Welcome to my practice.  This document contains important information about my professional services and business policies.  Please read it and jot down any questions you might have so that we can discuss them at our next meeting. The information below includes the majority of the polices and expectations and services provided. When you actually begin services, the same information will be provided to you (broken down into several policy forms to agree to and electronically sign online) through the online "Book Appointment" menu item (above). There is a lot of information below, and not all of it will apply to your case but my hope is the information answers some questions you might already have.

 

PSYCHOLOGICAL SERVICES

Psychotherapy is not easily described in general statements.  It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to address. There are many different methods I may use to deal with those problems.  Psychotherapy is not like a medical doctor visit.  Instead, it 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.  Because 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 as to 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.  You should evaluate this information along with your own opinions about whether you feel comfortable working with me.  At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and, if so, I will give you referrals to other practitioners whom I believe are better suited to help you. 

 

Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select.  If you have questions about my procedures, we should discuss them whenever they arise.  If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. 

 

MEETINGS

I normally conduct an evaluation that will last from 2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals.  If we agree to begin psychotherapy, I will usually schedule one [45-minute] session (one appointment hour of [45-50] minutes duration) per week, at a time we agree on, although some sessions may be longer or more frequent.  Once an appointment hour is scheduled, you will be expected to pay for the scheduled service(s) and times scheduled, unless you provide at least 24 hours [at least 1 full day] advance notice of cancellation. In rare cases, (if we both agree that you were both unable to cancel and unable to attend due to circumstances beyond your control) there may be consideration of to waive the payment (please make the payment; then, submit a written request and explanation for which you believe the fee should be waived and reimbursed). 

TERMINATION - DISCONTINUING ACTIVE STATUS

Should you fail to schedule an appointment for 3 three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons,  I must consider the active professional relationship discontinued.

 

In most cases, discontinuing active status is discussed and planned as part of the treatment process and is a very common, routine practice. Re-establishing active status requires re-assessment or an updated assessment if services active services are restarted in less than 6 months from a previous assessment or a more detailed assessment if longer than 6 months.

 

If you have been court ordered to participate in a forensic examination, you are not actually considered an established or active client/patient.; in these situations the court is the client and is ordering and paying for an professional opinion and there is no therapy or treatment provided; this is simply an assessment and opinion related to a specific issue for the court. *Note: (this is different from a court order listing as one of its requirements or expectations that you complete a mental health or psychological evaluation in the next 30 or 60 days - in that case, you are the client, you or your insurance are likely paying for this, and you may become active/established client. 

PROFESSIONAL FEES

My hourly fee is $90-$250 (per appointment hour of [45-50] minutes duration).  If we meet more than the usual time, I will charge accordingly.  In addition to weekly appointments, I charge this same hourly rate for other professional services you may need, though I will prorate the hourly cost if I work for periods of less than one hour.  Other requested professional services include report writing, telephone conversations lasting longer than 5 minutes, attendance at meetings with other professionals you have authorized, preparation of treatment summaries, and the time spent performing any other service you may request of me.

If you are a previously established client, and become involved in legal proceedings or psycho-legal matters such as employer related requirements, probation, social services, or similar which require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party.  in these situations, insurance will not likely cover and I may expect an initial retainer: (typically, $1,200). Fees for professional services which I am asked or required to perform in relation to your psycho-legal matter range from $125-$250 per hour. If you have reason to believe you might be involved in a custody disagreement, criminal proceedings, or other court and psycho-legal issues such as employment related requirements, it is expected you would disclose this information prior to establishing active services, failure to inform me until after services begin might create a conflict of roles for services being provided and prevent me from providing service in those areas.

If you are establishing services with me to meet the requirements of a third party agencies, such as the court, schools, and employer, and child protective services, a licensing body, etc., there is an expectation for you to disclose this and provide any documents which delineate the expectations of services. Failure to disclose these facts at our initial meeting or immediately upon you being informed would be grounds for terminating the psychological services.

