Sara Dittoe Barrett, Ph.D.,5412 N Clark Street

Psychological Services, Ltd South Suites # 2 sdbarrettphd.com Chicago, IL 60640

847.942.5652

Information about Psychological Treatment

Welcome to my practice. I appreciate your giving me the opportunity to be of help to you.

What is Informed Consent?Informed consent is the process of you learning about the psychological treatment I can offer you, which may include cognitive-behavioral types of therapy. Informed consent involves learning about the risks and benefits of this type of treatment. It also includes learning what my practice policies are and about confidentiality. Part of the informed consent process is standard written information. This is provided to you in written form so that you don’t miss anything important. Throughout the treatment process, I will talk to you about what types of treatment I think would be most helpful and we will talk about this. That is part of the informed consent process as well.

Your Involvement: Your very active involvement is a critical part of psychological treatment. This includes active participation during the session as well as practicing new skills that you learn in sessions.

Length and Frequency of Treatment: Standard session length is 50-55 minutes, but shorter and longer sessions may be an option. Some skills can be learned and some problems can be improved in just a few sessions. Other problems need longer-term treatment. Once I have evaluated you, I can answer any questions you have about the length of treatment. If you need longer-term treatment and I am not available, I can refer you to other qualified professionals.

Risks of Treatment: Sometimes people experience natural but difficult feelings during treatment. You may recall and discuss unpleasant memories. Also, there is a risk that this treatment may not work for you.

Benefits of Treatment: I use cognitive-behavioral approaches that often include Acceptance and Commitment Therapy, Compassion Focused Therapy, exposure-based treatments, mindfulness, meditation, biofeedback, and relaxation training. These are evidence-based treatments, meaning that the benefits of these types of treatments have been shown by scientists in many well-designed research studies. Studies have shown that these types of treatments can lead to greater ability to cope with emotions (such as anxiety, sadness, or anger) and physical symptoms (such as pain or tension), reduction of emotional distress and physical symptoms, improved health, and enhanced sense of well-being.

Additional and Alternative Treatments: If you could benefit from a treatment I do not provide, I will do my best to help you get it. You have a right to ask me about such other treatments, their risks, and their benefits. I may recommend a medical exam, an evaluation for medication, or other treatments. I may recommend you see another mental health professional with specialized expertise if I do not have it.

The Therapeutic Relationship: As a professional, I follow the standards of my professional organization, which puts ethical limits on the relationship between a clinical psychologist and a client. These limits are intended to protect your privacy and the therapeutic relationship. For example, I cannot have another rolein your life. I cannot, now or ever, be a close friend or socialize with you. I can never have a romantic relationship with any client during, or after, the course of treatment. I cannot have a business relationship with any clients, other than the therapeutic relationship. If I see you in a public place, I will do my best to protect your confidentiality. For example, I may not approach you or start a conversation, especially if you are with another person. For confidentiality reasons, I also cannot connect with you on social media or networking sites.

No Court Testimony: If you ever become involved in a divorce or custody dispute, or any other legal matter, I will not provide evaluations or expert testimony in court. Your signature indicates your agreement with this provision.

Complaint Procedures: If you are not satisfied with my work, please raise your concerns with me as soon as possible. These conversations can be very helpful, and often enhance the working relationship.

EMERGENCIES

It is important that we have a shared understanding of what is expected in the event of an emergency. I am not available at all times, and may not always be available by phone. If you are feeling suicidal or are at risk of harming yourself, it is your responsibility to seek out help immediately.Go to your nearest emergency room or call 911. If there is an emergency and I become concerned about your personal safety, I may need to contact someone close to you—perhaps a relative, spouse, partner, or close friend. I may also need to contact this person or the authorities if I become concerned about your harming someone else, or if there is evidence of child or elderly abuse.

Questions: Please feel free to ask questions about what to do in an emergency or any other questions you may have about treatment at any time.

PRACTICE POLICIES

Payment

Fees or copays are due at the time of the appointment. Cash, check, and credit card are accepted forms of payment. If you are paying out of pocket and would like a receipt to submit to insurance, one will be provided. Out-of-network benefits vary, and you may or may not receive some reimbursement for treatment. Please contact your insurance provider to check your benefits.

Cancellation Policy

If you need to cancel, please call at least 24 hours ahead, otherwise you there is a $100 fee.

If you do not show up for your appointment and do not call, there is a $100 fee.

Availability

I am not available at all times. If you think this will be a problem, please ask me for a referral to someone else who may meet your needs better.

Solo Practitioner

Please note that, although there may be other practitioners using space in this office suite, I am not part of a group practice.

CONFIDENTIALITY

My professional ethics and the laws of this state prevent me from telling anyone else what you tell me unless you give me written permission. These rules and laws are the ways our society recognizes and supports the privacy of what we talk about—in other words, the confidentiality of therapy. But I cannot promise that everything you tell me will never be revealed to someone else. The HIPAA Notice of Privacy Practicesprovides details about these limits to confidentiality. Please review it carefully.

Releasing Your Health Information. If you want me to send information out of my office, or I need information about you from someone else, or I need to coordinate your health care with another professional, I will ask you to sign a release-of-information form. This form states what information is to be shared, with whom, and why, and it also sets time limits.

Professional Consultation. I sometimes consult other psychologists or counselors. This helps me give high-quality treatment. These persons are also required to keep your information private. Your name will never be given to them, and they will be told only as much as they need to know to understand your situation.

Professional Educational Use of Case Materials. I would be grateful for your consent to use your case material in my other professional activities. Your material may help in the development of the mental health field or in the education of health care workers. It is possible that I may use some information about your treatment in teaching, supervision, consultation with other therapists, professional presentations, or publishing. You would not get any financial benefit from this. When I use information from my work, I do not want anyone who hears, reads, or sees it to be able to identify the clients involved. Therefore, I will not use any identifying information or will change identifying information. If you do not agree to the uses of case materials as indicated, you will not be penalized in any way, and it will not affect the care you receive in any way. You may draw an X through this section if you do not want your case materials used in this way.

Signature Section

Information about Psychological Treatment

I have received and read the section entitled Information about Psychotherapy and agree to abide by Dr. Barrett’s practice policies. If at any time I have any questions about the subjects discussed in this handout, I can talk with Dr. Barrett about them. I understand that I will receive a copy of this form. My signature does not indicate that I am waiving any rights. I understand that I have the right not to sign this form.

Cancellation Policy

I have reviewed the cancellation policy and understand that I may charged for late cancellations or missed appointments. I agree to this policy.

HIPAA Notice of Privacy Practices Handout

I have received and read the handout entitled HIPAA Notice of Privacy Practices. My signature below shows that I understand how my personal health information may and may not be disclosed by Dr. Barrett. I understand the limits of confidentiality as described in the Notice of Privacy Practices.

Case Materials

I give Dr. Barrett my permission to use her knowledge of my case and our work together for professional purposes including publishing or presenting case reports or other professional writing, teaching, or presentations. I understand that my name and other identifying information will not be used. (Please X out this paragraph if you do not agree to it).

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Signature of client Date

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Printed name