INFORMED CONSENT FOR THERAPY SERVICES
PSYCHOLOGIST-CLIENT PSYCHOLOGICAL SERVICE AGREEMENT
Welcome to my Practice. This document contains important information about my professional services and business policies.
It contains summary information about the), privacy protections and patient rights about the use and disclosure of your
Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these
documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it
will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the
Therapy or psychological treatment is a relationship between people that works in part because of clearly defined rights and
responsibilities held by each person. As a client in psychotherapy or other psychological services assessment-therapy consultation, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your therapist or counselor or psychologist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.
Psychotherapy or above mentioned have benefits and chances of 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 few 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.
Appointments will ordinarily be 45-50 minutes in duration, once per week at a time we agree on, although some sessions may
be more or less frequent as needed. 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 canceled 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.
The standard fee for the initial intake is 2100 and each subsequent session is 3000 and other therapies will vary in
amount. You are responsible for paying at the time of your session unless prior arrangements have been made.
Payment must be made by online or cash.
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.
I am required to keep appropriate records of the psychological services that I provide. Your records are
maintained in a secure location in the office. I keep brief records noting that you were here, your reasons for
seeking therapy, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical,
social, and treatment history, records I receive from other providers, copies of records I send to others, and your
Except in unusual circumstances that involve danger to yourself, you have the right to a copy of
your file. Because these are professional records, they may be misinterpreted and/or upsetting to untrained
readers. For this reason, I recommend that you initially review them with me, or have them forwarded to another
mental health professional to discuss the contents. If I refuse your request for access to your records, you have a
right to have my decision reviewed by another mental health professional, which I will discuss with you upon your
request. You also have the right to request that a copy of your file be made available to any other health care
provider at your written request.
My policies about confidentiality, as well as other information about your privacy rights, are fully described in a
separate document entitled Notice of Privacy Practices. You have been provided with a copy of that document
and we have discussed those issues. Please remember that you may reopen the conversation at any time during
our work together.
“Notice of Privacy Practices”
THIS NOTICE INVOLVES YOUR PRIVACY RIGHTS AND DESCRIBES HOW INFORMATION ABOUT YOU MAY BE
DISCLOSED, AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.