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INFORMED CONSENT FOR THERAPY
Client #: ____________ Updated: 3/26/04
This Informed Consent Form is intended to provide sufficient information for you to make informed choices about entering and continuing therapeutic treatment.
INFORMATION ABOUT THERAPY
THERAPIST’S EDUCATION AND TRAINING
Your therapist, Cassandra A. Erickson, Ph.D., L.M.F.T., is a Marriage and Family Therapist in private practice. She obtained her doctorate from Purdue University—one of the leading institutions in research, theoretical and clinical training in her field. She is a Clinical Member of AAMFT—the American Association for Marriage and Family Therapy—and a Licensed Marriage and Family Therapist in the State of Indiana. A copy of her Curriculum Vita (professional “resume”), with more detailed education and training, is available upon request.
WHAT TO EXPECT – BENEFITS AND RISKS
There are benefits and risks in seeking individual, marital or family therapy. Some of the potential benefits of therapy include developing your ability to handle or cope with your relationships and providing you with greater insight into your personal goals and values. In working to achieve these benefits, however, you may address issues or make changes that you may experience as distressing. These risks of therapy include, but are not limited to: feelings or circumstances becoming worse before they get better; changes in your emotional state, such as feelings of depression or anxiety; the possibility of hallucinations or dissociations; changes in perception or behavior; and changes in occupational, social, or personal relationships. This Informed Consent form contains information about other potential risks as well (e.g., leaving therapy, confidentiality, etc.).
MEASURING PROGRESS
To achieve the greatest progress in therapy, your therapist will work to provide the best and most appropriate therapy for you and your family. You can facilitate this process by maintaining motivation, complying with recommendations and policies, and communicating openly and honestly. The length and frequency of sessions as well as the duration of treatment varies significantly, and can be discussed at the beginning and throughout the course of therapy.
Because success or satisfaction with treatment cannot be guaranteed, you are requested to inform your therapist if you do not feel satisfied with your progress. You and your therapist may then be able to work through the issues, modify treatment, or negotiate a new therapeutic contract. In some instances, this may mean making an appropriate referral or terminating therapy. You may choose to leave therapy at any time; however, leaving therapy is best accomplished in consultation with your therapist.
ALTERNATE TREATMENT OPTIONS
You may also elect to pursue alternative options for treatment. These options may include self-help groups, community based clinics, psychotropic medications, physical exams, psychiatric hospitals, emergency services, and other mental health professionals who may offer different training, techniques, specialties, personalities, and theoretical approaches. Some of these options will have similar risks and benefits to those outlined above.
PRIVACY POLICIES AND PROCEDURES
RIGHTS OF CONFIDENTIALITY
Your therapist pledges to uphold privacy and confidentiality concerning your treatment process and records as outlined by Indiana Statute and the Federal HIPAA Privacy Regulations. She will do everything within her power to protect the physical records of treatment and the information contained therein, including safeguarding their use, transportation and storage. Your therapist has posted a Notice of Privacy Practices in the Waiting Room for your review. This Notice describes the current and more detailed outline of the uses and disclosures of your protected health information, including when authorization is required and when it is not; your rights regarding this information; and how your health information is safeguarded by your therapist. Some of this information is summarized below. You are encouraged to review this Notice of Privacy Practices and may request a copy of the current Notice at any time.
STANDARD USES AND DISCLOSURES
Generally, your health information may be used and disclosed during the normal course of providing and receiving payment for your care. Your voluntary agreement to seek treatment provides this permission by law. These standard uses and disclosures include: 1) therapist’s consultation with peer professionals, supervisors, attorneys, accountants, etc. (identifying information is not disclosed); 2) information about the cost of care and maintenance of treatment required by third-party payers (e.g., Insurance/Managed Care companies, State agencies, etc.); 3) completion of necessary billing, banking, and collection activities; 4) data collection, research and information for monitoring Managed Care providers by State agencies or to satisfy reporting requirements; 5) phone calls, voice messages, electronic transmissions, written correspondence, and mailings sent to the addresses and phone numbers provided, unless specific alternate instructions are given; and 6) disclosures made during the course of therapy involving a client’s partner, family, or other third parties, in which statements made in individual or group sessions may, of necessity or inadvertently, be repeated to others, unless the handling of that disclosure was previously and clearly agreed upon with your therapist. Your signature represents your understanding and consent to these standard uses and disclosures of your health information to provide and receive payment for your care.
