INFORMED CONSENT FOR PSYCHOTHERAPY AND TELEMENTAL HEALTH TREATMENT

Therapy is a relationship that works in part because of clearly defined rights and responsibilities held by each person. As a client in psychotherapy, you have certain rights that are important for you to know about because this is your therapy. There are also certain limitations to those rights that you should be aware of. As a therapist, I have corresponding responsibilities to you, too.

I do not have 24-hour emergency or on-call coverage.  If you believe you will need a therapist with 24-hour coverage, I will assist you with a referral.  If you experience a psychiatric emergency, you should call 911 or go to the nearest hospital emergency room rather than waiting for me to get in touch.

​

YOUR RESPONSIBILITIES AS A THERAPY CLIENT

You are responsible for coming to your session on time and at the time we have scheduled. Sessions last for 45-55 minutes. If you are late, we will still end on time. If you are 15 minutes late (or more), you will not be seen. If you miss a session without canceling or cancel with less than twenty-four (24) hours’ notice, you may be charged a small fee for that session, unless circumstances beyond your control have caused your cancelation. If you miss a scheduled appointment, you must contact me to reschedule – I will not automatically reschedule your appointment.

Should a habit of not attending your scheduled appointments develop, you will be placed on a same day appointment program until commitment to attending sessions has been demonstrated.

Most therapy clients experience an increase in symptoms at the beginning of therapy; this is normal and will lessen as you progress through therapy.  You have the right to ask questions about anything that happens in therapy. I’m always willing to discuss how and why I’ve decided to do what I’m doing, and to look at alternatives that might work better. Feel free to ask me to try something that you think will be helpful. You can ask me about my training for working with your concerns, and can request that I refer you to someone else if you decide I’m not the right therapist for you. You are free to leave therapy at any time, although I recommend finding a way to give me advance notice so that I can help you end treatment well and consolidate gains (please see section on Ending Therapy). 

​

MY RESPONSIBILITIES TO YOU AS YOUR THERAPIST

I.  CONFIDENTIALITY

With the exception of certain specific exceptions described below, you have the absolute right to the confidentiality of your therapy. I cannot and will not tell anyone else what you have told me, or even that you are in therapy with me without your prior written permission. Under the provisions of the Health Care Information Act of 1992, I may legally speak to another health care provider or a member of your family about you without your prior consent, but I will not do so unless the situation is an emergency. I will always act so as to protect your privacy even if you do release me in writing to share information about you. You may direct me to share information with whomever you chose, and you can change your mind and revoke that permission at any time. You may request anyone you wish to attend a therapy session with you. You are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA).

The following are legal exceptions to your right to confidentiality. I would inform you of any time when I think I will have to put these into effect.

1. If I have good reason to believe that you will harm another person, I must attempt to inform that person and warn them of your intentions. I must also contact the police and ask them to protect your intended victim.

2. If I have good reason to believe that you are abusing or neglecting a child or vulnerable adult, or if you give me information about someone else who is doing this, I must inform Child Protective Services or Adult Protective Services immediately.

3. If I believe that you are in imminent danger of harming yourself, I may legally break confidentiality and call the police or the county crisis team. I am not obligated to do this, and would explore all other options with you before I took this step. If at that point you were unwilling to take steps to guarantee your safety, I would call the crisis team.

 

II.  TELEHEALTH DISCLOSURE

I understand I have the option of receiving services through telemedicine (e.g., internet or telephone-based therapy) a mode of my psychotherapy treatment. I understand that telemedicine includes the practice of health care delivery, including mental health and substance abuse care, delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, and/or data communications.

I understand that I have the following rights with respect to telemedicine: (1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment or risking the loss or withdrawal of any program benefits to which I would otherwise be entitled. (2) The laws that protect the confidentiality of my medical information also apply to telemedicine.

I understand that there are risks and consequences from telemedicine. These may include, but are not limited to, the possibility, despite reasonable efforts on the part of my therapist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; the electronic storage of my medical information could be accessed by unauthorized persons; and/or misunderstandings can more easily occur, especially when care is delivered in an asynchronous manner.

