Consent for Psychotherapy

You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

CONFIDENTIALITY

The session content and all relevant materials to your treatment will be held confidential unless you request in writing to have all, or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are described below:

1. If a client threatens or attempts to commit suicide or otherwise conducts himself/herself in a way where there is a substantial risk of incurring serious bodily harm.

2. If a client threatens grave bodily harm or death to another person.

3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional, or sexual abuse of children under the age of 18 years.

4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

5. Suspected neglect of the parties named in items #3 and # 4.

6. If a court of law issues a legitimate subpoena for information stated on the subpoena.

7. If a client is in therapy or being treated by order of a court of law, or if the information is obtained for the purpose of rendering an expert’s report to an attorney.

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

Consent for Telehealth Consultation and Treatment

All services provided by Golden Sky Counseling will be done through telehealth video conferencing. By signing this consent form, you are confirming your understanding and agreement with the following:

1. I understand that a telehealth consultation session will not be the same as a direct client/health care provider visit since I will not be in the same room as my provider.

2. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from the location of my choosing.

3. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

4. I have had a direct conversation with my provider, during which I had the opportunity to ask questions regarding this method of communication. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

Appointments and Cancellations

Please remember to cancel or reschedule appointments 24 hours in advance. Cancellations and the re-scheduled session will be subject to a full charge if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time.

Payment Policy

Although I do not participate with most insurance companies, the services provided are often reimbursable through your insurance plan through out-of-network benefits. Upon request, I will provide you with a monthly receipt, called a Superbill, that will contain all the necessary information required by insurance companies. You can submit this bill to the insurance company to be compensated through your out-of-network benefits.

Payment in full is expected at the time of each visit. Fees for therapy and consultations are based on a 50-minute session.

Payment for services can be made through Zelle bank transfer (use rikki@goldenskycounseling.org to find the account).

By signing this document, you are also confirming your understanding that if for any reason, payment is not received, Golden Sky Counseling will submit overdue fees to a collection agency after 30 days if no repayment plan is formally documented/agreed upon. Golden Sky Counseling will make a good faith effort to try and resolve overdue fees before submitted to collections, based upon the contact information you provide.

Communications

If you need to contact me between sessions, please leave a message on my voice mail or send me a text. I will do my best to return your message within 24 hours. If a true emergency arises, please call 911 or any local emergency room.

I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so.

 Social Media

Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept a friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc.) I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.

Termination

Ending relationships can be difficult. Therefore, it is important to have a termination process to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after an appropriate discussion with you if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.

Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.