USES AND DISCLOSURES WITH AUTHORIZATION
For uses and disclosures of your health information other than during the normal course of business operations and providing treatment, your therapist is required to have your written authorization, unless the use or disclosure falls within one of the exceptions described below (see “Uses and Disclosures Not Requiring Authorization”). If you request or are asked to provide written authorization for the release of any information regarding your treatment or records, you must submit a written, signed, and dated request for release specifying the content or material to be released, to whom, and the purpose of the release. Your therapist can provide an Exchange of Information form to sign. You may specify or limit the scope of information to be released at any time, and it will expire one year, if not otherwise specified, from the date of your signature.
Your signed consent may be required for the release of diagnostic and treatment information to any third-party payers. Your written permission also will be obtained if you or your therapist were to request audio or videotaping of treatment. Any information included in your records from another source (e.g., physician, therapist, family member, etc.) will not be released without a signed authorization from that source.
You may revoke an authorization, in writing, at any time (see Notice of Privacy Practices for exceptions). If you do wish to revoke an authorization, your written revocation must include the date of the authorization, the name of the person/organization authorized to receive the information, your signature, and the date of the revocation.
USES AND DISCLOSURES NOT REQUIRING AUTHORIZATION
(LIMITS TO CONFIDENTIALITY)
The use and disclosure of your health information and rights of confidentiality may be limited by law under the following circumstances: 1) therapy with minors, which requires parental consent; 2) equal access of a minor’s records to both custodial and non-custodial parents if requested, unless a court order states otherwise; 3) threat of bodily harm or death to yourself or others; 4) information is revealed concerning child or elder abuse or neglect; 5) a crime has been committed; 6) information is required by a coroner or medical examiner; 7) information is required by a National security or intelligence Agency, such as for protection of the President; 8) a judge issues a court order for a court appearance or release of records following a hearing showing good cause; 9) you are involved in certain processes of litigation (e.g., child custody, lawsuit, mental health status); or 10) therapy and/or evaluations are court ordered. Under some these circumstances, your therapist may be required by law to release requested information about the treatment process and results, and/or to inform the intended victim(s), their families, and appropriate law enforcement authorities.
RIGHTS REGARDING YOUR HEALTH INFORMATION
You have several rights regarding your health information: 1) You have the right to request, in writing, how you would like your therapist to restrict the uses and disclosures of your healthcare information. Your therapist will consider this request, but is not legally bound to agree to the restriction. 2) You have the right to ask, in writing, that your therapist contact or send you information at an alternate address or by an alternate means, such as contacting you only at work. You may specify how you prefer your therapist contact you when you fill out the Personal Data Inventory form at the beginning of therapy. Your therapist will agree to this request as long as it is reasonable to do so. 3) You are generally entitled to inspect and copy your records; however, your therapist is permitted by law to withhold all or any portion of your records a) in order to permit her to freely record diagnostic and therapeutic information regarding your treatment, or b) if she believes with reasonable certainty and in her professional judgment that seeing these records may be detrimental to your physical or mental health. You will be responsible for any costs associated with copying, mailing, and time incurred by your therapist in responding to your request to inspect or copy your records. Prior to their release, your therapist may require, at her discretion, a 50-minute session or longer to review your records with you, to be charged at the current rate. Your therapist is required by law to retain possession of treatment records for a minimum of seven (7) years. 4) If you believe there is a mistake or missing information in the record of your health information, you may request, in writing, that your therapist correct or add to the record. Your therapist may deny your request for an amendment under certain conditions outlined in the Notice of Privacy Practices. 5) You have a right to request, in writing, an accounting of disclosures—a list of what disclosures have been made of your health information—other than instances of disclosure for national security purposes; for treatment, payment or operations purposes; to law enforcement officials or correctional facilities; or for which you have given your written authorization. 6) You have a right to receive a paper copy of the Notice of Privacy Practices, which outlines information in this section in more detail.