If you are court ordered to participate in mental health counseling or court ordered to complete mental assessment and follow the recommendations: In most cases, I will expect you sign a release of information and to obtain a copy of the order. If the court, probation, your employer, etc. require verifications and report updates I may require additional releases, discussions and disclosures before we be able to proceed. Communications and updates to agencies, such as courts, probation, and employers, schools, etc. which are voluntarily agreed upon by you as the client for conditions of the third party agency, (i.e., probation, parole, employment, enrollment in schools) will include additional fees for services which are not typically included or covered in general mental health services or by insurance plans. The additional cost of communicating and reporting to these agencies will be billed directly to you at my standard rate of $90 - 250 per hour (in most cases routine updates are simple check-box forms which take less than fifteen minutes). In some cases, when there are routine monthly reports and updates, we may be able to determine an alternate package/cost or fee. The charge for copying fee of $.50 per page for records requests.

Established service arrangements, with governmental agencies, and other contracts such as reimbursements or payments from health insurance companies, may include agreements to various limits and rates.

 

Pre-Paid - Discount

Direct-pay Clients who are not obtaining psycho-legal services, and are obtaining routine psychological services and pre-paid (which do not require or use of insurance billing for services) and which are paid entirely from online credit card/or debit card, are discounted. This includes, some uncomplicated psychological testing services. 

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 that requires another arrangement.  Payment schedules for other professional services will be agreed to when such services are requested.  In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan.

 

If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment.  This may involve hiring a collection agency or going through small claims court.  If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information I will release regarding a patient’s treatment is his/her name, the dates, times, and nature of services provided, and the amount due. 

 

INSURANCE REIMBURSEMENT

In order for us to set realistic treatment goals and priorities, it is important to evaluate 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 will provide you with whatever assistance I can in helping you receive the benefits to which you are entitled such as filling out forms and submitting them to your insurance company; however, you (not your insurance company) are responsible for full payment of my fees.  

 

It is very 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 the coverage, call your plan administrator.  Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company.  

 

If necessary, I am willing to call the insurance company on your behalf to obtain clarification.  Due to the rising costs of health care, insurance benefits have increasingly become more complex.  It is sometimes difficult to determine exactly how much mental health coverage is available.  “Managed Health Care” plans often require authorization before they provide reimbursement for mental health services.  These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning.  It may be necessary to seek approval for more therapy after a certain number of sessions. Though a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end.  Some managed-care plans will not allow me to provide services to you once your benefits end. If you are need assistance in finding another provider, and let me know, I will try to assist you in finding another provider who will help you continue your psychotherapy.

You should also be aware that most insurance companies require that I provide them with your clinical diagnosis.  Sometimes I have to provide additional clinical information, such as treatment plans, progress notes or summaries, or copies of the entire record (in rare cases).  This information will become part of the insurance company files.  Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands.  In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any records I submit, if you request it.  Youunderstand that, by using your insurance, you authorize me to release such information to your insurance company.  I will try to keep that information limited to the minimum necessary. 

 

Once we have all of 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.  It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above (unless prohibited by the insurance contract). 

CONTACTING ME

I am often not immediately available by telephone.  Although I have a wide range of office availability to schedule you, a lot of my work is done at other locations  and my visible office hour are limited. If you do not see workable office times, please feel free to email or call to see if other options can be worked out.  I will probably not answer the phone directly, but will try to get back to you immediately if I am not in the middle of other work. I monitor my voice mail frequently. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays (I typically will not return calls made to me after 5pm, until the next day). If you are difficult to reach, please inform me of some times when you will be available. Some common problems in contacting clients occur such as:
A) your voice mail is full or not set-up;

B) your phone number does not accept calls from numbers without caller ID;

C) I will not leave messages on your voicemail, unless you specifically requested me to contact to you at your phone number and to leave a message (in which case I will only leave my name and number or confirm an appointment time, or other non-personal information - this can seem odd to family or a spouse who is answers the call - but it is designed to protect you.

