Informed Consent Form for Psychotherapy and/or Counseling with David McGue, MS, LMHC, NCC
Informed Consent Statement for Psychotherapy and Counseling
Therapy is a relationship 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, whose goal is your well-being. There are also certain limitations to those rights that you should be aware of. As a therapist, I have corresponding responsibilities to you, too.
My Responsibilities to You as Your Therapist
I. Confidentiality
With the exception of certain specific exceptions 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. Under the provisions of the Health Care Information Act of 1992, I may legally speak to another health care provider or a member of your family about you without your prior consent, but I will not do so unless the situation is an emergency. I will always act so as to protect your privacy even if you do release 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. You may request anyone you wish to attend a therapy session with you. You are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA).
If you elect to communicate with me by email at some point in our work together, please be aware that email is not completely confidential.
The following are legal exceptions to your right to confidentiality. I would inform you of any time if or 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 else who is doing this, I must inform Child Protective Services within 48 hours and Adult Protective Services immediately.
3. If I believe that you are in imminent danger of harming yourself, I may legally break confidentiality and call the police or a crisis team. I am not obligated to do this, and would explore all other options with you before I took this step. If at that point you were unwilling to take steps to guarantee your safety, I would call the crisis team.
4. If you and your partner decide to have some individual sessions as part of the couples therapy, what you say in those individual sessions will be considered to be a part of the couples therapy, and can and probably will be discussed in our joint sessions. Do not tell me anything you wish kept secret from your partner. I will remind you of this policy before beginning such individual sessions.
II. Record-keeping.
I keep very brief records, noting only that you have been here, what interventions happened in session, and the topics we discussed.
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 to be paid. Diagnoses are 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.
IV. Other Rights
You have the right to ask questions about anything that happens in therapy. I'm 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.
V. Fees:
Individual therapy is $80 per 50-minute session. Couples and family sessions are $100 per 50-minute session. I offer sliding-scale fees as well, if unable to make full payment. Payment is requested at the end of each session. Payment can be by check, cash, or credit card. Receipts will be provided upon payment.
VI. Ending Therapy
I want to make your therapy as successful as possible. For that reason, it works best to find a rhythm and structure to the beginning stages with sessions that meet regularly. To support your leaving, I request several weeks of notice prior to your actual leaving to allow you to have an experience of leaving well, with a sense of completion. If I initiate terminating you from our therapy, it will be because I feel that I am not able to be helpful to you any longer. I will offer you referrals to other sources of care, but cannot guarantee that they will accept you for therapy.
Your Responsibilities as a Therapy Client
You are responsible for coming to your session on time and at the time we have scheduled. Sessions last for 50 minutes. 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 will be charged for that session, unless we can reschedule within the same calendar week.
Complaints
If you're unhappy with what's happening in therapy, I hope you'll talk about it with me so that I can respond to your concerns.
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 understand the limits to confidentiality required by law. I understand the fee per session and my rights and responsibilities as a client, and my therapist's responsibilities to me. I know I can end therapy at any time I wish.
________________________________________
Client Name (Print)
________________________________________ Date:________________
Client Signature
________________________________________ Date:________________
David McGue, MS, LMHC, NCC
I. Confidentiality
With the exception of certain specific exceptions 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. Under the provisions of the Health Care Information Act of 1992, I may legally speak to another health care provider or a member of your family about you without your prior consent, but I will not do so unless the situation is an emergency. I will always act so as to protect your privacy even if you do release 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. You may request anyone you wish to attend a therapy session with you. You are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA).
If you elect to communicate with me by email at some point in our work together, please be aware that email is not completely confidential.
The following are legal exceptions to your right to confidentiality. I would inform you of any time if or 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 else who is doing this, I must inform Child Protective Services within 48 hours and Adult Protective Services immediately.
3. If I believe that you are in imminent danger of harming yourself, I may legally break confidentiality and call the police or a crisis team. I am not obligated to do this, and would explore all other options with you before I took this step. If at that point you were unwilling to take steps to guarantee your safety, I would call the crisis team.
4. If you and your partner decide to have some individual sessions as part of the couples therapy, what you say in those individual sessions will be considered to be a part of the couples therapy, and can and probably will be discussed in our joint sessions. Do not tell me anything you wish kept secret from your partner. I will remind you of this policy before beginning such individual sessions.
II. Record-keeping.
I keep very brief records, noting only that you have been here, what interventions happened in session, and the topics we discussed.
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 to be paid. Diagnoses are 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.
IV. Other Rights
You have the right to ask questions about anything that happens in therapy. I'm 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.
