Therapy Information and Consent to Treatment

  • Welcome to Friendswood Family Counseling. The purpose of this document is to ensure that all participants in the therapeutic process are aware of their rights and responsibilities, and it contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides 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. I encourage you to ask questions about any of these topics at any point during the time that we are working together.

  • Psychological Services

  • Therapy 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, you have certain rights and responsibilities, which are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.

    Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness. These feelings may arise since the process of psychotherapy often requires discussing the unpleasant aspects of your life. The greatest risk of psychotherapy is that it may not, by itself, resolve your concerns. However, psychotherapy also 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 our sessions.

    The first 1-2 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 are ordinarily 55 minutes in duration, once per week at a mutually agreeable time although some sessions may be more or less frequent as needed. The time scheduled for your appointment is for you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours of notice. If you miss a session without canceling, or cancel with less than 24-hour notice, my policy is to collect $75 (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 cancelled 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.

  • Professional Fees and Appointments

  • The standard fee for therapy is $160.00 per session. You are responsible for paying at the time of your session unless prior arrangements have been made. Payment may be made by HSA card, debit/credit card, check or cash. Any checks returned to my office are subject to an additional fee of up to $25.00 to cover the bank fee that I incur. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment.

    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. If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required even if another party compels me to testify.

  • Insurance

  • I am a private pay therapist and am therefore, out of network for individuals wanting to use insurance to help with payments.

    In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. You are responsible for knowing your coverage and for letting me know if/when your coverage changes.

    Due to the rising costs of healthcare, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. Managed Health Care plans such as HMOs and PPOs often require advance authorization, without which they may refuse to provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to help you find another therapist who will continue your psychotherapy.

    You should also be aware that insurance companies require you to authorize me to provide them with a clinical diagnosis. (Diagnoses are technical terms that describe the nature of your problems and whether they are short-term or long-term problems. All diagnoses come from a book entitled the DSM-V. There is a copy in my office and I will be glad to let you see it to learn more about your diagnosis, if applicable.) Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company’s files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information database. At your request, I will provide you with a copy of any report I submit. By signing this Agreement, you agree that I can provide requested information to your carrier if you plan to be reimbursed by your insurance company for the services I’ve rendered to you.

    In addition, if you plan to use your insurance, authorization from the insurance company may be required before they will cover therapy fees. If you did not obtain authorization prior to therapy and it is required, you may be responsible for full payment of the fee. Many policies leave a percentage of the fee (which is called co-insurance) or a flat dollar amount (referred to as a co-payment) to be covered by the patient. I require payment in full at the time of your appointment and will supply you with a CMS 1500 to submit to the insurance company in order to seek reimbursement. In addition, some insurance companies also have a deductible, which is an out-of-pocket amount that must be paid by the patient before the insurance companies are willing to begin paying any amount for services. This will typically mean that you will be responsible to pay for initial sessions with me until your deductible has been met; the deductible amount may also need to be met at the start of each calendar year. Once you have all of the information about your insurance coverage, we will discuss what we can reasonably expect to accomplish with the benefits that are available and what will happen if coverage ends before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above.

    Please note that not all insurance companies reimburse for out-of-network providers. If you prefer to use a participating provider, I will refer you to a colleague.

  • Professional Records

  • I am required by the Texas Administrative Code for the Texas State Board of Examiners of Psychologists under chapter 465 to keep appropriate records of the psychological services that I provide. Your records are maintained in a secure location. I keep brief records noting the following:

    • that you were here
    • your reasons for seeking therapy
    • the goals we set for treatment and your progress
    • your diagnosis
    • topics we discussed
    • your medical, social, and treatment history
    • records I receive from other providers
    • copies of records I send to others
    • your billing records

    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.

  • Confidentiality

  • Confidentiality means that I have a responsibility to safeguard information obtained during treatment. It is important that you understand that all identifying information about your assessment and treatment is kept confidential. In order to protect your confidentiality, any written, telephone, or personal inquiries about clients will not be acknowledged unless I receive a written release of information from you. In order for me to coordinate your treatment with other mental health or medical professionals, I may ask you to sign a release of information to allow me to talk to or correspond with other professionals who may play a role in meeting your needs (such as physicians, school officials, legal system representatives, or family members not participating in therapy with you).

