KELLY RICE, M.A., LMFT
INFORMED CONSENT
This document provides important information regarding your treatment. Please read it carefully and ask your therapist any questions you have.
Information about your therapist:
I am a Licensed Marriage and Family Therapist. I received my undergraduate degree in Sociology from University of California San Diego (UCSD) and one of my two Master’s degreesis in Counseling Psychology from National University. I operate from many different theoretical orientations, depending on the presenting problem and treatment unit. Among these are: Psychodynamic, Cognitive-Behavioral, Existential, Gestalt, and Family Systems.
Fees and Insurance
My standard fee per session is: $125 per 45-50 minute session.(If sliding scales are requested, a separate scholarship/sliding scale form will be completed by the client). I will begin and end on time, unless, of course, some kind-of client emergency arises. Also, sliding scale fees are available on a limited basis. Fees for service will be established prior to the commencement of therapy.
If you do choose to continue in therapy, your feesare payable at the beginning of each session. Your therapist is happy to provide a SuperBill for you to submit to your PPO for reimbursement. However, all fees will be due in cash (or select credit cards) upfront for each session. Please check with your insurance company regarding what they offer in terms of mental health treatment and how you are to be reimbursed.
Confidentiality
All communications between you and I are held in confidence unless you provide written permission to release information about your treatment. If you participate in conjoint therapy, your therapist will not disclose confidential information about your treatment unless all persons who participated in treatment with you provide their written authorization(s)for confidentiality as well.
There are exceptions to confidentiality and are as follows: Therapists are required to report instances of suspected child and/or elder abuse. Therapists may be required or permitted to break confidentiality upon determining that a patient presents a serious danger of physical violence to another person, or when a patient is dangerous to him or herself. In addition, a federal law, the Patriot Act of 2001, requires therapists, in certain circumstances, to provide FBI agents with books, records, papers, and documents and prohibits therapists from disclosing to the client that the FBI sought or obtained the items under the Act.
“No-Secrets” Policy: If you participate in marital/couples/family therapy, your therapist is permitted to use information obtained in an individual session (or on the phone or in passing) when working with other members of your family. This is intended to instill trust for all members in the therapeutic process and to avoid coalitions and alliances.
Minors and Confidentiality
Communications between therapists and patients who are minors (under 18) are confidential. However, parents and other guardians who provide authorization for their child’s treatment, are often involved in the overall process. Consequently, your therapist, in the exercise of her professional judgment, may discuss overall treatment progress of a minor with parents.
Appointment Scheduling and Cancellation Policies
Sessions are typically scheduled to occur weekly on the same day and at the same time, if possible. Your consistent attendance greatly contributes to a successful outcome. If rescheduling or canceling an appointment, please notify your therapist at least 24 hours in advance. If you do not provide this advance notice, you will be responsible for payment of the missed session.
Therapist Availability/Emergencies
Although I check my voice messages at the very least every 24 hours during the business week, I let all of my clients know upfront that I am not readily available after business hours, or on the weekends and do not check my phone regularly during those times. In addition, that should a mental health crisis occur, clients should go to their nearest emergency room if they feel that might be necessary. If there is an emergency, and I am notified via voicemail, I will respond to the message as soon as I am able to on the following business day. EMERGENCY NUMBERS AND NAMES OF LOCAL HOSPITALS ARE LISTED BELOW AND ALSO ON MY WEBSITE.
Telephone consultations between sessions can possibly be scheduled in case of extreme need/crisis; however, I will attempt to keep those contacts brief due to a belief that important issues are better addressed in the therapy session. If extended phone sessions are necessary based on unusual circumstances, the client will be charged my standard hourly rate of $125/hr. I do not offer extended case management services for clients (especially outside of regular business hours). Rather, if consultation or collaborationwith a family memberis deemed important by my client, I will encourage my client to invite the family member in for at least a portion of an upcoming therapy session. This usually also serves to reduce any triangulation patterns and increase healthy communication.
You may leave a message at any time on my confidential voicemail. If you wish for me to return your call, please be sure to leave your name and phone number(s) along with a brief message concerning the nature of your call. Please be aware that Icheck voicemail throughout the day and will return your call, if possible, before the next therapy session. Otherwise, we will address the content in the next therapy session.