 

Crisis: f 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/psychiatrist on call. If there is an emergency dial #911.  If I will be unavailable for an extended time, there are resources on my website https://www.countrypsychology.com and I can provide you with the name of a colleague to contact, if necessary. 

 

OFFICE WAITING AREA - EXPECTATIONS - SUPERVISION OF CHILDREN

There are several other professionals and agencies with offices in the building. There is a large waiting area with chairs which is designated for clients to wait in. The area is carpeted and clean. Family and children are welcome to bring quiet games, reading material, etc. However, it is important to be respectful of noise level from loud voices and "louder play" as these can easily disrupt the work going-on behind closed doors.. Children should not be left unattended. When a parent brings siblings along who must sit in the waiting area, this can create some problems if the siblings become restless, bored, and struggles to quietly occupy themselves.

MINOR CHILDREN/ADOLESCENTS IN SESSIONS

Children who are 14 years or younger are expected to always have parents or guardians remain in the waiting area or attending sessions with their child. 

 

Working with your child(ren) alone in an office can create concerns, apprehensions, and fears. In most cases, initial sessions with a child and their parent (or parents) can quickly and comfortably transition to parent(s) moving to the  waiting area.  It can be helpful to parents to know that the office door can be left ajar and there is is a large shoulder-height window between the waiting area the office (which looks directly into the office). 

 

Adolescent who are 15 years and older will be expected to have a parent, guardian involved initially and whether a parent or guardian must be present can be determined by stability and maturity of the adolescent, along with other factors. For example,  if there are sub-zero blizzard conditions; if the office is closing and there are concerns about getting a ride after an appointment; or if there are accountability and behavioral history which warrant concerns; etc. 

 

Also, I have no interest in meeting with children and adolescents when others are not active in the building and or family and parents close by. So, if

the scheduled appointment times with adolescent or minors are during times when the building is not in more active use, I will expect them to be accompanied by an adult or and older sibling, (if in not a parent). This can be discussed; so if your online appointment for a minor child or adolescent  was declined it may simply be that the time of day is not a good fit - feel free to call and discuss. Also, with younger ages, engaging youth in therapy often require more class-room like tasks and activities from drawing to puzzles and even making collages - and although tele therapy might seem convenient for parents - I am highly reluctant to do tele-therapy with youth under 15 years old. 

ELECTRONIC COMMUNICATION POLICY

In order to maintain clarity regarding our use of electronic modes of communication during your treatment, I have prepared the following policy. This is because the use of various types of electronic communications is common in our society, and many individuals believe this is the preferred method of communication with others, whether their relationships are social or professional. Many of these common modes of communication, however, put your privacy at risk and can be inconsistent with the law and with the standards of my profession. Consequently, this policy has been prepared to assure the security and confidentiality of your treatment and to assure that it is consistent with ethics and the law.  If you have any questions about this policy, please feel free to discuss this with me.

 

Email Communications

I use email communication and text messaging only with your permission and only for administrative purposes unless we have made another agreement. That means that email exchanges and text messages with my office should be limited to things like setting and changing appointments, billing matters and other related issues.  Please do not email me about clinical matters because email is not a secure way to contact me. If you need to discuss a clinical matter with me, please feel free to call me so we can discuss it on the phone or wait so we can discuss it during your therapy session. The telephone or face-to-face context simply is much more secure as a mode of communication.

 

Text Messaging

Because text messaging is a very unsecure and impersonal mode of communication, I do not text message to nor do I respond to text messages from anyone in treatment with me.  So, please do not text message me unless we have made other arrangements. Instead please leave a voice message or send an email.

 

Social Media

I do not communicate with, or contact, any of my clients through social media platforms like Twitter and Facebook.  In addition, if I discover that I have accidentally established an online relationship with you, I will cancel that relationship.  This is because these types of casual social contacts can create significant security risks for you.

