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CONSENT TO TREATMENT This document (the Agreement) contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a new federal law that provides new privacy protections and new Patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your Personal Health Information in greater detail. The law requires that VISIONS obtain your signature acknowledging that I have provided you with this information. Although these documents are long and sometimes complex, it is very important that you read them carefully before our next session. We can discuss any questions you have about the procedures at that time. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have taken action in reliance on it; if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred. Outpatient Psychotherapy Services Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and Patient, and the particular problems you or your child are experiencing. There are many different methods I may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you or your child will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. Before we begin working together, it is important to understand that I cannot guarantee that you or your child will benefit from therapy. No therapist can make such a guarantee because each Patient responds differently to this experience. Our first few sessions will involve an evaluation of needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you obtain an appropriate consultation with another mental health professional. The goals of a psychological evaluation are: a) to provide insight into how you (or your child) is currently functioning, including possibly the evaluation of intellectual potential, academic achievement level, attentional abilities, and/or emotional/ behavioral functioning; b) to diagnose or rule out particular difficulties; and c) to identify strengths. An evaluation may involve the use of a number of procedures such as interviews and psychological questionnaires. Psychological evaluation can have benefits and risks. An evaluation may not answer the questions that motivated the assessment, or it may suggest something that you might find distressing. However, evaluations usually do provide insights that can be valuable in obtaining appropriate care. Psychotherapy Sessions The therapist normally conducts an evaluation that will last from 2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you or your child need in order to meet your treatment goals. If psychotherapy is begun, I will usually schedule one 45 minute session once per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours notice of cancellation (see details under Financial Arrangements section). Contacting your therapist Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office regular hours, I probably will not answer the phone when I am with a Patient. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call as soon as possible. If you are difficult to reach, please inform me of times when you will be available. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician, call 911, or call the nearest emergency room and ask for the psychiatrist on-call. If I will be unavailable for an extended time. Confidentiality The law protects the privacy of all communications between a Patient and a therapist. In most situations, I can only release information to others about your treatment (or your child’s treatment) if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this current agreement provides consent for those activities, as follows: • I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my Patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel it is important for our work together. I will note all consultations in your Clinical Record. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this agreement. • If a Patient threatens to harm himself / herself, I may be obligated to seek hospitalization for him/her and/or to contact family members, or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or authorization: • If I have reason to believe that a child has been abused, the law requires that I file a report with the appropriate governmental agency. Once such a report is filed, I may be required to provide additional information. • If I have reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon him or her, other than by accidental means, or that he or she has been neglected or exploited, I must report to an agency designated by the Department of Human Services. Once I have filed such a report, I may be required to provide additional information. • If I determine that a patient presents a serious danger of violence to another, I may be required to take protective actions. These actions may include notifying the potential victim, and /or contacting the police, and/or seeking hospitalization for the Patient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. • If you are involved in a court proceeding and a request is made for information concerning my professional services, such information is protected by the therapist /Patient privilege law. I cannot provide any information without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. • If a Patient files a complaint or lawsuit against me, I may disclose relevant information regarding that Patient in order to defend myself. • If a Patient files a worker’s compensation claim, and I am providing treatment related to the claim, I must, upon appropriate request, furnish copies of all medical reports and bills. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a Patient’s treatment. Professional Records You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you or your child in two sets of professional records. One set constitutes your Clinical Record. It includes information about: your reasons for seeking therapy, a description of the ways in which you or your child’s problem impacts on your life, diagnosis, the goals that we set for treatment, progress towards those goals, medical and social history, treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself, your child, or others or makes reference to another person (unless such other person is a health care provider) and I believe that access is reasonably likely to cause substantial harm to such other person (or if information is supplied to me confidentially by others), you or your legal representative may examine and /or receive a copy of your or your child’s Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I require that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most situations, I am allowed to charge a copying fee. The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your records, you have a right of review (except