OUTPATIENT SERVICES CONTRACT AND INFORMED CONSENT

This document contains important information about our professional services and business policies. Please read it carefully. When you sign or click “I Agree”, it will represent your agreement to this contract.

PSYCHOLOGICAL 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 bring forward. There are many different methods that may be used 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 will have to work on things both during your 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, anxiety, depression and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress and anxiety. Working toward these benefits requires effort on your part. Psychotherapy requires your active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. You will be asked for your feedback and views on your therapy and its progress. Sometimes more than one approach can be helpful. You may need to challenge some of your assumptions or perceptions, or have to adopt different ways of thinking about or handling situations that may cause you to feel upset, angry, depressed, anxious or disappointed. Attempting to resolve issues that brought you into therapy may result in changes that were not originally intended. Psychotherapy may result in decisions to change behaviors, employment, substance use, schooling, housing, or relationships. Change can sometimes be quick and easy, but more often it can be gradual and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results.

Your first few sessions will involve an evaluation of your needs. By the end of the evaluation, you will be offered some first impressions of what your therapy will include and a treatment plan to follow if you decide to continue with treatment. The plan will include attempts on to help you achieve your goals. You should evaluate this information along with your own opinions of whether you feel comfortable working with your therapist. Therapy involves a commitment of time, money, and energy, so you should be careful about the therapist you see. If you have questions about the therapist’s procedures, you should discuss them whenever they arise. If your doubts persist, you can see another mental health professional.

PHONE CALLS & EMERGENCIES

If you need to contact your therapist between sessions, please contact your assigned health coach, who will address your concerns or contact your therapist on your behalf. Emergency phone consultations of 5 minutes or less are normally free. However, if you and your therapist spend more than 5 minutes in a week on the phone, if your therapist spends more than five minutes reading and responding to messages from you during a given week, or if your therapist spends more than five minutes involved in case management or coordination of care, you may be billed on a prorated basis for that time. If you feel the need for many phone calls and cannot wait for your next appointment, we may need to schedule more sessions to address your needs. 

If an emergency situation arises, please indicate it clearly in your message to your therapist or your health coach. If your situation is an acute emergency and you need to talk to someone right away, contact the closest 24­hour emergency psychiatric service: Dial 911 or Go to your nearest Emergency Room

THERAPY SESSIONS

During your first therapy sessions, your therapist will assess whether he/she can be of benefit to you. If your therapist does not think he/she can help you, he/she will refer you to others who work well with your particular issues. Within a reasonable period of time after starting treatment, your therapist will discuss his/her working understanding of your issues, a proposed treatment plan, and therapeutic objectives and possible outcomes of the therapy. If you have questions about any of the procedures used in the course of your therapy, their possible risks, your therapist’s expertise, or about the treatment plan in general, please ask your therapist. You also have the right to ask about other possible treatments for your condition and their risks and benefits. If you could benefit from any treatments that your therapist does not provide, your therapist will provide assistance or referral information for obtaining those treatments. During the time it takes for your therapist to evaluate you, you or your therapist can decide if the assigned therapist is the best person to provide the services you need in order to meet your treatment goals. If psychotherapy is begun, your therapist will usually schedule one session per week at an agreed time, although some sessions may be longer or more or less frequent. Once an appointment is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation, unless your therapist agrees that you were unable to attend due to circumstances beyond your control.

Deciding when to stop your work with your therapist is meant to be a mutual process. Before it is stopped, you and your therapist will discuss how you will know if or when to come back or whether a regularly scheduled "check­in" might work best for you. If it is not possible for you to phase out of therapy, it is recommended that you have closure on the therapy process with at least two termination sessions. 

Noncompliance with treatment recommendations may necessitate early termination of services. Your therapist will look at your issues with you and exercise his/her educated judgment about what treatment will be in your best interest. Your responsibility is to make a good faith effort to fulfill the treatment recommendations to which you have agreed. If you have concerns or reservations about treatment recommendations, you are strongly encouraged to express them so that any possible differences or misunderstandings can be resolved.

If at some point your therapist assesses that he/she is not effective in helping you reach your therapeutic goals, your therapist is obliged to discuss this with you and, if appropriate, terminate treatment and give you referrals that may be of help to you. If you request it and authorize it in writing, your therapist may talk to the psychotherapist of your choice in order to help with the transition. If at any time you want another professional's opinion or wish to consult with another therapist, your therapist will assist you in finding someone qualified. You have the right to terminate treatment at any time. If you choose to do so, your therapist may offer to provide you with names of other qualified professionals whose services you might prefer.

If you commit violence to, verbally or physically threaten or harass your therapist or the therapist’s colleagues or family, your therapist reserves the right to terminate your treatment unilaterally and immediately. Failure or refusal to pay for services after a reasonable time is another condition for termination of services. Please contact your therapist or health coach to discuss arrangements any time your financial situation changes.

DUAL RELATIONSHIPS

Therapy never involves sexual, business, or any other dual relationships that could impair the objectivity, clinical judgment or therapeutic effectiveness of your therapist or could be exploitative in nature. Please discuss this with your therapist if you have questions or concerns.

