By Laura S. Brown, Ph.D. ABPP Diplomate in Clinical Psychology
Informed consent in mental health services is one of the most important and least understood concepts with which consumer/survivors must deal. Dr. Laura Brown has written the following document for her clients and has given Sidran permission to post it for reproduction and individual use. It is an excellent tool for survivor empowerment, providing practical application of the education and information Sidran advocates.
This document, which specifies the rights and responsibilities of both the survivor and the helping professional in a therapeutic relationship, represents a “high bar” in the ethics of psychotherapy. We encourage all participants in therapeutic interactions to maximize the safety and quality of trauma treatment by striving for this level of ethical excellence.
Please feel free to substitute your name (if used by a helping professional) or the name of your therapist (if used by a consumer/survivor), and specifics of roles, policies, rates, etc. agreed upon in a specific psychotherapy relationship.
We thank Dr. Brown for sharing this valuable tool for consumer empowerment.
PSYCHOTHERAPY INFORMATION DISCLOSURE STATEMENT Therapy is a relationship that works in part because of clearly defined rights and responsibilities held by each person. This frame helps to create the safety to take risks and the support to become empowered to change. As a client in psychotherapy, you have certain rights that are important for you to know about because this is your therapy, whose goal is your well-being. There are also certain limitations to those rights that you should be aware of. As a therapist, I have corresponding responsibilities to you.
My Responsibilities to You as Your Therapist I. Confidentiality With the exception of certain specific exceptions described below, you have the absolute right to the confidentiality of your therapy. I cannot and will not tell anyone else what you have told me, or even that you are in therapy with me without your prior written permission. Under the provisions of the Health Care Information Act of 1992, I may legally speak to another health care provider or a member of your family about you without your prior consent, but I will not do so unless the situation is an emergency. I will always act so as to protect your privacy even if you do release me in writing to share information about you. You may direct me to share information with whomever you choose, and you can change your mind and revoke that permission at any time. You may request anyone you wish to attend a therapy session with you.
You are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA). This law insures the confidentiality of all electronic transmission of information about you. Whenever I transmit information about you electronically (for example, sending bills or faxing information), it will be done with special safeguards to insure confidentiality.
If you elect to communicate with me by email at some point in our work together, please be aware that email is not completely confidential. All emails are retained in the logs of your or my internet service provider. While under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrator(s) of the internet service provider. Any email I receive from you, and any responses that I send to you, will be printed out and kept in your treatment record. The following are legal exceptions to your right to confidentiality. I would inform you of any time when I think I will have to put these into effect.
The next is not a legal exception to your confidentiality. However, it is a policy you should be aware of if you are in couples therapy with me. If you and your partner decide to have some individual sessions as part of the couples therapy, what you say in those individual sessions will be considered to be a part of the couples therapy, and can and probably will be discussed in our joint sessions. Do not tell me anything you wish kept secret from your partner. I will remind you of this policy before beginning such individual sessions.
II. Record-keeping I keep very brief records, noting only that you have been here, what interventions happened in session, and the topics we discussed. If you prefer that I keep no records, you must give me a written request to this effect for your file and I will only note that you attended therapy in the record. Under the provisions of the Health Care Information Act of 1992, you have the right to a copy of your file at any time, giving me the chance to print it out from my computer. You have the right to request that I correct any errors in your file. You have the right to request that I make a copy of your file available to any other health care provider at your written request. I maintain your records in a secure location that cannot be accessed by anyone else.
III. Diagnosis If a third party such as an insurance company is paying for part of your bill, I am normally required to give a diagnosis to that third party in order to be paid. Diagnoses are technical terms that describe the nature of your problems and something about whether they are short-term or long-term problems. If I do use a diagnosis, I will discuss it with you. All of the diagnoses come from a book titled the DSM-IV; I have a copy in my office and will be glad to let you borrow it and learn more about what it says about your diagnosis.
IV. Other Rights You have the right to ask questions about anything that happens in therapy. I’m always willing to discuss how and why I’ve decided to do what I’m doing, and to look at alternatives that might work better. You can feel free to ask me to try something that you think will be helpful. You can ask me about my training for working with your concerns, and can request that I refer you to someone else if you decide I’m not the right therapist for you. You are free to leave therapy at any time.
V. Managed Mental Health Care If your therapy is being paid for in full or in part by a managed care firm, there are usually further limitations to your rights as a client imposed by the contract of the managed care firm. These may include their decision to limit the number of sessions available to you, to decide the time period within which you must complete your therapy with me, or to require you to use medication if their reviewing professional deems it appropriate. They may also decide that you must see another therapist in their network rather than me, if I am not on their list. Such firms also usually require some sort of detailed reports of your progress in therapy, and on occasion, copies of your case file, on a regular basis. I do not have control over any aspect of their rules. However, I will do all that I can to maximize the benefits you receive by filing necessary forms and gaining required authorizations for treatment, and assist you in advocating with the MC company as needed.
My Training and Approach to Therapy I have a Ph. D. in Clinical Psychology earned in 1977 at Southern Illinois University. I am a licensed psychologist (#615) in Washington State. I was awarded the Diplomate in Clinical Psychology of the American Board of Professional Psychology in 1986. My areas of special training and expertise include women’s and gender issues in general, and specifically working with survivors of trauma, abuse, and victimization, and people in recovery from alcohol and drugs.
