CONSENT FOR TREATMENT AND LIMIT OF LIABILITY
Limits of Services and Assumption of Risks:
Therapy sessions carry both benefits and risks. Therapy sessions can significantly reduce the amount of distress someone is feeling, improve relationships, and/or resolve other specific issues. However, these improvements and any “cures” cannot be guaranteed for any condition due to the many variables that affect these therapy sessions. Experiencing uncomfortable feelings, discussing unpleasant situations and/or aspects of your life are considered risks of therapy sessions.
Limits of Confidentiality:
What you discuss during your therapy session is kept confidential. No contents of the therapy sessions, whether verbal or written may be shared with another party without your written consent or the written consent of your legal guardian. The following is a list of exceptions:
Duty to Warn and Protect
If you disclose a plan or threat to harm yourself, the therapist must attempt to notify your family and notify legal authorities. In addition, if you disclose a plan to threat or harm another person, the therapist is required to warn the possible victim and notify legal authorities.
Abuse of Children and Vulnerable Adults
If you disclose, or it is suspected, that there is abuse or harmful neglect of children or vulnerable adults (i.e., The elderly, disabled/incompetent), the therapist must report this information to the appropriate state agency and/or legal authorities.
Prenatal Exposure to Controlled Substances
Therapists must report any admitted prenatal exposure to controlled substances that could be harmful to the mother or the child.
Minors/Guardianship
Parents or legal guardians of non-emancipated minor clients have the right to access the clients’ records. Minors are legally entitled to consent for their treatment at the age of 12.
Insurance Providers
Insurance companies and other third-party payers are given information that they request regarding services to the clients.
Couple and Family Therapy
In couples and family therapy, the “relationship” is viewed as the “client” that is treated. In order to protect the best interest of both or all parties involved, the therapist reserves the right to confidentiality to any information disclosed from any individual.
The type of information that may be requested includes types of service, dates/times of service, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, summaries, etc. By signing below, I agree to the above assumption of risk and limits of confidentiality and understand their meanings and ramifications.
CANCELLATION POLICY
If you are unable to attend an appointment, we request that you provide at least 24 hours advanced notice to our office. Since we are unable to use this time for another client, please note that you will be billed for the entire cost of your scheduled appointment if it is not timely cancelled, unless such cancellation is due to illness or an emergency.
For cancellations made with less than 24 hour notice (unless due to illness or an emergency) or a scheduled appointment that is completely missed, you will be responsible for the full session fee.
Communication by email, text message, and other non-secure means
It may become useful during the course of treatment to communicate by email, text message (e.g. “SMS”) or other electronic methods of communication. Be informed that these methods, in their typical form, are not confidential means of communication. If you use these methods to communicate with Alexa Thurman, there is a reasonable chance that a third party may be able to intercept and eavesdrop on those messages. The kinds of parties that may intercept these messages include, but are not limited to:
- People in your home or other environments who can access your phone, computer, or other devices that you use to read and write messages
- Your employer, if you use your work email to communicate with Alexa Thurman
- Third parties on the Internet such as server administrators and others who monitor Internet traffic If there are people in your life that you don’t want accessing these communications, please talk with Alexa Thurman about ways to keep your communications safe and confidential.
Consent for transmission of protected health information by non – secure means.
I consent to allow Alexa Thurman to use email and mobile phone text messaging to transmit to
me the following protected health information:
- Information related to the scheduling of meetings or other appointments
- Information related to billing and payment
- Any other questions that the client may ask or information client requests via email or mobile phone text messaging.
I have been informed of the risks, including but not limited to my confidentiality in treatment, of transmitting my protected health information by unsecured means. I understand that I am not required to sign this agreement in order to receive treatment. I also understand that I may terminate this consent at any time.