INFORMED CONSENT

***Phone and Email Clients: BY CALLING/EMAILING YOU AGREE AND UNDERSTAND THE FOLLOWING CLAUSES REGARDING ALL SESSIONS:***


CONFIDENTIALITY

 All sessions, including telephone or email contacts are confidential to persons outside of the therapy with some exceptions:

 I am required by law to disclose confidential information if any of the following conditions exist:



*You are a danger to yourself or others.

* You seek treatment to avoid detection or apprehension, or enable anyone to commit a crime.

*I was appointed by the court to treat you. (This is not the same as being court-referred.)

*I receive a court order. (This is not the same as a subpoena.)

*Your contract with me is for the purpose of determining sanity in a criminal preceding.

*Your contract with me is for the purpose of establishing your competence.

*You are under the age of 16 and a victim of a crime.

*You are a minor and I reasonably suspect you are the victim of a crime.

*You are a person over the age of 65, or a dependent adult, and I believe you are the victim of physical, financial abuse, neglect, isolation or abduction.  I may also report emotional abuse.

*You file suit against me for breach of duty, or I file a suit against you.

* You have filed a suit against someone and have claimed mental/emotional damages as part of the suit.

*You waive your rights to privilege (as in the case of a subpoena) or give consent.

*Your insurance company paying for services has the right to review all records.


All records, written information, or any electronic data are marked CONFIDENTIAL and are kept under lock and key. No one inside or outside the office will have access to your case except me. This applies as well to the other therapists in the office. Each one of us keep separate locked file cabinets. Computer files are also confidential and kept on our individual computers; that, includes insurance records, all password protected. 


Therapy is a unique and highly individual experience with the outcome determined by the effort and motivation you bring to work towards a change in yourself and how you see the world around you. In the beginning, we will discuss your concerns and goals for therapy. If possible, I will give you an approximate time for length of therapy. Because feelings will be explored, you may feel a range of emotions that can be intense at times. This is part of a normal process and does not mean there is something bad or wrong with you. The hope is that the experience and expression of feelings will bring to the surface “what is right” with you. While therapy should end through mutual agreement once desired goals have been reached, you have the right to end therapy at any time. Please feel you always have the right to ask questions of me. Therapy only works if you have trust and confidence in me and feel my respect and concern for you.

As a therapist, I participate in case consultations and peer supervision, to provide excellence in the service I give and in accordance with accepted professional behavior.  


I will discuss a fee with you before the first session. The therapy session/hour is normally 50 minutes, but occasionally a longer session may be recommended.

(In counseling children or adolescents, confidentiality is a necessity; as much as possible, in order for the therapeutic process to work. While you as parent or guardian have a legal right to information, I will speak with you in a general way unless there is a danger to the child’s life. This is conveyed to the child as well. Usually I ask the child and parent to meet with me together so that the parent can voice concerns or ask questions. Sessions with minors may only last 30-45 minutes, depending upon age.)

CONTACTING ME:

Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office between 9 AM and 5 PM, I will not answer the phone when I am with a client. When I am unavailable, my telephone is answered by my voice mail that I monitor frequently. I will make every effort to return your call within 24 hours of the day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. [In emergencies, you can try me on my cell phone.] If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist [psychiatrist] on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary.   *Please note that on phone calls that go beyond 15 minutes you will be charged based on my hourly rate.  You may also contact me by email.  If you choose to do so, please be aware of confidentiality issues.  As mentioned I will keep emails, and electronic documents, under password protection, but you are responsible for the confidentiality of incoming emails and electronic information on your end.

PROFESSIONAL FEES/ BILLING AND PAYMENTS:

My hourly fee is $150.00. You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. [In circumstance of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan.] 

If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situation, the only information I release regarding a client’s treatment is his/her name, the nature of services provided, and the amount due. [If such legal action is necessary, its costs will be included in the claim.]

CLIENT AGREEMENT AND POLICIES

Payment policy: You agree to make payment at the time of service. Because some insurance companies pay many months in arrears or not at all, you understand that you are responsible for the total fee.  There will be a $25.00 service charge on all returned checks.  In the event that your account goes to collections, there will be a 20% collection fee added to my balance.  If you wish to pay with credit card, you may also do so, and it may be charged to avoid collection fees.

Cancellation policy: You agree to cancel appointments only in the event of extreme necessity.  There is a 24-hour cancellation policy.  You must cancel within the hours of 9AM - 5PM Monday through Friday to avoid being charged. I understand I will be charged full fee unless I provide 24 hours advance notice.

In the case of insurance, last minute cancellations will need to be paid in full by you since insurance is not responsible for a late cancel or “no show.”  If you are a credit card customer, your credit card may be charged.



Participation in treatment: You acknowledge that it is YOUR choice to participate in psychotherapy (or to have your child participate), and agree to participate fully and voluntarily. Also, the therapist and you have discussed your case (or your child's case) and you have been informed of the risks, approximate length of treatment, alternative methods to treatment, and the possible consequences of the chosen treatment.

Attendance: You understand that regular attendance will produce the maximum possible benefits, and realize that the outcome of therapy depends upon your personal investment in the therapy process. If you decide to terminate treatment, which you are free to do at any time, you will discuss termination before ending treatment.

 

Treatment Outcomes:  While you expect benefits from this treatment you fully understand and accept that because of factors beyond our control, such benefits and desired outcomes cannot be guaranteed.

 

Confidentiality:  You have been informed and understand the limits of confidentiality, that by law, the therapist must report to appropriate authorities any suspected child abuse or serious threats of harm to myself or another person. 

Please read and if applicable: 
I authorize Mou Wilson, MFT (Licensed Marriage and Family Therapist) to file my insurance and authorize her to provide the necessary diagnostic/treatment information, as well as any information related to my psychotherapy that my insurance company and/or managed care organization may require.