My approach to therapy is called Feminist Therapy. This is a philosophy of psychotherapy which looks at the relationship of gender, power, and cultural forces in determining a person’s developmental experiences and the problems they are bringing to therapy. If you would like to learn more about this approach, I have books about it that I will lend to you. I use a variety of techniques in therapy, trying to find what will work best for you. These techniques are likely to include dialogue, interpretation, cognitive reframing, awareness exercises, self-monitoring experiments, visualization, journal-keeping, drawing, and reading books. If I propose a specific technique that may have special risks attached, I will inform you of that, and discuss with you the risks and benefits of what I am suggesting. I may suggest that you consult with a physical health care provider regarding somatic treatments that could help your problems; I refer both to traditional and non-traditional (homeopathic and Oriental medicine) practitioners, and will be glad to discuss with you the pros and cons of various alternatives. I may suggest that you get involved in a therapy or support group as part of your work with me. If another health care person is working with you, I will need a release of information from you so that I can communicate freely with that person about your care. You have the right to refuse anything that I suggest. I do not have social or sexual relationships with clients or former clients because that would not only be unethical and illegal, it would be an abuse of the power I have as a therapist.
Therapy also has potential emotional risks. Approaching feelings or thoughts that you have tried not to think about for a long time may be painful. Making changes in your beliefs or behaviors can be scary, and sometimes disruptive to the relationships you already have. You may find your relationship with me to be a source of strong feelings. It is important that you consider carefully whether these risks are worth the benefits to you of changing. Most people who take these risks find that therapy is helpful.
You normally will be the one who decides therapy will end, with three exceptions. If we have contracted for a specific short-term piece of work, we will finish therapy at the end of that contract. If I am not in my judgment able to help you, because of the kind of problem you have or because my training and skills are in my judgment not appropriate, I will inform you of this fact and refer you to another therapist who may meet your needs. If you do violence to, threaten, verbally or physically, or harass me, the office staff, or my family, I reserve the right to terminate you unilaterally and immediately from treatment. If I terminate you from therapy, I will offer you referrals to other sources of care, but cannot guarantee that they will accept you for therapy.
I am away from the office several times in the year for extended vacations. I will tell you well in advance of any lengthy absences, and give you the name and phone number of the therapist who will be covering my practice during my absence. I am available for brief between-session phone calls during normal business hours. If you are experiencing an emergency when I am out of town, or outside of my regular office hours (after 5 p.m. weekdays or over the weekend), please call the Crisis Clinic at 206-461-3222. If you believe that you cannot keep yourself safe, please call 911, or go to the nearest hospital emergency room for assistance.
Your Responsibilities as a Therapy Client I. You are responsible for coming to your session on time and at the time we have scheduled. Sessions last for 45 minutes. If you are late, we will end on time and not run over into the next person’s session. If you miss a session without canceling, or cancel with less than twenty-four hours notice, you must pay for that session at our next regularly scheduled meeting. The answering machine has a time and date stamp which will keep track of time to cancellation. I cannot bill these sessions to your insurance. The only exception to this rule is if you would endanger yourself by attempting to come (for instance, driving on icy roads without proper tires). II. You are responsible for paying for your session weekly unless we have made other firm arrangements in advance. My fee for a session is $110.00. If we decide to meet for a longer session, I will bill you prorated on the hourly fee. Emergency phone calls of less than ten minutes are normally free. However, if we spend more than 10 minutes in a week on the phone, if you leave more than ten minutes worth of phone messages in a week, or if I spend more than 10 minutes reading and responding to emails from you during a given week I will bill you on a prorated basis for that time. My fees go up $10.00 every two years, on the even year. If a fee raise is approaching I will remind you of this well in advance. III. If you have insurance, you are responsible for providing me with the information I need to send in your bill. You must pay me your deductible at the beginning of each calendar year if it applies and any co-payment. You must arrange for any pre-authorizations necessary. I will bill directly to your insurance company via electronic means for you once a month. You must provide me with any forms, completely filled out as needed, your complete insurance identification information, and the complete address of the insurance company. If a check is mailed to you, you are responsible for paying me that amount at the time of our next appointment. If the insurance over-pays me, I will credit it to your account or refund it to you if you would prefer that. IV. I am not willing to have clients run a bill with me. I cannot accept barter for therapy, nor can I take DSHS medical coupons. I am a Medicare participating provider and accept assignment from them. As of January, 2001, I am no longer accepting new Medicare clients. Any overdue bills will be charged 1.5% per month interest. If you eventually refuse to pay your debt, I reserve the right to give your name and the amount due to a collection agency.
Complaints If you’re unhappy with what’s happening in therapy, I hope you’ll talk about it with me so that I can respond to your concerns. I will take such criticism seriously, and with care and respect. If you believe that I’ve been unwilling to listen and respond, or that I have behaved unethically, you can complain about my behavior to the Examining Board for Psychology, Dept. of Health, Olympia WA 98504. You are also free to discuss your complaints about me with anyone you wish, and do not have any responsibility to maintain confidentiality about what I do that you don’t like, since you are the person who has the right to decide what you want kept confidential.
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 consent to the use of a diagnosis in billing, and to release of that information and other information necessary to complete the billing process. I agree to pay the fee of $110.00 per session. I understand my rights and responsibilities as a client, and my therapist’s responsibilities to me. I agree to undertake therapy with Laura S. Brown, Ph.D. I know I can end therapy at any time I wish and that I can refuse any requests or suggestions made by Dr. Brown. I am over the age of eighteen.