Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it.
Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy 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. The first sessions will involve a comprehensive evaluation of your needs.
By the end of the evaluation, I will be able to offer you some initial impressions of what our work might include. At that point, we will discuss your treatment goals and create an initial treatment plan. You should evaluate this information and make your own assessment about whether you feel comfortable working with me.
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 set up a meeting with another mental health professional for a second opinion. 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, my policy is to collect the amount of your co-payment [unless we both agree that you were unable to attend due to circumstances beyond your control].
It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the portion of the fee as described above. If it is possible, I will try to find another time to reschedule the appointment. 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. You are responsible for paying at the time of your session unless prior arrangements have been made.
Payment must be made by check or cash; I am not able to process credit card charges as payment. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment.
In addition to weekly appointments, it is my practice to charge this amount on a prorated basis I will break down the hourly cost for other professional services that you may require such as report writing, telephone conversations that last longer than 15 minutes, attendance at meetings or consultations which you have requested, or the time required to perform any other service which you may request of me.
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 even if another party compels me to testify.
If you have a health insurance policy, it will usually provide some coverage for mental health treatment. Due to the rising costs of health care, insurance benefits have increasingly become more complex.
It is sometimes difficult to determine exactly how much mental health coverage is available. Managed Health Care plans such as HMOs and PPOs often require advance authorization, without which they may refuse to provide reimbursement for mental health services. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end.
Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.
You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Diagnoses are technical terms that describe the nature of your problems and whether they are short-term or long-term problems.
There is a copy in my office and I will be glad to let you see it to learn more about your diagnosis, if applicable. Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record in rare cases.
This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier if you plan to pay with insurance.
In addition, if you plan to use your insurance, authorization from the insurance company may be required before they will cover therapy fees. Outline the responsibilities of all parties involved, add a detailed release of liability, and include any other information necessary to provide indemnity and protect both your company and the individual giving their informed consent. Why not spice up your form by adding your logo and changing the background color too?
Connect with Google Sheets or Airtable to instantly generate a spreadsheet of all form submissions, or link your form to HubSpot, Zoho, or SalesForce to automatically add participants to your CRM database. Be sure to collect e-signatures to make your consent forms legally binding! Easy to customize and share. No coding required. A Professional Counseling Informed Consent Form is a document provided by the counseling service to their clients in order to properly acquire consent from them treatment for mental health.
The form contains information about the services and the agreement to be made by the counseling service and the client. By having this document, it also helps inform of the risks, limitations, and benefits of the treatment.
This Professional Counseling Informed Consent Form is a direct and simple form for clients who wish to receive therapy, which may be used by the counsel for reference. It serves as a reference for the therapist in informing his or her client of the client's rights and what to expect in the sessions.
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