COMPLAINTS ABOUT PRIVACY PRACTICES
If you believe your privacy rights have been violated, or if you disagree with a decision made about access to your health information, you may discuss or file a formal complaint directly with your therapist. You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint.
ADDITIONAL INFORMATION
CONTACTING YOUR THERAPIST
Since your therapist is often in session during the weekdays and not in the office on weekends, she may be difficult to reach directly. To contact her, please leave a detailed message with your full name and phone number on her confidential voice mail, at (317) 875-9555 or 767-5775. She checks messages often and will return your call as promptly as possible. Whenever possible, please be specific with your message or request, and let her know if you would like a return call. If you leave a message at any source you may have for your therapist (e.g. cellular phone, e-mail, etc.), she cannot assure she will get the message in a timely fashion.
HELP FOR EMERGENCIES
If you feel you need to reach your therapist urgently, you should leave a message specifically stating that it is urgent. Your therapist will do her best to return your call promptly; however, in the event that she is unable to call or see you as soon as you need, you may choose to contact an alternate source of support, including the following 24-hour Crisis Lines:
St. Vincent’s 24-hour StressLine - (317) 338-4800
Crisis & Suicide Intervention Hotline – (317) 251-7575
Gallahue 24-hour Crisis Service - (800) 662-3445
Midtown 24-hour Crisis Clinic - (317) 630-8485
CONSUMER’S GUIDE TO MFT
Your therapist will provide a brochure from the American Association for Marriage and Family Therapy (AAMFT) entitled A Consumer’s Guide to Marriage and Family Therapy. This brochure provides additional information relevant for you to make an informed choice regarding your decision to seek therapy. Specifically, it outlines the theoretical perspective of the field of Marriage and Family Therapy (MFT), reasons and circumstances appropriate to seeking therapy (e.g., signs of distress), training requirements and qualifications of an MFT, and information on finding and choosing a qualified therapist.
FINANCIAL POLICIES AND PROCEDURES
SESSION FEES
The fee for individual, marital/relationship, or family therapy services is $ per 50-minute session, payable to Cassandra A. Erickson, Ph.D. Therapeutic services delivered over the phone are subject to the same hourly rate as regular sessions and will be billed on a pro-rated basis. Please inform your therapist should these fees pose a hardship at any time so you may jointly negotiate alternative arrangements. Fees are re-evaluated and subject to change every six months.
PAYMENT POLICY
Payment in full is expected at the time of service, unless alternate arrangements are mutually agreed upon. Payment is accepted in the form of cash, check, or credit card—including Visa, Mastercard, American Express, and Discover. Debit cards from your checking or savings account are accepted, although a check is preferred since there are additional merchant fees applied when using debit cards.
When making payment by check, please have your check written before the start of the session, whenever possible. All checks returned for non-sufficient funds (NSF) may be automatically forwarded by your therapist’s bank to CheckBack Electronic Check Services. Your signature below authorizes CheckBack to electronically debit your account for the face amount of the check and the State allowable processing fee. The debit entries will be shown on your bank statement and your original check will not be returned. Returned checks are subject to a $20 returned check fee.
Payment by credit card requires that you provide your credit card at the time of service to obtain your signature and authorization. You will be asked to sign a Credit Card Pre-Authorization form so your signature will be on file for future charges. Your signature below also represents pre-authorization to use your credit card to charge for fees and services.
INSURANCE REIMBURSEMENT
If you have medical insurance that provides coverage for mental health outpatient services and choose to use these benefits, your therapist will work to help you receive your maximum allowable benefits. Your therapist has chosen not to participate in any managed care insurance plans, including HMO’s and PPO’s, since the extraordinary amount of time and paperwork required takes away from client care.
Your therapist will provide, upon request, a receipt for each session or a monthly statement of services to help you process your insurance claim for reimbursement. You therapist will gladly answer questions relating to your insurance; however, as the insured you must realize that:
1) Your insurance is a contract between you, your employer and the insurance company—your therapist is not a party to that contract.