If, at any point in time during out therapeutic relationship, you believe that you need a therapist who is more on-call or available, please feel free to talk with me about this and we can discuss it, and if need be, I can refer you to a therapist who has more on-call availability. An important issue is that your mental health needs are met in a way that you remain satisfied with.
In the event of a medical / mental health emergency, or an emergency involving a threat to your safety and/or the safety of others, please call 911 to request emergency assistance.
Please be aware of the following resources that are available to assist individuals in crisis.
Crisis Hotline……………………………………1 (800) SUICIDE or 1(800) 784-2433
Domestic Violence Help…………………………………………………..1-800-799-7233
Psychiatric Hospital: (College Hospital Costa Mesa)………………….1-800 642-2734
CollegeHospitalMobile Crisis Team (for Psychiatric Emergencies)…...1-800 773-8001
Orange County Resource Line………………………………………………………2-1-1
About the Therapy Process
It is my intention to provide services that will assist you in reaching your goals. Based upon the information that you provide to me and the specifics of your situation, I will provide recommendations to you regarding your treatment. Therapists and clients collaborate in the therapeutic process. You have the right to agree or disagree with my recommendations.
Due to the individuality of each client, I am unable to predict the length of your therapy or to guarantee a specific outcome, but may try to provide you with an estimate based on your goals, if at all possible.
When beginning the therapeutic process, strong emotions and deep-seated issues may arise. They can be confusing and/or difficult to experience. This is normal and part of the process. Sometimes things feel like they are getting worse as they are on their way to getting better. Please discuss these thoughts and feelings with me.
Termination of Therapy
The length of your treatment and timing of your termination depend on the specifics of your treatment plan and the progress being achieved. It is a good idea to plan ahead for your termination in collaboration with me.
You naturally may discontinue therapy at any time. If you and/or I determine that you are not benefitting, either may discuss treatment alternatives, including the possible terminationof therapy.
Your signature indicates that you have read this agreement for services carefully and understand its contents.
Client’s Printed Name______
Client’s Signature ______Date: ______
KELLY RICE, M.A., LMFT
INFORMED CONSENT FOR TREATMENT-
CLIENT ACKNOWLEDGMENT AND PARTICIPATION
I hereby request that ______
(Patient Name)
______who resides at ______
(Date of Birth) (Street address)
______(City, State) (Zip Code) (Telephone #)
be accepted for outpatient mental health treatment by Kelly Rice, LMFT.
- I give my authorization and consent to receive outpatient diagnostic and mental health treatment from Kelly Rice, M.A., LMFT.
- I have been informed of my rights and responsibilities as a mental health patient.
- I have been give information regarding the limits of confidentiality of my records.
- I have been given information regarding the costs of services from Kelly Rice, M.A., LMFT. I understand that I am responsible to pay for these services in whole at each treatment visit.
- I am freely choosing to enter treatment, and I understand that I may discontinue treatment at any time.
- I have been given information about the advantages and disadvantages of the treatment recommended as well as other alternatives as may be appropriate.
______
(Date) (Patient/Parent signature)
(Date) (Witness)
KELLY RICE, M.A., LMFT
OFFICE POLICIES & GENERAL INFORMATION
AGREEMENT FOR PSYCHOTHERAPY SERVICES
This form provides you (patient) with information that is additional to that detailed in the Notice of Privacy Practices.
When Disclosure May Be Required: Disclosure may be required pursuant to a legal proceeding. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by Kelly Rice, M.A., LMFT. In couple and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. Kelly Rice will use her clinical judgment when revealing such information. Kelly Rice will not release records to any outside party unless she is authorized to do so by all adult family members who were part of the treatment.
