John Roberts, Ph. D.
P.O. Box 1854
San Ramon, CA 94583
(925) 227-1122
Informed Consent for Psychotherapy Treatment
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) and/or access to Flexible Spending (FSA) or Medical Savings (MSA) accounts. It is often helpful for clients to be already informed these resources when we have discussions about professional fees. Although I do not have contracts with any third party payors, many clients have “out of network provider” coverage and I can assist them in obtaining covered benefits by providing a statement that facilitates insurance claims processing.
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 of service.
Billing and Payments
You will be expected to pay for each session at the time it is held, unless we make other arrangements.
Insurance Coverage
As a part of setting realistic treatment goals and priorities, it is important for you to understand what resources you have available to pay for your treatment. If you have a health insurance policy, it may cover some of the cost associated with mental health treatment. We can make arrangements for me to provide you with a statement, containing information that is usually necessary for insurance claims processing and payment, that you can submit to your insurance company. In addition, I will provide whatever assistance I can to help you to 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 and understand how payment to you is determined.
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 also discuss other options that may be available.
Contacting Me
I am often not available by telephone. While I am usually working between 7:45 and 5:00 on Mondays, Tuesdays, and Wednesdays, I usually do not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by HIPAA-compliant, confidential voice mail. I will make every effort to return your call on the same day you make it, with the exception of Fridays, week-ends, 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 you cannot wait for me to return your call, contact your personal physician or nearest emergency room and ask for the psychologist (or psychiatrist) on call. If I will be unavailable for an extended period of 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.
Emergencies
If you are unable to reach me and feel that you cannot 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. My website (www.JohnRobertsPhD.com) has a list of crisis mental health resources.
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 may 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 Roberts, Ph.D. & Date : _______________________________________________________