PROFESSIONAL FEES

In addition to scheduled appointments, your therapist charges fees for other professional services you may need, though your therapist will break down the hourly cost if he/she work for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 5 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of your therapist. If you become involved in legal proceedings that require your therapist’s participation, you will be expected to pay for your therapist’s professional time even if your therapist is called to testify by another party. Because of the difficulty of legal involvement, your therapist may charge more per hour for preparation and attendance at any legal proceeding.

BILLING AND PAYMENTS

You will be expected to pay for each session at the time it is held or prior thereto.
Payment schedules for other professional services will be agreed to when they are
requested.

Unless otherwise required by your therapist, billing will be provided after each session, although you may be required to pay for the service prior to your scheduled session(s). Therapy fees may be periodically raised, and you will be provided at least 30 days notice. If your therapist is a provider of your insurance panel, this consent authorizes your therapist to send treatment records to your insurance company in order to receive reimbursement. It is your responsibility to determine that your sessions will be covered by your insurance if your therapist is a member of your insurance panel. Regardless of whether your therapist is a member of your insurance panel or not, you will be responsible for the fees not paid by insurance.

If services have not been paid within 30 days, you will be notified in writing that payment has not been made and that the patient make payment or contact the insurance carrier in order to get them to pay for the services in a timely manner. If your account has not been paid for more than 30 days, a 3% per month fee may be added to the bill or the maximum amount allowed by law (whichever is less). If your account has not been paid for more than 90 days and arrangements for payment have not been agreed upon, your therapist has the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information releases regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due.

An Important Note About Credit Card Pre­Authorization:

This consent gives permission to charge the patient’s credit card for any services. This consent allows for credit card processing and the charge will appear on the patient’s statement. This consent is valid unless the patient cancels the authorization in writing. The patient’s signature below constitutes pre­authorization to provide payment in this manner.

INSURANCE REIMBURSEMENT

You are responsible for the fees for your therapy services– not your insurance company. You will be provided with a billing form that you may use to claim insurance reimbursement for treatment costs, but any dealings with the insurance company will be through you and solely your responsibility.

CONTACTING YOUR THERAPIST

Your therapist is often not immediately available by telephone. When he/she is unavailable, your health coach may be contacted. Your therapist will make every effort to return to respond within 24 hours of your message, with the exception of weekends and holidays. If you are difficult to reach, please inform your therapist or health coach of some times when you will be available. If you are unable to reach your therapist and feel that you can’t wait for your therapist to return your call, contact your family physician or the nearest emergency room. If your therapist will be unavailable for an extended time, your therapist will provide you with the name of a colleague to contact, if necessary; or, otherwise please contact your health coach. Please note that email systems are not entirely secure, and you acknowledge this and consent to use of email when you correspond with your therapist by email.

PROFESSIONAL RECORDS

The laws and therapy standards require that your therapist keep treatment records. You are entitled to inspect a copy of certain professional records regarding your treatment unless your therapist believes that seeing them would be harmful, in which case your therapist will be happy to send them to a mental health professional of your choice, or your therapist can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, it is recommended that you review them in your therapist’s presence so that the contents can be discussed. Patients will be charged an appropriate fee for any professional time spent in responding to information requests.

MINORS

If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records.

CONFIDENTIALITY

In general, the privacy of all communications between a patient and a therapist is protected by law, and a therapist can only release information about his/her work with a patient with the patient’s written permission. But there are a few exceptions.

In most legal proceedings, you have the right to prevent your therapist from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order your therapist to testify if the judge determines that the issues demand it.

There are some situations in which a therapist is legally obligated to take action to protect others from harm, even if he/she has to reveal some information about a patient’s treatment. For example, if a therapist believes that a child, an elderly person or disabled person has been abused or neglected, the therapist must file a report with the appropriate agency.

If a therapist believes that a patient is threatening serious bodily harm to another, the therapist is required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If the patient threatens to harm himself/herself, the therapist may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection.

Your therapist may occasionally find it helpful to consult other professionals – either as individuals or in a consultation group ­ about a case. The consultant(s) is/are also legally bound to keep the information confidential. If you don’t object, your therapist will not tell you about these consultations unless your therapist feels that it is important to your therapy. This consent allows your therapist to share information and/or records regarding your treatment with others in compliance with state and federal laws (such as HIPAA) and the Notice of Privacy Practices. Please refer to the Notice of Privacy Practices.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that you raise with your therapist any questions or concerns that you may have.

IN THE EVENT OF UNEXPECTED INTERRUPTION(S) OF PRACTICE

This consent verifies that you release your therapist to provide someone with your records and your contact information due to your therapist’s death or disability, unless you otherwise advise your therapist in writing that you do not wish to provide such information.

COMPLAINTS

To facilitate consumers in receiving appropriate psychological services, all licensees and registrants are required to post the Notice below in a conspicuous location in their principal psychological business office. Since your therapist works in multiple locations, that Notice is in this Contract:

NOTICE: the Department of Consumer Affairs receives questions and complaints regarding the practice of psychology. If you have any questions or complaints, you may contact this department by calling (916) 263­2699, or by writing to the following address:

Board of Psychology
1625 N. Market Blvd., Suite N­215
Sacramento, CA 95834