INFORMED CONSENT
General Guidelines. Mental Health and Therapeutic Counseling require a great deal of participation and cooperation from the Patient. Your effort will be important in determining how much benefit you will receive. Much of what occurs during a session is dialogue. You will be expected to relate not only to problems and concerns, but successes as well. At times, you may be given homework assignments such as reading, keeping a journal, monitoring your own behavior, practicing new behavior, etc. You may also be asked to complete some questionnaires and/or tests. If a need for medication to relieve emotional discomfort or psychological difficulties seems indicated, a consultation with your physician and or a psychiatrist will recommended for you to arrange. It is important that you regularly and promptly attend scheduled sessions. No guarantees are made as to the result of treatments, assessments, or consultations. If you have questions about your therapist’s procedures, please discuss the same as they arise.
Professional Records. Professional records, including protected health information and psychotherapy notes, are handled in accord with HIPAA requirements, as detailed in your HIPAA notice.
Client’s Rights. HIPAA provides you with several rights with regard to your professional records and disclosure of protected health information. These rights include amendments to records, restrictions or disclosures, requests for accounting, and registering complaints.
Revocation. Either party may revoke this contract at any time. Your revocation will be binding on your therapist unless action has been taken in reliance on it. If there are obligations imposed on your therapist by law, or by your health insurer in order to process or substantiate claims made under your policy, or if you have not satisfied any financial obligation you have incurred.
Limits on Confidentiality. The laws governing confidentiality can be quite complex. In situations where specific advice is required. Your therapist reserves the right to seek legal advice.
Consultations – Your therapist may occasionally find it helpful to consult other health and mental health professionals about your case. During a consultation, your therapist will make every effort to avoid revealing your identity. Other professionals are legally bound to keep the information confidential. If you don’t object, your therapist will not tell you about these consultation unless they believe that it is important to your work together. All consultation will be noted as Protected Health Information
Business Practices – Ms. Knight operates independently. A billing professional is retained to assist with billing and payments accounting. Protected Health information is shared for administrative purposes. Business associates will be bound by contract to provide the same level of protection as required by HIPAA.
Special Situations: Separation, Divorce and/or Child Custody-If the Patient is a child and counseling is related to the parents’ separation, divorce or a child custody matter, or if the Patient Counseling is Court ordered, the Patient is the child. Each parent must hire their own, different mental health professional for services relating to their needs or care.
Further, it is probable that the therapist notes, files, and records will be the subject of review by the Court or others involved in any legal proceedings, including lawyers for the parents and guardians ad litem. If subpoena is issued for therapist files and records or for testimony at a deposition or court proceeding, the Patient (or parents if the Patient is a minor) will be notified. It is up to the Patient to seek a protective order if privacy is demanded by the Patient and notify the therapist of such an intention. Absent written notice, the therapist will comply with the subpoena, unless the release of the Patient’s disclosures in therapy is likely to result in emotional harm, then the Therapist may require a Court order to produce with disclosure protective provisions.
In the case of Patient Counseling secondary to co-parenting, the Therapist will not disclose reports and notes or testify in court related proceedings. Co-parenting counseling is a time to gain perspective in a secure environment. While co-parenting counseling may be ordered by the Court to avoid disputes, it is nevertheless intended and designed to be therapeutic.
Reunification counseling is typically court ordered to promote reunification of the Patient (child) with parent(s). Accordingly, reunification is not a ‘if it is completed” scenario, it is an “it will be done” scenario. At times the Therapist may require counseling sessions with a third party supervising parent visits, in addition to reunification therapy. This gives additional time for bonding in a non-therapeutic environment. Supervised visits will not be in lieu of reunification counseling sessions ordered by the court.
If the parent that is reunifying with the Patient has access to the Patient, that parent will transport the child to reunification sessions. If the other parent is transporting, that parent will wait for completion of the reunification counseling session in the conference room. Both parents will not participate in reunification counseling with the Patient at the same time because in high conflict situations the presence of both parents increases the Patient’s stress awareness levels, which should be avoided. The Patient should never be questioned about the counseling sessions by a parent as it puts them in the middle of a high conflict situation.
Exceptions to Confidentiality. The following are situations where your therapist is permitted or required to disclose information without either Patient (or parent) consent or authorization:
- If the Patient threatens to harm someone else, the therapist is required under the law to take steps to inform the intended victim and appropriate law enforcement agencies.
- If the Patient threatens to cause severe harm to himself\herself, the therapist is permitted to reveal information to others if she believes it is necessary to prevent the threatened harm.
- If the therapist has reasonable suspicion that any child, elderly person or incompetent person is being abused or neglected, the law requires that the therapist report this to the appropriate government agency.
- If a court orders the therapist to release information, the therapist is required provide that specific information to the court.
- If the patient has been referred to the therapist by a court of law for therapy or testing, the results of the treatment or tests ordered may have to be revealed to the court.
- If the Patient is or becomes involved in any kind of lawsuit or administrative procedure, where the issue of the patient’s mental health involved, the records may be subpoenaed in those records may not remain private in court.
- If the Patient sees the therapist in couples, group, or family therapy, the therapist asks that each member of the therapy session program promise to keep whatever happens in treatment confidential; however, the therapist cannot guarantee that others will keep information provided by the Patient confidential.
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Patient Name (printed) Authorized Signature Date
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Therapist Name (printed) Authorized Signature Date