for information provided to me confidentially by others) which I will discuss with you upon request. In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you or your child with the best treatment. While the contents of Psychotherapy Notes vary from Patient to Patient, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your or your child’s therapy. They also contain particularly sensitive information that you or your child may reveal to me that is not required to be included in your Clinical Record and information supplied to me confidentially by others. These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you. They also cannot be sent to anyone else, including insurance companies without your written, signed authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it. Statement of Patient Rights HIPAA provides you with several new or expanded rights with regard to your clinical records and disclosures of protected health information. These rights include requesting that I amend your or your child’s record; requesting restrictions on what information from your clinical record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this agreement; the attached notice form, and my privacy policies and procedures. Patients have the right to be treated with dignity and respect. Patients have the right to fair treatment regardless of race, religion, gender, ethnicity, age, disability, or source of payment. Patients have the right to have their treatment and to their information kept private and only disclosed to designated individuals given on a release form signed by the patient. Patients have the right to information from staff/providers in a language they can understand as well as an explanation of their condition and treatment. Patients have the right to know all about their treatment choices regardless of cost coverage. Patients have the right to get information about services offered by their providers and patient role in the treatment process. Patients have the right to request professional information about their provider. Patients have the right to know the clinical guidelines used in providing and/or managing their care. Patients have the right to provide suggestions on office policies and procedure. Patients have the right to complain and to know about the complaint, grievance, and appeals process. Patients have the right to know about State and Federal laws governing their rights and responsibilities. Patients have the right to participate in the formation of their plan of care. Minors & Parents Patients under 18 years of age who are not emancipated, as well as their parents should be aware that the law allows parents to examine their child’s treatment records unless I believe that doing so would endanger the child or we agree otherwise. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is typically my policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, I will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. AGREEMENT TO AVOID COURT At some point in your treatment there may be family sessions you invite other family members into your counseling session. We understand that family therapy begins with an evaluation of our relationship, past and present. All parties acknowledge that the goal of psychotherapy focusing on the family or couple, is for the sole purpose of the amelioration of psychological distress and that the process of psychotherapy depends on trust and openness during the therapy sessions. We understand that information discussed in therapy is for therapeutic purposes and is not intended for use in any legal proceedings involving the parties. We understand that in family therapy the family is the identified patient and the clinical focus in on treating the family and providing guidance on what is in the best interest of the family. Family therapy is not the individual mental health needs of any party. Therefore; it is understood by both parties that if they request Visions therapist’s services as a psychotherapist, they are expected not to subpoena her to testify for or against either party, to provide records in a court action or be presented in a deposition or court hearing of any kind such as divorce, child custody, domestic relations, civil or criminal proceedings. We agree to not use information shared during the therapy process against the other party in a judicial setting of any kind, be it civil, criminal, or circuit. We understand that while working as a family or couple, anything a member of the family tells Visions’ therapist individually, whether on the phone or in an individual meeting, may not be held as confidential, and at the therapist’s discretion may be shared with the spouse/partner during a subsequent family session. We have been given the opportunity to ask questions and discuss confidentiality and disclosure policies with the therapist. We understand the limits and benefits of using insurance to pay for family therapy. If we use insurance, we agree to provide all information needed to comply with insurance regulations. If we use insurance, we understand that the focus of treatment will be on one identified patient and the family work will be focused on ways the family can work together to alleviate the mental health concerns of the patient. We understand that if we use insurance, Visions’ therapist will not retain control over information provided to the insurance company. We understand that insurance companies conduct audits and when insurance companies do so, additional information from the file will need to be released. We understand that in family or couples therapy, records cannot be released without ALL of the adults participating in the therapy, signing consenting to the release of information. This does not apply to insurance disclosures for billing purposes or for insurance audit purposes. This contract is an agreement between the interested parties that neither party shall for any reason attempt to subpoena my testimony or my records to be presented in a deposition or court hearing of any kind for any reason, such as a divorce case. Both parties acknowledge that the goal of psychotherapy, either family or family with emphasis on the couple as the sole purpose of the amelioration of psychological distress and that the process of psychotherapy depends on trust and openness during the therapy sessions. By signing below, we agree to accept mental health services from Visions according to the terms identified above and accept full responsibility for payment for such services. If applicable, by signing below acknowledge I am the legal guardian of said patient and have legal custody or valid written authorization to act on behalf of said patient. (Please provide the court order if applicable)