Informed Consent Form

General Information 

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for me to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

The Therapeutic Process 

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 our 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 the client’s treatment will be held confidential unless the client requests 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 itemized below:

  1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which 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 information is obtained for the purpose of rendering an expert’s report to an attorney.

Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

If accidentally, we come across each other 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. 

 

In the process of couple or family therapy, I also have unique confidentiality responsibilities when working with couples, families, and children because the family as a whole may be considered the client. When working with families, we have an obligation to more than one person. We may share information disclosed to us in individual sessions, phone conversations, or written messages with those family members who have consented to treatment. We have a strict policy of not keeping potentially hurtful or damaging secrets from other family members who are also participating in therapy.

Clients often prefer to communicate via email or text message to schedule or confirm appointments, as well as provide updates regarding their situations. While I have a duty to act with professionalism and diligence to protect your information, I cannot guarantee the confidentiality of email correspondence and text messages due to the logistics of these types of communication.

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.

 

Professional Supervision

I am a Licensed Marriage and Family Therapist-Associate (LMFT-Associate) with License Number 204177 providing clinical services under the supervision of Kristina Delhomme, LMFT-S with License Number 201567, who may be contacted directly at ___{Contact Number}___ or ___{Email Address}___. My status as an LMFT-Associate means that I have completed a graduate degree or its equivalent in marriage and family therapy, passed the national licensing exam, and been approved by the Texas State Board of Examiners of Marriage and Family Therapists. Upon successful completion of Board requirements, I will become a fully Licensed Marriage and Family Therapist (LMFT). To fulfill the requirements of full licensure, I meet once weekly with Kristina Delhomme for clinical supervision, including discussion and direction for my work with clients. As a function of her role as my clinical supervisor, Kristina Delhomme will have full access to your clinical records and private health information.

Fees And Appointments

A standard therapy hour consists of approximately 50 minutes for the therapy session and 10 minutes to allow me to complete necessary paperwork and prepare for my next client. Payment for psychotherapy is due at the time services are rendered. 

As a LMFT-Associate, I am not an “in-network” provider for any insurance companies; however, I will complete necessary paperwork if you elect to submit your own claim for my services to your insurance company for reimbursement. Your insurance company may or may not reimburse for my services provided under supervision. Please be aware that insurance companies require a mental health diagnosis to be assigned to a single, identified client to consider psychotherapy to be medically necessary, and thus eligible for reimbursement. If my professional assessment does not determine a mental health disorder to be present or relevant to the therapy provided, I will not be able to complete a claim for your insurance company. 

For each session, we will both have a 15 minute window to accommodate delays that might come up due to technical or other issues, after which, if I fail to show, I will make every effort to reschedule, and if you fail to show, your session is forfeited. Please give at least 24 hours’ notice if you need to reschedule. I will give you at least 24 hours’ notice if I need to reschedule too. Life happens, emergencies come up and sometimes things don’t go as planned. I get that. I will make every attempt to accommodate changes, however, due to having several hourly sessions booked closely, last minute changes may be impossible. Not showing up for sessions repeatedly is discouraged, as it can impede our working relationship.

 

Between sessions, you can email me at gbemi@untangletogether.com and I will do my best to respond within 24 hours.

 

Feedback And Complaints

I am being supervised clinically by Kristina Delhomme, LMFT-S with License Number 201567 and she may be contacted directly at ___{Contact Number}___ or ___{Email Address}___. However, I invite and strongly encourage clients with any concerns or complaints to first talk with me directly. I will make every effort to address the issues professionally and collaboratively with you.

Additionally, clients who choose to file a complaint against me for violations of state laws and regulations or my professional ethics code should contact:

 

Texas State Board of Examiners of Marriage and Family Therapists

Complaints Management and Investigative Section

P.O. Box 141369

Austin, Texas 78714-1369

Phone: 1-800-942-5540 

 

Notice of Privacy Practices 

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. MY PLEDGE REGARDING HEALTH INFORMATION: 

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

  • Make sure that protected health information (“PHI”) that identifies you is kept private. 

  • Give you this notice of my legal duties and privacy practices with respect to health information. 

  • Follow the terms of the notice that is currently in effect. 

  • I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request and on my website. 

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: 

The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

 

For Treatment Payment, or Health Care Operations: Federal privacy rules and regulations allow health care providers who have direct treatment relationship with the client to use or disclose the client’s personal health information without the client’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, I would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition. 

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested. 

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

1. Psychotherapy Notes. I keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is: 

a. For my use in treating you. 

b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy. 

c. For my use in defending myself in legal proceedings instituted by you. 

d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA. 

e. Required by law and the use or disclosure is limited to the requirements of such law. 

f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes. 

g. Required by a coroner who is performing duties authorized by law. 

h. Required to help avert a serious threat to the health and safety of others. 

2. Marketing Purposes. I will not use or disclose your PHI for marketing purposes. 

3. Sale of PHI. I will not sell your PHI in the regular course of my business. 

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

  1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law. 

  2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety. 

  3. For health oversight activities, including audits and investigations. 

  4. For judicial and administrative proceedings, including responding to a court or administrative order, although our preference is to obtain an Authorization from you before doing so. 

  5. For law enforcement purposes, including reporting crimes occurring on my premises. 

  6. To coroners or medical examiners, when such individuals are performing duties authorized by law. 

  7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition. 

  8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions. 

  9. For workers' compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers' compensation laws. 

  10. Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer. 

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT. 

1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object

in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations. 

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI: 

  1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask us not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care. 

  2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full. 

  3. The Right to Choose How I send PHI to you. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests. 

  4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so. 

  5. The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided us with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request. 

  6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request. 

  7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right to get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it. 

 

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE 

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By signing this document, you are acknowledging that you have received a copy of HIPPA Notice of Privacy Practices.

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