 

I participate on various social networks, but not in my professional capacity. If you have an online presence, there is a possibility that you may encounter me by accident. If that occurs, please discuss it with me during our time together.  I believe that any communications with clients online have a high potential to compromise the professional relationship. In addition, please do not try to contact me in this way. I will not respond and will terminate any online contact no matter how accidental.

 

Websites

I have a website that you are free to access. I use it for professional reasons to provide information to others about me and my practice. You are welcome to access and review the information that I have on my website and, if you have questions about it, we should discuss this during your therapy sessions.

 

Web Searches

I will not use web searches to gather information about you without your permission. I believe that this violates your privacy rights; however, I understand that you might choose to gather information about me in this way. In this day and age there is an incredible amount of information available about individuals on the internet, much of which may actually be known to that person and some of which may be inaccurate or unknown. If you encounter any information about me through web searches, or in any other fashion for that matter, please discuss this with me during our time together so that we can deal with it and its potential impact on your treatment. 

 

Recently it has become fashionable for clients to review their health care provider on various websites. Unfortunately, mental health professionals cannot respond to such comments and related errors because of confidentiality restrictions. If you encounter such reviews of me or any professional with whom you are working, please share it with me so we can discuss it and its potential impact on your therapy. Please do not rate my work with you while we are in treatment together on any of these websites. This is because it has a significant potential to damage our ability to work together.

 

CONFIDENTIALITY [for adult patients]

In general, the privacy of all communications between a patient and a psychologist is protected by law, and I can only release information about our work to others with your written permission.  But there are a few exceptions. In most legal proceedings, you have the right to prevent me from providing any information about your treatment.  In some legal proceedings, a judge may order my testimony if he/she determines that the issues demand it, and I must comply with that court order. 

 

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 or has been abused, I may be required to make a report to the appropriate state agency. If I believe that a patient is threatening serious bodily harm to another, I may be required to take protective actions.  

 

These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for you. If the you threaten to harm yourself, I may be obligated to seek hospitalization for you or to contact family members or others who can help provide protection.  If a similar situation occurs in the course of our work together, and I will attempt to fully discuss it with you before taking any action, (if I believe discussing this with you will not  significantly increase  risk). 

I may occasionally find it helpful to consult other professionals about a case.  During a consultation, I make every effort to avoid revealing the identity of clients. The consultant is also legally bound to keep the information confidential.  Ordinarily, I will not tell you about these consultations unless I believe that it is important to our work together. 

 

Although this written summary of exceptions to confidentiality is intended to inform you about potential issues that could arise, it is important that we discuss any questions or concerns that you may have at our appointments. I will be happy to discuss these issues with you and provide clarification when possible.  However, if you need specific clarification or advice I am unable to provide, formal legal advice may be needed, as the laws governing confidentiality are quite complex and I am not an attorney.  

Public settings, confidentiality and "multiple relationships"

:Seeing me in public, at a store, social event, restaurant, park etc. In small and rural communities this more likely to occur. Everyone has different level of privacy concerns. In regards to you working with me, you own the right. to privacy and in order to protect that, if we happen to see each other in public, I  will not initiate contact with you (suggesting to others I might know you somehow). If you initiate contact and say hello, I will enjoy casual exchanges with you and would still make every effort to avoid suggesting how I know you if others are present; if you share that information that is up to you; however, I would like to encourage the idea that discussion of clinical issues and therapy remains in the session.

  

Multiple Relationships (Ethical Principles of Psychologists and Code of Conduct).

(a) A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person.

Because there are many subtle ethics related to psychologists and the conflicts that multiple-relationship roles can create,  if I have worked with you as a client, I will avoid developing any other role with you. For example, i may avoid sitting on the same committee, and would decline invitations to most gatherings.