2) Your therapist’s fees are generally considered to fall within the acceptable range by most companies, called “Usual, Customary, and Reasonable” (UCR). Some companies pay a percentage of the UCR for a given area, while others reimburse based on an arbitrary “schedule” of fees, which bears no relationship to the current standard and cost of care in this area.
3) Insurance contracts do not necessarily provide coverage for all services or all types of providers. Some insurance companies arbitrarily disallow coverage for certain services (i.e., marital counseling) and types of providers (i.e., non-psychiatrists).
4) Your insurance company will require that your therapist include on any statement of services a Procedural Code(s) from the CPT-4 Manual and a Primary Diagnostic Code, or ICD-9-CM Code, from the DSM-IV (Diagnostic and Statistical Manual for Psychiatry, 4th edition). You may discuss the use of these codes, but all final diagnostic decisions must be left to your therapist’s discretion.
5) You therapist will discuss with you the diagnosis to be submitted to your insurance company and may require your signature on an Exchange of Information form.
6) If your insurer requests a report from your therapist in order to process your claim, this will be charged at the regular hourly fee.
7) It is your responsibility to contact your insurance company to verify eligibility, benefits and reimbursement policies, as well as to mail and track your reimbursement.
ASSIGNMENT OF BENEFITS
Payment in full is expected at the time of service unless your therapist has agreed to accept direct payment from insurance, called an “assignment of benefits.” If your therapist accepts payment directly from your insurance company, you will be asked to sign a generic HCFA-1500 insurance form (or one provided by your insurance company, if available), and an Assignment of Benefits form. You will be responsible for payment in full for your portion of the fee not covered by your policy, including your annual medical or separate mental health deductible. You will also be responsible for any portion of the balance due that is denied by the insurance company, regardless of the circumstances (e.g., misquoting by an insurance representative, unexpected change in benefits, etc.).
CANCELLATION POLICY
The time for which your appointments are scheduled has been reserved for you. You are required to give notice of cancellation at least 24 hours prior to a scheduled appointment. If you do not give 24-hour notice or fail to show for a scheduled appointment without prior notification, you will be charged the full session fee. Exceptions can be made in the event of an emergency; however, you are asked to call as soon as possible to inform your therapist of the circumstances. Your therapist will provide an appointment card so you can verify the times and dates, unless the appointment is made over the phone or you decline to receive one.
OTHER FEES
Your therapist may charge different fees for some services. The fee of $175 per hour applies to services other than those that are directly related to your therapeutic process as outlined above. These services include: conducting negotiations, performing evaluations, providing written reports, or consulting with other professionals at your therapist's discretion. The fee of $225 per hour applies to services related to the court process, including testifying, consultation with your attorney or other professionals, travel time, and taking your therapist’s deposition.
Any additional fees for testing and assessment will be discussed at the time your therapist makes the recommendation.
DELINQUENT/DEFAULTED BALANCES
You are responsible for making any payments due in a timely manner. Your account will be considered delinquent if a balance remains after two months from the date the fee is assessed, and will be charged interest at a rate of 1.5% per month (18% APR). If you anticipate difficulty in paying your balance, please discuss the situation with your therapist to work out a repayment schedule that will not cause undue hardship for either party.
If your balance remains delinquent for more than four months and you have not attempted to make satisfactory arrangements with your therapist, the account will be considered defaulted. Once your balance due has defaulted, it may be forwarded to a collection agency and you will be responsible for all court costs, attorney fees, interest, and related damages or expenses associated with pursuing payment of the balance.
CONSENT FOR TREATMENT/ACCEPTANCE OF POLICIES
Your therapist has attempted to answer your questions about treatment satisfactorily. If you have further questions or concerns, your therapist will do her best to answer them or find answers for you.
Your signature represents a statement that you have read and understood the information above and as outlined by your therapist, have received a copy of this Informed Consent form, have been made aware of your rights and the privacy practices of this office, agree to comply with fees and policies, agree to read the brochure provided, and consent to the therapy process as described above. You have the right to withdraw your consent for treatment at any time.
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