Genuine DBT 572 Rio Lindo Ave. suite 204 Chico CA 95926 530.433.1001
Informed Consent Form for Psychotherapy
This document contains important information about professional services, experience, policies and practices. It also outlines your special rights and responsibilities as a psychotherapy consumer and Genuine DBT’s responsibilities as a psychotherapy provider. Please read this document carefully and feel free to ask any questions. Signing this document confirms an agreement between both parties.
Risks and Benefits to Psychotherapy
Engaging in psychotherapy entails potential risks as well as potential benefits. Making changes in your beliefs or behaviors can be uncomfortable and may generate intense feelings of any variety including those of sadness, guilt, anger or frustration. In addition, attempting to resolve issues that brought you into therapy could have other unintended consequences. You may decide to make changes in behavior, employment, substance use, schooling, relationships, or other aspects of your life. It may be helpful for you to know that most people who have taken the risk of trying psychotherapy have found it beneficial. Psychotherapy has been shown to have significant benefits to people who try it; including having more positive relationships, finding solutions to problems, reducing substance abuse and a reduction in distressing feelings. However, you must be aware that there is not a guarantee that psychotherapy will be effective for you or your specific issue.
Confidentiality
With the exception of certain specific exceptions and people described below, you have the absolute right to the confidentiality of your therapy. With the exception of the people listed below, Genuine DBT employees cannot tell anyone else what you have told us, or even that you are in therapy without your prior written permission. If we see you in a public location we will not acknowledge you unless you greet us first in order to further protect your privacy.
You may direct us to share information with whomever you choose, and you may choose what we can share with them. You can change your mind and revoke that permission at any time. You are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA).
Please be aware that email, text and other electronic media are not completely confidential. We do not use an encrypting program on our email and we cannot guarantee it will remain confidential.
We may share information with employees, volunteers, or interns who work with Genuine DBT and they are all held to the same legal and ethical standards of confidentiality.
The following are legal exceptions to your right to confidentiality:
1. If a staff member has good reason to believe that you will harm another person, we must attempt to inform that person and warn them of your intentions. We must also contact the police and ask them to protect your intended victim.
2. If we have good reason to believe that you or someone else are abusing or neglecting a child or vulnerable adult, we must inform Child or Adult Protective Services Protective Services immediately about the abuse.
3. If we believe that you are in imminent danger of harming yourself, we may legally break confidentiality and take reasonable steps to protect your safety including contacting family members or emergency services. We are not obligated to do this, and would explore all other options with you before taking this step. If at that point you were unwilling to take steps to guarantee your safety, we would then take the necessary steps.
4. If you are in family therapy and you and your family members decide to have some individual sessions as part of the family therapy, what you say in those individual sessions will be considered to be a part of the family therapy, and can and probably will be discussed in our joint sessions.
5. If copies of your records are subpoenaed by a court Genuine DBT may be legally forced to turn over the records or testify at a hearing under certain circumstances, especially if ordered to by a judge.
6. If you do not pay your fees as we have agreed upon, Genuine DBT has the right to use your records to seek payment for the service rendered.
Diagnosis
If a third party such as an insurance company, is paying for part of your bill, Genuine DBT will normally be required to give a diagnosis to that third party in order to be paid. If you want to discuss your diagnosis, or if you feel that it will be beneficial to your treatment, your therapist can discuss it with you.
Other Rights
You have the right ask about the training, credentials and experience of any of the clinical staff that you work with. You can request that we refer you to someone else if you decide our services are not for you. You are free to leave therapy at any time, although we recommend giving advance notice so that we can help you end treatment well and consolidate gains. (please see section below on Ending Therapy)
Emergencies and Crisis Calls
Genuine DBT does not have 24 hour emergency or “on call” coverage. If you are experiencing a behavioral health crisis situation, please call (800) 334-6622 or (530) 891-2810. If you are in a life threatening emergency situation, dial 9-1-1 or go to the nearest hospital emergency room rather than waiting for a call back.
Ending Therapy Well
To support your leaving, we 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 we initiate terminating you from our therapy, it will be because we feel that we are not able to be helpful to you any longer. Our ethics and training require that we offer quality service and have our clients’ needs as paramount in our treatment planning. If we no longer feel that we are the best or right service for you, we will offer referrals to other sources of care, but cannot guarantee that they will accept you for therapy or how they will approach your treatment.
Your Responsibilities as a Therapy Client
Attendance, Schedules, and Fees
There will be an initial Assessment fee based on the therapist you will be seeing. This and all other fees will be reviewed on our “Fee Agreement” forms.
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 understand that I can end therapy at any time I wish.
Signed: ______Date: ______
Telehealth Disclosure
If you will be participating in Telehealth services, or if you are considering this type of service in the future, please read our below disclosure on electronic distance therapy. (Telehealth)
You may withhold or withdraw this informed consent at anytime throughout your treatment; please provide us with such a request in writing.
These services are reserved for clients who reside in the state of California and find it extremely challenging to come to in-person sessions with their therapist. Please be reminded, that not all of our therapists provide telehealth services and that Telehealth is offered at our discretion based off of the client’s necessity for this service.
Telehealth involves the use of electronic communications to enable mental health care providers to offer services, which may have otherwise been unattainable. Providers may include therapists, skills trainers, psychologists or case managers. You will be choosing to communicate with your provider by using your personal device for internet capabilities.
To improve the privacy and security of your information, please note the following:
· Do not access the internet or wireless communications at work.
· You are encouraged to use your own personal computer or device. If you must use a shared device, always close the browser when you have completed your session.
· You may choose to create a separate account for Vsee (download at Vsee.com), or live chatting sessions so that your username cannot be easily identified as you.
· Your provider also commits to accessing and providing telehealth services through private internet access, devices, and accounts.
As with any therapeutic interventions, there are additional potential risks associated with the use of Telehealth or Electronic Distance Therapy.
· In rare cases, information transmitted via electronic devices may not be sufficient in allowing for appropriate interpretation by both the provider and the participant; or may be lost due to technology failures or flaws.
· Delays in evaluation and treatment could occur due to failure of equipment.
· Security protocols could fail, causing a breach of privacy or personal information.
· Your privacy could be compromised by the use of a cell phone, wireless device, internet access, etc.
· It is possible that although long distance therapy may provide access to needed services, it could also reduce the positive effects of exposure for patients with anxiety related disorders.
**Emergency situations should always be handled by calling 911
As with any therapeutic interventions, there are additional potential benefits associated with the use of Telehealth or Electronic Distance Therapy.
· Some research on telehealth show equal effectiveness to in-person services.
· The use of Telehealth services allows for greater access to services that my otherwise be difficult to access.
All confidentiality regulations and laws regarding access to medical information apply to telehealth.
Note: Your health insurance provider may not cover telehealth services as provided by Genuine DBT.
Signed: ______Date: ______
Release of Information for Insurance Reimbursement
I hereby authorize Genuine DBT, to release information required in the course of my examination or treatment for the purpose of payment and processing of claims. I hereby assign my insurance benefits to be paid directly to Genuine DBT, and authorize payment directly to Genuine DBT. I understand I will be financially responsible to Genuine DBT, for charges not covered by my insurance. Please note: It is your responsibility to check with your insurance company regarding your eligibility and benefits.
Signed: ______Date: ______
Emergency Contact List:
Name: ______Relationship: ______
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Address: ______
City: ______State: ______Zip Code: ______
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