In many cases outside of the session or in other settings, If I appear to be more superficial and less encouraging of more elaborate dialogue, or steering a topic away from personal or clinical issues, it does not mean I do not care, or that I do not appreciate you. However, professionally, I am likely trying to protect the privacy issues, keep clinical topics in the therapy session, and set a boundary about developing any other type of role with you. 

TELE-THERAPY / TELEPSYCHOLOGY

Telehealth by SimplePractice is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in (a link will be emailed or texted to you within 15 minutes of the appointment time)

  1. My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.

  2. I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.

  3. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

  4. I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

  5. Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.

  6. Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.

  7. The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.

  8. I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service.

  9. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

 10. Tele-therapy with adolescents 15 and older will be determined on a case by case basis. 

 

MINORS 

Parent Authorization for Minor’s Mental Health Treatment

In order to authorize mental health treatment for your child, you must have either sole or joint legal custody of your child.  If you are separated or divorced from the other parent of your child, please notify me immediately.  I will ask you to provide me with a copy of the most recent custody decree that establishes custody rights of you and the other parent or otherwise demonstrates that you have the right to authorize treatment for your child.

If you are separated or divorced from the child’s other parent, please be aware that it is my policy to notify the other parent that I am meeting with your child.  I believe it is important that all parents have the right to know, unless there are truly exceptional circumstances, that their child is receiving mental health evaluation or treatment.

One risk of child therapy involves disagreement among parents and/or disagreement between parents and the therapist regarding the child’s treatment. If such disagreements occur, I will strive to listen carefully so that I can understand your perspectives and fully explain my perspective.  We can resolve such disagreements or we can agree to disagree, so long as this enables your child’s therapeutic progress.  Ultimately, parents decide whether therapy will continue.  If either parent decides that therapy should end, I will honor that decision, unless there are extraordinary circumstances.  However, in most cases, I will ask that you allow me the option of having a few closing sessions with your child to appropriately end the treatment relationship. 

 

Individual Parent/Guardian Communications with Me

In the course of my treatment of your child, I may meet with the child’s parents/guardians either separately or together.  Please be aware, however, that, at all times, my patient is your child – not the parents/guardians nor any siblings or other family members of the child.

 

If I meet with you or other family members in the course of your child’s treatment, I will make notes of that meeting in your child’s treatment records. Please be aware that those notes will be available to any person or entity that has legal access to your child’s treatment record.  

 

Mandatory Disclosures of Treatment Information

In some situations, I am required by law or by the guidelines of my profession to disclose information, whether or not I have your or your child’s permission.  I have listed some of these situations below.

Confidentiality cannot be maintainedwhen:

  • Child patients tell me they plan to cause serious harm or death to themselves, and I believe they have the intent and ability to carry out this threat in the very near future. I must take steps to inform a parent or guardian or others of what the child has told me and how serious I believe this threat to be and to try to prevent the occurrence of such harm.

  • Child patients tell me they plan to cause serious harm or death to someone else, and I believe they have the intent and ability to carry out this threat in the very near future. In this situation, I must inform a parent or guardian or others, and I may be required to inform the person who is the target of the threatened harm [and the police].

  • Child patients are doing things that could cause serious harm to them or someone else, even if they do not intend to harm themselves or another person.  In these situations, I will need to use my professional judgment to decide whether a parent or guardian should be informed.

  • Child patients tell me, or I otherwise learn that, it appears that a child is being neglected or abused--physically, sexually or emotionally--or that it appears that they have been neglected or abused in the past.  In this situation, I may be required by law to report the alleged abuse to the appropriate state child-protective agency.

  • I am ordered by a court to disclose information. 

 

Disclosure of Minor’s Treatment Information to Parents 

Therapy is most effective when a trusting relationship exists between the psychologist and the patient.  Privacy is especially important in earning and keeping that trust.  As a result, it is important for children to have a “zone of privacy” where children feel free to discuss personal matters without fear that their thoughts and feelings will be immediately communicated to their parents.  This is particularly true for adolescents who are naturally developing a greater sense of independence and autonomy.

