AGREEMENT FOR PSYCHOTHERAPY SERVICES
This form provides you (client) with information that is additional to
that detailed in the Notice of Privacy Practices.
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 (client’s) written permission, except where disclosure is
required by law. Most of the provisions
explaining when the law requires disclosure were described to you in the Notice
of Privacy Practices that you received with this form.
When Disclosure Is Required By Law: Some of the circumstances where disclosure is
required by the law are: where there is a reasonable suspicion of child,
dependent or elder, abuse or neglect; and where a client presents a danger to
self, to others, to property, or is gravely disabled (for more details see also
Notice of Privacy Practices form).
When Disclosure May Be Required: Disclosure may be required pursuant to a legal
proceeding. If you place your mental
status at issue in litigation initiated by you, the defendant may have the
right to obtain the psychotherapy records and/or testimony by your
therapist. In couple and family therapy,
or when different family members are seen individually, confidentiality and
privilege do not apply between the couple or among family members. Your therapist will use his clinical judgment
when revealing such information. Your
therapist will not release records to any outside party unless he is authorized
to do so by all adult family members
who were part of the treatment.
Emergencies: If there is an emergency during our work
together, or in the future after termination, where your therapist becomes
concerned about your personal safety, the possibility of you injuring someone
else, or about you receiving proper psychiatric care, he will do whatever he
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, he may also contact the
person whose name you have provided on the biographical sheet.
Health Insurance & Confidentiality of Records: Disclosure of confidential
information may be required by your health insurance carrier or HMO/PPO/
Confidentiality of E-mail, Cell Phone and Faxes
Communication: It
is very important to be aware that e-mail and cell phone communication can be
relatively easily accessed by unauthorized people and hence, the privacy and
confidentiality of such communication can be compromised. E-mails, in particular, are vulnerable to
such unauthorized access due to the fact that servers have unlimited and direct
access to all e-mails that go through them.
Faxes can easily be sent erroneously to the wrong address. Please notify your therapist at the beginning
of treatment if you decide to avoid or limit in any way the use of any or all
of the above-mentioned communication devices.
Please do not use e-mail or faxes for emergencies.
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
(client) nor your attorney, nor anyone else acting on your behalf will call on
your therapist to testify in court or at any other proceeding, nor will a
disclosure of the psychotherapy records be requested.
Consultation: Your therapist consults regularly with other professionals regarding his clients; however, the client’s name or other identifying information is never mentioned. The client’s identity remains completely anonymous, and confidentiality is fully maintained.
* Considering all of the above exclusions, if it is
still appropriate, upon your request, your therapist will release information
to any agency/person you specify unless he concludes that releasing such
information might be harmful in any way.
TELEPHONE
& EMERGENCY PROCEDURES: If you need to contact your therapist between
sessions, please leave a message on his voice mail
PAYMENTS &
INSURANCE REIMBURSEMENT: Clients are expected to pay the standard fee of $95.00 per 45-50
minute session at the beginning of each session unless other arrangements
have been made. Telephone conversations,
site visits, report writing and reading, consultation with other professionals,
release of information, reading records, longer sessions, travel time, etc.
will be charged at the same rate, unless indicated and agreed otherwise. Please notify your therapist if any problem
arises during the course of therapy regarding your ability to make timely
payments. Clients who carry insurance
should remember that professional services are rendered and charged to the
clients and not to the insurance companies.
Unless agreed upon differently, your therapist will provide you with a
copy of your receipt every session, which you can then submit to your insurance
company for reimbursement if you so choose.
As was indicated in the section, Health
Insurance & Confidentiality of Records, you must be aware that
submitting a mental health invoice for reimbursement carries a certain amount
of risk. Not all issues/conditions/problems,
which are the focus of psychotherapy, are reimbursed by insurance
companies. It is your responsibility to
verify the specifics of your coverage.
MEDIATION
& ARBITRATION: All disputes arising out of or in relation to this agreement to provide
psychotherapy services shall first be referred to mediation, before, and as a
pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party
chosen by agreement of your therapist and client(s). The cost of such mediation, if any, shall be
split equally, unless otherwise agreed.
In the event that mediation is unsuccessful, any unresolved controversy
related to this agreement should be submitted to and settled by binding
arbitration in
THE PROCESS OF
THERAPY/EVALUATION: Participation in therapy can result in a number of benefits to you,
including improving interpersonal 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 therapist
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 your experiencing considerable
discomfort or strong feelings of anger, sadness, worry, fear, etc. or
experiencing anxiety, depression, insomnia, etc. Your therapist may challenge some of your
assumptions or perceptions or propose different ways of looking at, thinking
about, or handling situations that 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 therapist is likely to draw on
various psychological approaches according, in part,
to the problem that is being treated and his/her assessment of what will best
benefit you. These approaches include
behavioral, cognitive-behavioral, psychodynamic, existential, system/family,
developmental (adult, child, family), or psycho-educational.
Discussion of Treatment Plan: Within a reasonable period of time after the
initiation of treatment, your therapist , CSW will
discuss with you (client) his working understanding of the problem, treatment
plan, therapeutic objectives, and his view of the possible outcomes of
treatment. If you have any unanswered
questions about any of the procedures used in the course of your therapy, their
possible risks, your therapist’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. If you could benefit from any treatment that
your therapist ,
does not provide, he has an ethical obligation to assist you in
obtaining those treatments.
Termination: As set forth above, after
the first couple of meetings, your therapist, will assess if he can be of
benefit to you. Your therapist does not
accept clients who, in his opinion, he cannot help. In such a case, he will give you a number of
referrals that you can contact. If at any point during psychotherapy, your therapist assesses that
he is not effective in helping you reach the therapeutic goals, he is obliged
to discuss it with you and, if appropriate, to terminate treatment. In such a case, he would give you a number of
referrals that may be of help to you. If
you request it and authorize it in writing, your therapist 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
therapist will assist you in finding someone qualified, and, if he has your
written consent, he will provide her or him with the essential information
needed. You have the right to terminate
therapy at any time. If you choose to do
so, your therapist will offer to provide you with names of other qualified
professionals whose services you might prefer.
Dual Relationships: Not all dual relationships are unethical or avoidable. Therapy never involves sexual or any other dual relationship that impairs your therapist’s objectivity, clinical judgment, or therapeutic effectiveness or can be exploitative in nature. He will assess carefully before entering into non-sexual and non-exploitative dual relationships with clients. The Greater Rochester area is a small community and many clients know each other and your therapist from the community. Consequently you may bump into someone you know in the waiting room or into your therapist out in the community. Your therapist will never acknowledge working therapeutically with anyone without his/her written permission. Many clients choose your therapist as their therapist because they know him before they enter into therapy with him and/or are aware of his stance on the topic. Nevertheless, your therapist will discuss with you, his client(s), the often-existing complexities, potential benefits, and difficulties that may be involved in such relationships. Dual or multiple relationships can enhance therapeutic effectiveness but can also detract from it and often it is impossible to know that ahead of time. It is your, the client’s, responsibility to communicate to your therapist if the dual relationship becomes uncomfortable for you in any way. Your therapist will always listen carefully and respond accordingly to your feedback. He will discontinue the dual relationship if he finds it interfering with the effectiveness of the therapeutic process or the welfare of the client and, of course, you can do the same at any time.
CANCELLATION: Since scheduling of an appointment involves the reservation of time specifically for you, a minimum of 48 hours (2 days) 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 Agreement and Office Policies and General
Information carefully; I understand them and agree to comply with them:
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Client/Guardian name Date Print
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Client/Guardian name Date Print
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Therapist Name Date Print