    It is important that you understand that the laws of the State of Texas allow exceptions to confidentiality. In certain situations, as a mental health professional, I am required by law to reveal information obtained during your sessions to other persons or agencies without your permission. Also, in these situations I am not required to inform you of my actions. Possible exceptions to confidentiality include but are not limited to:

    1. I am required to report suspected child abuse or neglect as well as suspected abuse of the disabled or elderly to the Texas Department of Family and Protective Services.
    2. I may disclose information to law enforcement personnel in order to protect you or others when there is a probability of imminent physical injury. I may be required to disclose information to law enforcement personnel in order to protect you when there is a probability of immediate mental or emotional injury.
    3. I may be required by the court to disclose treatment information in proceedings affecting the parent-child relationship.
    4. I may disclose confidential information in proceedings brought by a client against a professional.
    5. There is no confidentiality of mental health information in connection with criminal proceedings, except communications by a person voluntarily involved in a substance abuse program.
    6. In the treatment of a minor client, I may advise a parent, managing conservator, or guardian of a minor, with or without minor’s consent, of the treatment needed by or given to the minor.
    7. I may submit a collections claim or lawsuit against a client or former client for failure to pay for services received.

    I meet regularly with other licensed mental health professionals for peer consultation to ensure my therapeutic skills remain strong. In peer consultation, I may share information about your clinical case in a confidential format with no names or other identifying information.

  • Parents, Minors, and Family Therapy

  • While privacy in therapy is crucial to successful progress, parental involvement can also be essential. It is my policy not to provide treatment to a child under age 12 unless s/he agrees that I can share whatever information I consider necessary with a parent. For children 13 and older, I request an agreement between the client and the parents allowing me to share general information about treatment progress and attendance, as well as a treatment summary upon completion of therapy. In order to build trust and rapport with children and teens, my practice is to consult with them in an individual session when I believe the child/teen needs additional parental involvement to successfully handle the situation they are facing. The minor and I will then make a plan of action about how to approach parents with that information including ways that parents can be involved in handling it for the benefit of the minor. All other communication will require the child’s agreement, unless I feel there is a safety concern, in which case I will make every effort to notify the child of my intention to disclose information ahead of time and make every effort to handle any objections that are raised.

    Another important element of confidentiality is the expectation that participating parties respect the privacy of other participating family members by refraining from sharing contents of the sessions with outside parties. Further, recording devices of any kind (audio, video, or photographic) are not allowed in the therapy sessions without written consent of all parties attending, including your therapist. In order to achieve your therapeutic goals, it is essential for all parties to experience trust and personal safety during therapy sessions.

  • Contacting Me

  • I am often not immediately available by telephone. I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a message on my confidential voicemail, and your call will be returned as soon as possible. I will make every attempt to inform you in advance of planned absences and provide you with the name and phone number of the mental health professional covering my practice while I am unavailable. For any number of unseen reasons, you may not quickly hear from me, or I may be unable to reach you. If this happens and you feel you cannot wait for a return call, or if you feel unable to keep yourself safe:

    1. go to your Local Hospital Emergency Room,
    2. contact the Suicide Text and Hotline at 741-741 (for Text) or 800-0273-8255 for a phone call, or
    3. call 911 and ask to speak to the mental health worker on call.
  • Other Rights

  • The therapist-client relationship is a key aspect in successful psychotherapy. If at any time you are unhappy with what is happening in therapy, I hope you will talk with me so that I can respond to your concerns. Such comments will be taken seriously and will be handled with care and respect. You may also request that I refer you to another therapist and you are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect that I will not have social or sexual relationships with clients or with former clients.

  • Electronic Communication and Confidentiality

  • Information sent electronically, such as by fax, email, Zoom or text, contains a risk of breach of confidentiality because they are not secure modes of communication. I do not put any client information into my phone for the protection of my clients, nor do I accept requests to “friend” clients on social media. Your initials indicate that you understand that I cannot protect these forms of communication as effectively as I can other modes of communication, and using them indicates you are willing to accept that risk.


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