V. Fees:
Individual therapy is $80 per 50-minute session. Couples and family sessions are $100 per 50-minute session. I offer sliding-scale fees as well, if unable to make full payment. Payment is requested at the end of each session. Payment can be by check, cash, or credit card. Receipts will be provided upon payment.
VI. Ending Therapy
I want to make your therapy as successful as possible. For that reason, it works best to find a rhythm and structure to the beginning stages with sessions that meet regularly. To support your leaving, I request several weeks of notice prior to your actual leaving to allow you to have an experience of leaving well, with a sense of completion. If I initiate terminating you from our therapy, it will be because I feel that I am not able to be helpful to you any longer. I will offer you referrals to other sources of care, but cannot guarantee that they will accept you for therapy.
Your Responsibilities as a Therapy Client
You are responsible for coming to your session on time and at the time we have scheduled. Sessions last for 50 minutes. 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 will be charged for that session, unless we can reschedule within the same calendar week.
Complaints
If you're unhappy with what's happening in therapy, I hope you'll talk about it with me so that I can respond to your concerns.
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 understand the limits to confidentiality required by law. I understand the fee per session and my rights and responsibilities as a client, and my therapist's responsibilities to me. I know I can end therapy at any time I wish.
________________________________________
Client Name (Print)
________________________________________ Date:________________
Client Signature
________________________________________ Date:________________
David McGue, MS, LMHC, NCC
Policies for individual and couples psychotherapy:
Psychotherapy sessions are scheduled on an ongoing weekly basis, bi-weekly or monthly basis and last fifty minutes. Payment is due at the time of the session by cash, check, or credit card. Receipt will be provided.
All regularly scheduled sessions are your financial responsibility. I need 24 hrs. of notice in order to not charge you for your session. If you know that you must miss a session, I will make reasonable efforts to reschedule sessions when cancelled in a timely manner. While I know that at times 24 hrs advance notice is not possible, without this amount of notice you will be charged for the missed session, regardless of the reasons for the cancellation.
Either of us may end the therapy relationship. I would like to offer emotional support to all the phases of your work in therapy, including when you decide to leave therapy. I can support your decision to leave best if you give several weeks notice prior to actually leaving. The notice allows you to leave well, having an experience of completion.
If, at any time, you feel that your needs are not being met or you are not getting what you want out of our sessions, please tell me, so we can discuss your needs and adjust your therapy treatment plan.
As a licensed counselor, I protect the confidentiality of the communications with my clients, including my coaching clients. I will only release information about our work to others with your written permission, or if I am required to do so by a court order. There are some situations in which I am legally obligated to breach your confidentiality in order to protect others from harm, including (1) if I have information that indicates that a child or elderly or disabled person is being abused, I must report that to the appropriate state agency and (2) if a client is an imminent risk to him/herself or makes threats of imminent violence against another person, I am required to take protective actions. These situations rarely occur, but if such a situation does occur, I will make every effort to discuss it with you before taking any action.
Psychotherapy sessions are scheduled on an ongoing weekly basis, bi-weekly or monthly basis and last fifty minutes. Payment is due at the time of the session by cash, check, or credit card. Receipt will be provided.
All regularly scheduled sessions are your financial responsibility. I need 24 hrs. of notice in order to not charge you for your session. If you know that you must miss a session, I will make reasonable efforts to reschedule sessions when cancelled in a timely manner. While I know that at times 24 hrs advance notice is not possible, without this amount of notice you will be charged for the missed session, regardless of the reasons for the cancellation.
Either of us may end the therapy relationship. I would like to offer emotional support to all the phases of your work in therapy, including when you decide to leave therapy. I can support your decision to leave best if you give several weeks notice prior to actually leaving. The notice allows you to leave well, having an experience of completion.
If, at any time, you feel that your needs are not being met or you are not getting what you want out of our sessions, please tell me, so we can discuss your needs and adjust your therapy treatment plan.
As a licensed counselor, I protect the confidentiality of the communications with my clients, including my coaching clients. I will only release information about our work to others with your written permission, or if I am required to do so by a court order. There are some situations in which I am legally obligated to breach your confidentiality in order to protect others from harm, including (1) if I have information that indicates that a child or elderly or disabled person is being abused, I must report that to the appropriate state agency and (2) if a client is an imminent risk to him/herself or makes threats of imminent violence against another person, I am required to take protective actions. These situations rarely occur, but if such a situation does occur, I will make every effort to discuss it with you before taking any action.
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For a FREE Consultation or to schedule an appointment:
call David at 808-381-0139 or email: [email protected] |
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