Therapy is best experienced in an atmosphere of trust. For that reason, all therapy sessions are strictly confidential and may not be revealed to anyone without your written permission. Confidentiality is taken seriously and your information will not be discussed with or released to any individual, agency, or corporation except if such release is requested via a signed authorization form, or if a client indicates intent to do harm to themselves or others.
CONSENT FOR TELEHEALTH CONSULTATION
I understand that my health care provider wishes me to engage in a telehealth consultation.
1. I understand video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit since I will not be in the same room as my provider.
2. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
3. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
PRACTICE POLICIES APPOINTMENTS AND CANCELLATIONS
Please remember to cancel or reschedule at least 24 hours in advance of your scheduled appointment. You will be responsible for the entire fee if your appointment is canceled less than 24 hours prior. The standard meeting time for psychotherapy is 45 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the 45-minute session need to be discussed with the therapist for time to be scheduled in advance. Cancellations and re-scheduled sessions will be subject to a full charge if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time. If you need to contact me between sessions, please leave a message on my voice mail. I am often not immediately available; however, I will attempt to return your call within 24 hours. If a true emergency situation arises, please call 911 or any local emergency room. Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it. I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.
Effective coaching sessions are often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client.
As we are working together in a non-clinical setting and only for consultation purposes, I will not and cannot make clinical assessments, offer a diagnosis, provide letters for work/school or assist with court-ordered sessions. Our sessions cannot be billed to or covered by insurance.
While the therapeutic relationship is unique in that it is highly personal, at the same time it is a contractual agreement. Given this, it is important for us to reach a clear understanding of 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. You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and your repeating patterns, as well as to help you clarify what it is that you want for yourself.
Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name. If we see each other accidentally outside of therapy, 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, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.
By signing this form, I certify: That I have read or had this form read and/or explained to me. That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
Effective as of September 11, 2019