It is my policy to provide you with general information about your child’s treatment, but NOT to share specific information your child has disclosed to me without your child’s agreement.  This includes activities and behavior that you would not approve of — or might be upset by — but that do not put your child at risk of serious and immediate harm.  However, if your child’s risk-taking behavior becomes more serious, then I will need to use my professional judgment to decide whether your child is in serious and immediate danger of harm.  If I feel that your child is in such danger, I will communicate this information to you.

 

Example: If your child tells me that he/she has tried alcohol at a few parties, I would keep this information confidential.  If your child tells me that he/she is drinking and driving or is a passenger in a car with a driver who is drunk, I would not keep this information confidential from you.  If your child tells me, or if I believe based on things I learn about your child, that your child is addicted to drugs or alcohol, I would not keep that information confidential.

 

Example: If your child tells me that he/she is having voluntary, protected sex with a peer, I would keep this information confidential. If your child tells me that, on several occasions, the child has engaged in unprotected sex with strangers or in unsafe situations, I will not keep this information confidential.

 

You can always ask me questions about the types of information I would disclose.  You can ask in the form of “hypothetical situations,” such as: “If a child told you that he or she were doing _____________, would you tell the parents?”

 

Even when we have agreed to keep your child’s treatment information confidential from you, I may believe that it is important for you to know about a particular situation that is going on in your child’s life.  In these situations, I will encourage your child to tell you, and I will help your child find the best way to do so.  Also, when meeting with you, I may sometimes describe your child’s problems in general terms, without using specifics, in order to help you know how to be more helpful to your child.

 

Disclosure of Minor’s Treatment Records to Parents

Although the laws of Minnesota may give parents the right to see any written records I keep about your child’s treatment, by signing this agreement, you are agreeing that your child or teen should have a “zone of privacy” in their meetings with me, and you agree not to request access to your child’s written treatment records.

 

Parent/Guardian Agreement Not to Use Minor’s Therapy Information/Records in Custody Litigation

When a family is in conflict, particularly conflict due to parental separation or divorce, it is very difficult for everyone, particularly for children.  Although my responsibility to your child may require my helping to address conflicts between the child’s parents, my role will be strictly limited to providing treatment to your child.  You agree that in any child custody/visitation proceedings, neither of you will seek to subpoena my records or ask me to testify in court, whether in person or by affidavit, or to provide letters or documentation expressing my opinion about parental fitness or custody/visitation arrangements.  

 

Please note that your agreement may not prevent a judge from requiring my testimony, even though I will not do so unless legally compelled.  If I am required to testify, I am ethically bound not to give my opinion about either parent’s custody, visitation suitability, or fitness.  If the court appoints a custody evaluator, guardian ad litem, or parenting coordinator, I will provide information as needed, if appropriate releases are signed or a court order is provided, but I will not make any recommendation about the final decision(s).  Furthermore, if I am required to appear as a witness or to otherwise perform work related to any legal matter, the party responsible for my participation agrees to reimburse me at the rate of no less than $150 per hour and no more than $250 per hour depending service time, whether it is time spent traveling, speaking with attorneys, reviewing and preparing documents, testifying, being in attendance, case-related collateral contact communication, case-related phone calls and any other case-related costs.

 

 

Parent/Guardian of Minor Patient: (example signature page)

Please initial after each line and sign below, indicating your agreement to respect your child’s privacy:

 

I will refrain from requesting detailed information about individual therapy sessions with my child.  I understand that I will be provided with periodic updates about general progress, and/or may be asked to participate in therapy sessions as needed. 

                                                                                                         

 

Although I may have the legal right to request written records/session notes since my child is a minor, I agree NOT to request these records in order to respect the confidentiality of my child’s/adolescent’s treatment.

 

                                                                                                        

I understand that I will be informed about situations that could endanger my child.  I know this decision to breach confidentiality in these circumstances is up to the therapist’s professional judgment, unless otherwise noted above.