Health Insurance & Confidentiality of Records: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/EAP in order to process the claims. If you so instruct Kelly Rice, only the minimum necessary information will be communicated to the carrier. Unless authorized by you explicitly, the Psychotherapy Notes will not be disclosed to your insurance carrier. Kelly Rice has no control or knowledge over what insurance companies do with the information she submits or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy, or to future eligibility to obtain health or life insurance. The risk stems from the fact that mental health information is entered into insurance companies’ computers and soon will also be reported to the, congress-approved, National Medical Data Bank. Accessibility to companies’ computers or to the National Medical Data Bank database is always in question, as computers are inherently vulnerable to break-ins and unauthorized access. Medical data has been reported to have been sold, stolen, or accessed by enforcement agencies; therefore, you are in a vulnerable position.
Confidentiality of E-mail, Cell Phone and Faxes Communication:It is very important to be aware that e-mail and cell phone communication can be relatively easily accessed by unauthorized people and hence, the privacy and confidentiality of such communication can be compromised. E-mails, in particular, are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e-mails that go through them. Faxes can easily be sent erroneously to the wrong address. Please notify Kelly Rice at the beginning of treatment if you decide to avoid or limit in any way the use of any or all of the above-mentioned communication devices. Please do not use e-mail or faxes for emergencies.
Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) nor your attorney, nor anyone else acting on your behalf will call on Kelly Rice to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.
Consultation: Kelly Rice consults regularly with other professionals regarding her clients; however, the client’s name or other identifying information is never mentioned. The client’s identity remains completely anonymous, and confidentiality is fully maintained.
*Considering all of the above exclusions, if it is still appropriate, upon your request, Kelly Rice will release information to any agency/person you specify unless Kelly Rice concludes that releasing such information might be harmful in any way.
MEDIATION & ARBITRATION: All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of Kelly Rice and client(s). The cost of such mediation, if any, shall be split equally and/or paid for fully by the client, unless otherwise agreed upon during the process of mediation. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Orange County, California in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, Kelly Rice can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitrator will determine that sum.
Dual Relationships: Not all dual relationships are unethical or avoidable. Therapy never involves sexual or any other dual relationship that impairs Kelly Rice’s objectivity, clinical judgment, or therapeutic effectiveness or can be exploitative in nature. Kelly Rice will avoid dual relationships if at all possible, and will assess carefully before entering into non-sexual and non-exploitative dual relationships with clients, if such dual relationships are unavoidable. Costa Mesa/Newport Beach is a small community and many clients know each other and Kelly Rice from the community. Consequently you may bump into someone you know in the waiting room or into Kelly Rice out in the community. Kelly Rice will never acknowledge working therapeutically with anyone without his/her written permission. Many clients choose Kelly Rice as their therapist because they know her before they enter into therapy with her and/or are aware of her stance on the topic. Nevertheless, Kelly Rice will discuss with you, her client/s, the often-existing complexities, potential benefits, and difficulties that may be involved in such relationships. Kelly Rice will always listen carefully and respond accordingly to your feedback. Kelly Rice will discontinue any possible dual relationship if she finds it interfering with the effectiveness of the therapeutic process or the welfare of the client and, of course, you can do the same at any time. Kelly Rice will usually try to avoid them unless a situation is beyond her control.
CANCELLATION: Since scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours notice is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, you will be charged the full fee for sessions missed without such notification. Insurance companies do not reimburse for missed sessions.
I have read the above Agreement and Office Policies and General Information carefully; I understand them and agree to comply with them:
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Client name (print)Date Patient\Parent Signature
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Client name (print)Date Patient\Parent Signature
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TherapistDate Signature
KELLY RICE, M.A., LMFT
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HIPAA NOTICE OF PRIVACY PRACTICES
I. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
II. IT IS MY LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI).
By law I am required to insure that your PHI is kept private. The PHI constitutes information created or noted by me that can be used to identify you. It contains data about your past, present, or future health or condition, the provision of health care services to you, or the payment for such health care. I am required to provide you with this Notice about my privacy procedures. This Notice must explain when, why, and how I would use and/or disclose your PHI. Use of PHI means when I share, apply, utilize, examine, oranalyze information within my practice; PHI is disclosedwhen I release, transfer, give, or otherwise reveal it to a third party outside my practice. With some exceptions, I may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made; however, I am always legally required to follow the privacy practices described in this Notice.