Statement of Services/Notice of Privacy Practices
 
Informed Consent provides counseling services that include assessment, evaluation, diagnosis, and direct psychotherapy treatment in accordance with professional standards of practice. These standards of practice include providing each client with information concerning several aspects of the counseling process and the counseling relationship.
 
The Risks and Benefits of Therapy
 
Psychotherapy has been shown to be effective for the improvement and resolution of many kinds of personal problems. The process of psychotherapy, however, does involve risks on the part of the client. Change, and the processes involved increasing positive change, can at times be difficult and unsettling. While every attempt will be made to prepare each client for this, each client must make the decision to enter into this process with a clear understanding of these risks.
 
Estimated Length of Therapy
 
The length of the course of psychotherapy treatment can vary depending upon the severity of the problems presented, and the ability of each client to utilize therapeutic approaches. Whenever possible, each client will be given an estimation of how much time the psychotherapy process will take.
 
Length and Cost of Therapy Sessions
 
Unless otherwise stated, psycho therapy sessions will consist of 45-50 minutes of direct treatment, with 10-15 minutes allotted after the direct treatment for the clinician to complete treatment notes and review the content of the psychotherapy session. Unless otherwise agreed to, each psychotherapy session will be charged at the rate of $__________. Clients who have mental health benefits through their insurance will be billed at the rate covered by their insurance, under the arrangement noted in a section below.
 
Insurance Policy
 
Where a professional relationship exists between the provider and the client’s insurance carrier, the client will be expected to pay the co-insurance amount designated under the policies of the insurance carrier. Claims will be filed by the provider of services. Where a professional relationship does not exist with a client’s insurance policy, the client will be expected to pay the full amount for each psychotherapy session and to file his/her own claims. In such cases, where necessary, insurance forms and receipts will be filled out by the provider so as to allow the filing of claims by the client.
 
Cost for Secondary Services
 
Time spent performing services that support the counseling, such as writing reports, contact with outside parties by phone or letter, and supportive phone contact to the client outside of regular sessions, will be billed at the rate of $___________, prorated for the amount of time spent engaged in the service. Time spent in phone contact to set or re-arrange appointment times, or brief phone contact to give or receive relevant treatment information will not be billed. These services are generally not covered by insurance mental health benefits and will be billed directly to the client.
 
Payment Policy
 
Unless otherwise agreed to, payment will be expected at the end of each psychotherapy session.
 
Cancellation Policy
 
Clients are expected to provide 24 hours notice of cancellation of any scheduled psychotherapy session. For any session not cancelled prior to 24 hours, the client will be billed the full amount of the cost of the session, unless agreed to otherwise prior to the session. This cost is not covered by insurance, and the full amount will be billed to the client.
 
Client Rights
 
Each client has the right to expect competent psychotherapy treatment in accordance with accepted professional standards. Each client has the right to request information about any aspect of treatment, including but not limited to assessment results, treatment techniques utilized, course and direction of treatment. Each client has the right to provide feedback to the provider about where treatment is being successful and unsuccessful, and to terminate treatment at anytime.
 
Client Responsibilities
 
Each client is held to be responsible for engaging in the therapeutic process in ways that further treatment progress, making available to the provider such information as is needed to provide effective treatment, and participating in directing the course and direction of treatment.
 
Confidentiality
 
The confidentiality of all records is covered by state and federal law. Federal standards for maintenance of your records have been defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The records of clients with alcohol and drug abuse problems may also subject to further restrictions as outlined in Federal Law 42 CFR Part 2. The seguide lines mean that all client information, including records of treatment, may not be released except under the following conditions:
1) When the client signs a valid release of information;
2) When a disclosure is made to medical personnel in a medical emergency;
3) When a client expresses suicidal or homicidal intent with imminent risk;
4) When there is suspected child or elder abuse or neglect;
5) When disclosure is required by a valid court order. Your Rights
Under HIPAA,you have the following rights:
1) The right to inspect or copy your own health information, except to the extent that the information contains psychotherapy notes or information compiled for use in a civil,criminal, or administrative proceeding.
2) The right to request restrictions on certain uses and disclosures of your treatment information.
3) The right to amend health care information maintained in your client record.
4) The right to request and receive an accounting of disclosures of your health related information made during a period up to six years prior to your request.
 
Clinician Duties
 
Clinical Information is required bylaw to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices concerning your health information. In addition to fulfilling this obligation through the provision of this Statement of Services/Notice of Privacy Practice, the clinician is responsible for providing any additional information that may be required to make you fully aware of your privacy and treatment rights.
 
 
 
Statement of Validation.
 
I have read this Statement of Services, it has been adequately explained to me, and I understand its contents.