Client-Therapist Service Agreement
Welcome to my practice. This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patients' rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very _important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future. Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in therapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.
Goals of Therapy
There can be many goals for the therapeutic relationship. Some of these will be long term goals such as improving the quality of your life, overcoming and learning from past experiences or improving self-esteem. Others may be more immediate goals such as decreasing anxiety and depression symptoms, developing healthy relationships, changing behavior or decreasing/ending alcohol or drug use. Whatever the goals for therapy, they will be set by the clients according to what they want to work on in counseling. The therapist may make suggestions on how to reach that goal but you decide where you want to go.
Risks/Benefits of Therapy
Therapy is an intensely personal process which can bring unpleasant memories or emotions to the surface. There are no guarantees that counseling will work for you. Clients can sometimes make improvements only to go backwards after a time. Progress may happen slowly. Counseling requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions. However, there are many benefits to therapy. Therapy can help you develop coping skills, make behavioral changes, reduce symptoms of mental health disorders, improve the quality of your life, learn to manage anger, learn to live in the present and many other advantages
Appointments will ordinarily be 50 minutes in duration as needed and determined by the nature of the therapy. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours' notice. If you miss a session without canceling, or cancel with less than 24-hour notice, you will be required to pay for the session [unless we both agree that you were unable to attend due to circumstances beyond your control]. Cancellations without adequate notice prevent me from filling the time slot with others who could use that time. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible the cancellation fee. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.
Every effort will be made to keep your personal information private. If you wish to have information released, you will be required to sign a consent form before such information will be released. There are some limitations to confidentiality to which you need to be aware. Consultation with another professional counselor may occur in order to give you the best service. In the event of consultation, no identifying information such as your name would be released. Counselors are required by law to release information when the client poses a risk to themselves or others and in cases of abuse to children or the elderly. If there is receipt of a court order or subpoena, I may be required to release some information. In such a case, I will consult with other professionals and limit the release to only what is necessary by law.
Confidentiality and Technology
Some clients may choose to use technology in their counseling sessions. This includes but is not limited to online counseling via Facetime, telephone, email or text. Due to the nature of online counseling, there is always the possibility that unauthorized persons may attempt to discover your personal information. Every precaution to safeguard your information will be taken but cannot guarantee that unauthorized access to electronic communications could not occur. Please be advised to take precautions with regard to authorized and unauthorized access to any technology used in counseling sessions. Be aware of friends, family members, significant others or co-workers who may have access to your computer, phone or other technology used in your counseling sessions. If you wish, you can make scheduling arrangements via email. I do not do therapy or clinical work through email.
I will keep records of your counseling sessions and a treatment plan which includes goals for your counseling. These records are kept to ensure a direction to your sessions and continuity in service. They will not be shared except with respect to the limits to confidentiality discussed in the Confidentiality section. Should the client wish to have their records released, they are required to sign a release of information which specifies what information is to be released and to whom. Records will be kept for at least 7 years but may be kept for longer.
You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by cash, check or credit card If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required.
I currently do not accept insurance. I will assist with filing claims for you to be able to be reimbursed. I will provide you with a statement indicating your clinical diagnosis and the CPT code for the service provided which will enable you to file for reimbursement out of network.
I am often not immediately available by telephone. I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a message on my confidential voice mail and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters. If you feel you cannot wait for a return call or it is an emergency situation, go to your local hospital or call 911.
Consent to Therapy
Your signature below indicates that you have read this Agreement and agree to its terms.