John Roberts, Ph.D.
P.O. Box 1854
San Ramon, CA 94583
(925) 227-1122
Outpatient Services Agreement for Collaterals
Introduction
I want to thank you for accepting the invitation to assist in __________________________________’s psychotherapeutic treatment. Your participation is important, and is sometimes essential to the success of the treatment. This document is to inform you about the risks, rights and responsibilities of your participation as a collateral participant.
Who is a Collateral?
A collateral is usually a spouse, significant other, family member, or friend, who participates in therapy to assist the identified patient. The collateral is not considered to be a patient and is not the subject of the treatment. Psychologists have certain legal and ethical responsibilities to patients, and the privacy of the relationship is given legal protection. My primary responsibility is to my patient and I must place their interests first. You also have less privacy protection.
The Role of Collaterals in Therapy
The role of a collateral will vary greatly. For example, a collateral might attend only one session, either alone or with the patient, to provide information to the therapist and never attend another session. In another case, a collateral might attend all of the patient s therapy sessions and his/her relationship with the patient may be a focus of the treatment. We will discuss your specific role in the treatment at our first meeting and other appropriate times.
Benefits and Risks
Psychotherapy often engenders intense emotional experiences, and your participation may engender strong anxiety or emotional distress. It may also expose or create tension in your relationship with the patient. While your participation can result in better understanding of the patient or an improved relationship, or may even help in your own growth and development, there is no guarantee that this will be the case. Psychotherapy is a positive experience for many, but it is not helpful to all people.
Medical Records
No separate record or chart will be maintained on you in your role as a collateral. Notes about you may be entered into the identified patient s chart. The patient has a right to access the chart and the material contained therein. It is sometimes possible to maintain the privacy of our communications. If that is your wish, we should discuss it before any information is communicated. You have no right to access that chart without the written consent of the identified patient. You will not carry a diagnosis, and there is no individualized treatment plan for you.
Fees
As a collateral you are not responsible for paying for my professional services unless you are financially responsible for the patient.
Confidentiality
The confidentiality of information in the patient s chart, including the information that you provide me, is protected by both federal and state law. It can only be released if the patient specifically authorizes me to do so. There are some exceptions to this general rule:
- If I suspect you are abusing or neglecting a child or a vulnerable adult, I am required to file a report with the appropriate agency.
- If I believe you are a danger to yourself, I will take actions to protect your life even if I must reveal your identity to do so.
- If you threaten serious bodily harm to another, I will take necessary actions to protect that person even if I must reveal your identity to do so.
- If you, or the patient, is involved in a lawsuit and a court requires that I submit information or testify, I must comply.
- If insurance is used to pay for the treatment, the clients insurance company may require me to submit information about the treatment for claims processing purposes or utilization review.
You are expected to maintain the confidentiality of the identified patient in your role as a collateral.
Do Collaterals Ever Become Formal Patients?
Collaterals may discuss their own problems in therapy, especially problems that interact with issues of the identified patient. The therapist may recommend formal therapy for a collateral. These are some examples of when this might occur.
- It becomes evident that a collateral is in need of mental health services. In this circumstance the collateral needs to have a clinician, diagnosis, and chart records kept.
- Parents, being seen as collaterals as their child is being treated, need couples therapy to improve their relationship so they can function effectively as parents.
Confidentiality
Most often, but not always, your clinician will refer you to another clinician for treatment in these situations. There are two reasons the referral may be necessary:
- Seeing two members of the same family, or close friends, may interfere with the clinician s judgement. Making a referral helps prevent this from happening.
- The clinician must keep a focus on the original primary task of treatment for the identified patient. For example, if the clinician started treating a child s behavioral problem, then takes on couples therapy with mom and dad to address their relationship problems, the original focus of therapy with the child may be lost. A referral helps the clinician to stay focused.
One exception to these guidelines is when a couple or family therapy approach can be effectively and ethically used to treat the couple or all members of the family.
Release of Information
The identified patient is not required to sign an authorization to release information to the collateral when a collateral participates in therapy. The presence of the collateral with the consent of the patient is adequate.
In many instances, I will request an authorization to be signed to ensure that full consent has been given to the clinician for the patient s confidential information to be discussed with the collateral in therapy. The Authorization Form is also helpful to the clinician on those occasions when receiving a telephone call from a collateral or when the clinician calls a collateral for one reason or another. In most instances the clinician cannot discuss that patient s treatment with a collateral without an Authorization Form.
Summary
If you have questions about therapy, my procedures, or your role in this process, please discuss them with me. Remember that the best way to assure quality and ethical treatment is to keep communication open and direct with your clinician. By signing below you indicate that your have read and understood this document.
Signature: _________________________________________
Date: ____________________