality restrictions. If you encounter such reviews of me or any professional with whom you are working, please share it with me so we can discuss it and its potential impact on your therapy. Please do not rate my work with you while we are in treatment together on any of these websites. This is because it has a significant potential to damage our ability to work together.
If you are under fourteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy that parents agree to give up access to your records. If they agree, I will provide them only general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else.
It is recommended that any decision you make regarding termination of counseling be discussed in person. This ends treatment in a more satisfactory and therapeutic manner.
Thank you for choosing White Oak Counseling Center.