Finally, I understand that there are potential risks and benefits associated with any form of therapy and that, despite my efforts and the efforts of my psychotherapist, my condition may not improve and in some cases may even get worse. I understand that I may benefit from telemedicine, but results cannot be guaranteed or assured. The benefits of telemedicine may include, but are not limited to: finding a greater ability to express thoughts and emotions; transportation and travel difficulties are avoided; time constraints are minimized; and there may be a greater opportunity to prepare in advance for therapy sessions.

 

III. RECORD-KEEPING

I keep brief records of each session noting the dates we meet, the topics we cover, progress reports from the client’s perspective, interventions and impressions from the therapist and next steps.

 

IV. DIAGNOSIS

If a third party such as an insurance company is paying for part of your bill, I am normally required to give a diagnosis to that third party in order to be paid. Diagnoses are technical terms that describe the nature of your problems and something about whether they are short-term or long-term problems.

 

V. FEES

If there is no insurance to bill, individual therapy is $175 per session. You will be asked to pay for each session at the time of the session. Payment can be by check or credit card.  A monthly statement can be requested for tax purposes.

There is direct billing with several insurance companies, including Medicaid.  For clients using insurance with a co-payment, a statement of the month’s sessions will be furnished to you around the first of each month for the previous month’s sessions listing payments and any amounts owed.  Payment can be by check, cash or credit card.

Clients work via a private contract and informed consent with Peggy Defazio and are liable for charges of her services without any limits that would otherwise be imposed by any insurance company.

 

VI.  COURT APPEARANCE

I understand that there may be a time when you feel the need to have me in court on your behalf.  I strongly discourage this action.  My experience has been that the direct testimony of a mental health provider does not influence the court’s decision.  If you insist on having me in court, you will be responsible for paying my full hourly fee for the entire time I am in court, whether I am called to testify or not.  Payment must be made prior to my appearance.  An alternative is to request a treatment summary statement that you and your lawyer can present without my presence.

 

VII. ENDING THERAPY WELL

I want to make your therapy as successful as possible. For that reason, it works best to find a rhythm and structure to the beginning stages with sessions that meet regularly. To support your leaving, I request several weeks of notice prior to your actual leaving to allow you to have an experience of leaving well, with a sense of completion. If I initiate terminating you from our therapy, it will be because I feel that I am not able to be helpful to you any longer. My ethics and license requires that I offer quality service and have my clients’ needs as paramount in my treatment planning. If I no longer feel that I am the best or right practitioner for you, I will offer referrals to other sources of care, but cannot guarantee that they will accept you for therapy or how they will approach your treatment.

 

MY TRAINING AND APPROACH TO THERAPY

I earned a Master’s of Arts in Counseling from Dallas Baptist University in 1999. I have an active Licensed Professional Counselor (LPC) license in Oregon and inactive LPC licenses in Texas and Missouri. Earning and maintaining a LPC requires supervision from an experienced LPC and regular continuing education. My areas of special training and expertise include: cognitive behavioral, solution focused, emotional freedom technique, positive psychology and reality therapy approaches.

 

COMPLAINTS

If you’re not satisfied with the treatment you are receiving, I encourage you to talk with me about it so that I can respond to your concerns. You have the right to contact my licensing board if you feel it is appropriate:

Board of Licensed Professional Counselors & Therapists

3218 Pringle Rd SE, #250, Salem, OR  97302-6312  Phone: 503.378.5499

Email: lpct.board@state.or.us   Website: www.oregon.gov/OBLPCT

 

CONSENT TO PSYCHOTHERAPY & TELEMENTAL HEALTH TREATMENT

I have read this statement, had sufficient time to be sure that I considered it carefully, asked any questions that I needed to, and understand it. I understand the limits to confidentiality required by law. I understand the fee per session and my rights and responsibilities as a client, and my therapist’s responsibilities to me. I know I can end therapy at any time I wish.

​

My digital signature signals agreement of these policies.

 

Signed: Click or tap here to enter text.                                                                                      

Dated:   Click or tap here to enter text.

 

Address:  _________________________________________________________________________________________

Phone: _____________________________________________________Message okay? _______ Text okay?_________

Email Address: ___________________________________________________________________Email okay? _______