Disclosure Statement and Informed Consent to Treatment
Disclosure Statement and Informed Consent to Treatment
Therapy is a collaborative relationship between people that works in part because of clearly defined rights and responsibilities held by each person. This frame helps to create the safety to take risks and the support to become empowered to change. As a client in psychotherapy, you have certain rights that are important for you to know about because this is your therapy—the goal is your well being. There are also certain legal limitations to those rights that you should be aware of. As a therapist, I have corresponding responsibilities to you.
My Responsibilities to You as Your Therapist:
I. Confidentiality: With the exception of certain specific instances described below, you have the absolute right to the confidentiality of your therapy. I cannot and will not tell anyone else what you have told me, or even that you are in therapy with me without your prior written permission. I will always act so as to protect your privacy even if you do permit me in writing to share information about you. You may direct me to share information with whomever you chose, and you can change your mind and revoke that permission at any time. As well, you may request anyone you wish to attend a therapy session with you.
I consult with various experts in specific fields of mental health so that I can better serve my clients. I also participate in regular group consultation. If I consult on my work with you, I will not use your name or any information that can identify you. If there is any reason to believe you might know one of these professionals, I will tell you their name so you have the option to request I do not consult with them regarding your care.
The following are legal exceptions to your right to confidentiality. I would inform you of any time when I think I will have to put these into effect.
1. If I have good reason to believe that you will harm another person, I must attempt to inform that person and warn them of your intentions. I must also contact the police and ask them to protect your intended victim.
2. If I have good reason to believe that you are abusing or neglecting a child or vulnerable adult, or if you give me information about someone who is doing this, I must inform Child Protective Services or the police within 48 hours.
3. If I believe that you are in imminent danger of harming yourself, I may legally break confidentiality and call the police, the county crisis team or someone who can ensure your safety. I would first explore all other options with you before I took this step.
4. I may use and disclose your health information in order to bill and collect payment for the services and items you may receive from me. For example, I may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and I may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. I also may use and disclose your health information to obtain payment from third parties that may be responsible for such costs, such as family members. Also, I may use your health information to bill you directly for services and items. Usually what is only shared is the type of service I provided as well as a diagnosis from the DSM-IV (See III below)
5. Please keep in mind that although every safeguard possible is in place when using electronic communication such as email, computer, cell phone, or fax, I cannot guarantee there will be no interception. Nor can I protect your name when depositing your check at my bank if you choose to pay by check. As well, I file most insurance claims electronically, sharing your protected health information when required.
6. If you are filing a complaint or are a plaintiff in a lawsuit where you bring up the question of your mental health, you will have already automatically waived your right to the confidentiality of these records in the context of the complaint or lawsuit. In spite of that, I will not release information without your signed consent or a court order. We can also discuss obtaining a protective order to help maintain confidentiality of records. Please let me know if you are in this kind of situation so that I can take the utmost care possible to protect your privacy in my records.
II. Record-keeping: I normally keep very brief records, noting that you have been here, what we did in the session, and a few words describing the topics we have discussed. If you prefer that I keep no records, you must give me a written request to this effect for your file. Under the provisions of the Health Care Information Act of 1992, you have the right to a copy of your file at any time. You have the right to request that I correct any errors in your file. You have the right to request that I make a copy of your file available to any other health care provider at your written request. I maintain your records in a secure location in my office.
III. Diagnosis: If a third party such as an insurance company is paying for part of your bill, I am normally required to give a diagnosis to that third party in order for you to be paid. Diagnoses are the technical terms that describe the nature of your problems and something about whether they are short-term or long-term problems. If I do use a diagnosis, I will discuss it with you. All of the diagnoses come from a book title the DSM-IV; I have a copy in my office and will be glad to let you read more about what it says about your diagnosis.
IV. Scheduled appointments. I will do my best to have a regularly scheduled appointment time for you. If I need to cancel for some unforeseen circumstance, I will do my best to get a hold of you as soon as possible and do my best to accommodate you. I will tell you well in advance of any planned absences.
Your Rights as a Psychotherapy Client
I. You have the right to ask questions about anything that happens in therapy. I am always willing to discuss how and why I’ve decided to do what I’m doing, and to look at alternatives that might work better. You can feel free to ask me to try something that you think will be helpful. You can ask me about my training for working with your concerns, and can request that I refer you to someone else if you decide I’m not the right therapist for you. You are free to leave therapy at any time.
II. You have the right to decide whether the proposed treatment plan will provide you with the treatment that you want. At any point during treatment you are encouraged to let me know if something does not feel right, or if you want something else from treatment. Your input into the process of therapy, no matter how hard to put into words, is very important.
III. You have the right to confidential and safe treatment. As I said before what you say to me is confidential unless I am concerned about your safety or the safety of another person.
Your Responsibilities as a Psychotherapy Client:
I. You are responsible for coming to your sessions on time and at the time we have scheduled. If you are late, we will end on time and not run over into the next person’s session. If you miss a session without canceling, or cancel with less than twenty-four hours’ notice, you must pay for that session at our next regularly scheduled meeting.
II. You are responsible for paying for your session or your child’s session at the beginning of each session unless we have made other firm arrangements in advance. My fee is $105.00 for a fifty-minute session and $120.00 for couples, families and initial assessments. Please let me know if you feel that the fee is unaffordable; I am able to make some adjustments depending on your personal circumstances. If we decide to meet for a long session, I will bill you prorated on the hourly fee. Emergency phone calls are normally free. However if we spend more than fifteen minutes weekly on the phone, I will bill you on a prorated hourly basis.
1. Please check with me to see if I can be reimbursed directly by your insurance company or by Crime Victims Compensation. If I am not a preferred provider under your insurance, I will help you as best I can so that you might be reimbursed by your insurance company. In that case, it is your responsibility to pay my fee, and provide me with the correct forms and information necessary for you to be reimbursed, unless otherwise arranged.
2. If you end up having an outstanding bill with me and we have terminated therapy, I expect you to pay it. If you refuse to pay your debt, I reserve the right to give your name and the amount due to a collection agency.
Complaints:
If you are unhappy with what’s happening in therapy, I hope you’ll talk about it with me so that I can respond to your concerns. I will take such criticism seriously and with care and respect. If you believe that I have been unwilling to listen and respond, or that I have behaved unethically, you can complain about my behavior to: Washington State Department of Health, Health Professions Quality Assurance, P.O. Box 47865, Olympia WA 98504-7865.
I am a licensed independent clinical social worker by the State of Washington. My certificate number is: LW00004395.
Client Consent to Psychotherapy:
I have read this statement, had sufficient time to be sure that I considered it carefully, asked any questions that I needed to, and understand it. I consent to the use of a diagnosis in billing, and to the release of that information to my insurance company if I request so. I agree to pay $105.00 ($120 for initial assessment, couples or families) per session at the beginning of each session. I understand my rights and responsibilities as a client, and my therapist’s responsibilities to me. I agree to undertake therapy with Catherine Pagano, LICSW. I know I can end therapy at any time I wish and that I can refuse any requests or suggestions made by Ms. Pagano.
Print Client’s name:_____________________________________________________________________
Client Signature:____________________________________________Date:_______________________
Parent/Guardian Signature (if applicable):____________________________Date:_______________________
Catherine Pagano:____________________________________Date:_______________________
I have been offered additional printed information
on HIPAA. Client initials:______________________
