Consent to Treatment

John K. Roberts, Ph.D.
5700 Stoneridge Mall Road, Suite 265
Pleasanton, Ca.  94588
(925) 227-1122

Welcome to my practice.  This document contains important information about my professional services and business policies.  Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting.  When you sign this document, it will represent an agreement between us.

Psychological Services
Psychotherapy is not easily described in general statements.  It varies depending on the personalities of the psychologist and patient, and the particular concerns you bring forward.  There are many different methods I may use to deal with the difficulties that you wish to address.  Psychotherapy calls for a very active effort on your part.  In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.

Psychotherapy can have benefits and risks.  Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness.  On the other hand, psychotherapy has also been shown to have benefits for people who go through it.  Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress.  But there are no guarantees of what you will experience.

Our first few sessions will involve an evaluation of your needs.  By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy.  During this time, we can both decide if I am the best person to provide the services you need to in order to meet your treatment goals.  Therapy involves a significant commitment of time, money, and energy so you should carefully consider the therapist you select.  If you have questions about my procedures, we should discuss them whenever they arise.

Appointments
Although session length and frequency may vary, psychotherapy usually consists of one 50-minute session per week at a time we agree upon.  Once an appointment time is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation.  If unusual, exceptional circumstances occur, this may be waived on a instance-by-instance basis.

Professional Fees
Before or during the first session, financial arrangements will be made.  Many clients have third party payors (e.g., insurance coverage) — in some instances,  I will bill them in behalf of the client.

In the event that you require a professional service not covered by your insurance, my fee is charged on a (50 minute) hourly basis.  The fee will be set based upon the prevailing rate charged at the time the service is rendered.

Billing and Payments
You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage which requires another arrangement.

If your account has not been paid for more than 60 days and arrangements for payment have not been agreed to, I have the option of (1) adding an interest charge of 1% (compounded monthly) to any unpaid balance and (2) using legal means to secure payment.  This may involve hiring a collection agency or initiating legal action.  If either is necessary, the costs of doing so will be added to the balance due.  In most collection situations, the only information I release is the patient’s name, address, social security number, date of birth, phone number, occupation and employer, nature of services provided, dates of service, and amount due.

Insurance Coverage
As a part of setting realistic treatment goals and priorities, it is important to understand what resources you have available to pay for your treatment.  If you have a health insurance policy, it will usually provide some coverage for mental health treatment.  I can complete forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled.  However, you (not your insurance company) are responsible for full payment of my fees.  It is important that you find out exactly what mental health services your insurance policy covers.

You should carefully read the section in your insurance coverage booklet that describes mental health services.  If you have questions about coverage, contact  your insurance company.

Once we have all the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions.  If you are not comfortable with the terms required by your insurance company, we can discuss other options that may be available.

Contacting Me
I am often not immediately available by telephone.  While I am usually in my office between 7:45 AM to 7:00 PM on Mondays, Tuesdays and Wednesdays and from 7:45 AM to 5PM on Thursdays, I usually do not answer the phone when I am with a patient.  When I am unavailable, my telephone is answered by confidential voice mail.  I will make every effort to return your call on the same day that you make it, with the exception of Fridays, weekends, or holidays.  If you are difficult to reach, please inform me of some times when you will be available.  If you are unable to reach me or feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist (or psychiatrist) on call.  If I will be unavailable for an extended time, I will provide on my voice mail message, the name and phone number of a colleague to contact in the event of a crisis.

Minors
If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records.  It is my policy to request an agreement from parents that they agree to give up access to your records.  If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else.  In this case, I will notify them of my concern.  I will also provide them with a summary of your treatment when it is complete.  Before giving them any information, I will attempt to discuss it with you and, whenever possible, do my best to resolve any objections you may have with what I am prepared to discuss.

Confidentiality
In general, the privacy of all communications between a patient and a psychologist is protected by federal and state law – I can only release information about our work to others with your written permission.

In most legal proceedings, you have the right to prevent me from providing any information about your treatment.  In some proceedings (e.g., involving child custody and those in which your emotional condition is a important issue), a judge may order my records or testimony if he/she determines that the issues demand it.

There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a patient’s treatment.  For example, if I believe that a child, elderly person, or disabled person is being abused, I am required to file a report with the appropriate agency.

If I believe that person is threatening serious bodily harm another person or themselves,  I am required to take protective actions.  These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient.  If the patient threatens to harm himself/herself, I may seek hospitalization for him/her or to contact family members or others who can help provide protection.

These situations have rarely occurred in my practice.  If they occur with you, I will attempt to fully discuss them with you before taking any action.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential issues, it is important that we discuss any questions or concerns that you may have.  I am willing to discuss these issues with you if you need specific advice, but formal legal advice may be needed because the laws governing confidentiality are quite complex and I am not an attorney.

Your signature below indicates that you have read the information in this document and agreed to abide by its terms during our professional relationship.

 

 

Client Signature:____________________________________________

Date:___________________

 

 

John K. Roberts, Ph.D.:_______________________________________

Date:___________________