Client Consent Form
MAGGIE LAVEY, A.P.C.C.
Associate Professional Clinical Counselor (APCC#6507)
Phone: (805) 320-4077
Counselinganywhere.com
counselinganywhereCA@gmail.com
Informed Consent for Treatment
As a new client, you have the right to know about a variety of issues that might arise in the course of therapy. The Code of Ethics in my profession requires that I make you aware of specific policies so that you can make an informed decision whether or not to accept treatment. If you have any questions after reading this form, please bring them to my attention.
Participation in Treatment: Your participation in therapy is strictly voluntary and you may end treatment at anytime you wish. The primary goal of therapy is to eliminate psychological symptoms and addictive behaviors, improve relationships, along with social and occupational functioning. Therapeutic work often involves feeling states that can be distressing and may include episodes of conflicted feelings about the issues in one’s life. Although therapy often facilitates desired changes, you may also experience changes you had not originally anticipated (e.g., in your values and beliefs, in the nature of your relationships, etc). You should also be aware that there are other forms of treatment available, including treatment through medication, that can be helpful in relieving emotional distress. More information on these options can be provided upon your request.
Appointments and Cancellations: Psychotherapy sessions are 60 minutes long. A reasonable effort will be made to schedule your session at a time that is convenient for you. Once set, it becomes a reserved block of time that is put aside for your regular use. If you are late for an appointment, I will see you for the remainder of the time that was reserved for you. Since scheduling a session involves reserving a time specifically for you, a minimum of 24 hours’ notice is required for rescheduling or canceling an appointment. Please note that you will be charged the full fee for missed sessions without such notification.
Fees: Your fee is discussed and set during our initial phone conversation. It is customary to pay for services at the time they are rendered, unless other arrangements have been made. If you wish to pay by check, please make it payable to: Maggie Lavey. To avoid wasting your valuable session time, please have your check made out and ready before your session. I also accept credit cards (VISA or MasterCard).
Therapist & Telephone/Internet Accessibility: Should you need to speak with me between sessions, please call (805) 320-4077. If I am unavailable to answer your call, my telephone is answered by confidential voice mail that I monitor periodically throughout the day. I will make every effort to return your call the same day you make it. In the event that a lengthy telephone contact is required, (more than 5 minutes), you will be charged at the session rate. Whenever I am out of town, you will be given a referral to an alternate therapist who will cover my cases on an emergency basis. It is my policy to not accept clients as friends on Facebook. I will correspond with clients through email and text but know that this will be part of your confidential clinical record and information to guide your treatment.
Confidentiality: The information that you share with me during your therapy session and through email/text messaging is strictly confidential. This means that I cannot release any information about you, including the fact that you are a client, without your prior written consent. If a reason to share information with another party arises, you will be asked to sign a form authorizing me to do so. You may revoke this authorization at any time by written notice. Confidential information will not be revealed to a third-party payer without your permission.
Exceptions to Confidentiality: There are a few specific limitations to confidentiality. In certain instances, the law requires or permits the release of confidential information without your authorization. Disclosure of confidential information is legally required when abuse or neglect of a child, elder adult or dependent adult is suspected, and when a client makes a serious threat of physical violence to an identifiable victim. Disclosure may also be required in certain legal proceedings. Disclosure of confidential information is permitted when a client presents an imminent danger of self-harm or harm to another, if such disclosure is necessary to ensure safety. You should also be aware that you may be waiving your right to confidentiality if you enter your emotional status as an issue in any legal proceeding (e.g., a child custody evaluation, a workers compensation claim, etc.).
Safety: California law states that a therapist has a legal duty to take reasonable steps to prevent threatened suicide, with the least possible violation of the client’s privacy and self-determination. If a client makes a serious threat of physical violence to an identifiable victim, the therapist is required by law to notify the police and the intended victim. If a therapist has reason to suspect that a child, elderly adult or dependent adult is being abused or neglected, the therapist is mandated by law to make a report to the appropriate agency.
Confidentiality for Minors: Parents of minors have a legal right to access information about their child’s treatment, unless otherwise stated by law. This right must be balanced with the minor’s right to a confidential therapeutic relationship. The confidences of minors will be respected as deemed clinically appropriate.
Professional Conduct: It is the therapist’s responsibility to avoid intentional or reckless harm to the client and to maintain appropriate boundaries. Sexual contact with a client is both a civil and a criminal offense and should be reported to the California State Board of Behavioral Sciences.
Termination of Services: The client’s professional relationship with the therapist continues as long as the therapist is providing professional services, and until either the client informs the therapist that he or she wishes to terminate therapy, or the therapist notifies the client that therapy is being terminated. Assistance in making appropriate arrangements for continuation of services will be provided when necessary. I would recommend that when termination is considered, you discuss this with me, so that we can create a plan for termination to minimize any possible negative effects. If you don’t show-up for 3 consecutive scheduled appointments, your treatment will be considered canceled and terminated and you will be financially responsible for the fees of the missed sessions. A letter will be sent to you acknowledging the termination along with a closing bill for any unpaid balance.
Insurance Reimbursement: The client is responsible for payment of all therapy charges at the time of service. You may check with your insurance company to determine whether therapy costs are covered and to what extent. “Managed Health Care” PPO 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. While a lot can be accomplished in short-term therapy, some clients feel that they need more services after insurance benefits end. Seeking treatment after your insurance benefits end is your option to pursue and charges for services will be based on my current private pay rate. I will be providing you a monthly invoice, (including diagnostic code(s) and psychotherapeutic service code), which you can submit to your insurance carrier for reimbursement. If needed, I will be happy to complete forms needed to help you seek reimbursement from your insurance carrier. You should be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis and may ask for treatment plans or summary of treatment. Please note that most insurance carriers do not reimburse for missed or canceled sessions.
Your signature below indicates that you have read the information in this document, provided accurate information, and agree to abide by the terms during our professional relationship.
I acknowledge that I have received a copy of my authorization for my own records.
Print Name Signature Date
Additional Client Signature (Spouse/Partner/Friend/Family Member) Date
Signature of Psychological Services Provider Date
Associate Professional Clinical Counselor (APCC#6507)
Phone: (805) 320-4077
Counselinganywhere.com
counselinganywhereCA@gmail.com
Informed Consent for Treatment
As a new client, you have the right to know about a variety of issues that might arise in the course of therapy. The Code of Ethics in my profession requires that I make you aware of specific policies so that you can make an informed decision whether or not to accept treatment. If you have any questions after reading this form, please bring them to my attention.
Participation in Treatment: Your participation in therapy is strictly voluntary and you may end treatment at anytime you wish. The primary goal of therapy is to eliminate psychological symptoms and addictive behaviors, improve relationships, along with social and occupational functioning. Therapeutic work often involves feeling states that can be distressing and may include episodes of conflicted feelings about the issues in one’s life. Although therapy often facilitates desired changes, you may also experience changes you had not originally anticipated (e.g., in your values and beliefs, in the nature of your relationships, etc). You should also be aware that there are other forms of treatment available, including treatment through medication, that can be helpful in relieving emotional distress. More information on these options can be provided upon your request.
Appointments and Cancellations: Psychotherapy sessions are 60 minutes long. A reasonable effort will be made to schedule your session at a time that is convenient for you. Once set, it becomes a reserved block of time that is put aside for your regular use. If you are late for an appointment, I will see you for the remainder of the time that was reserved for you. Since scheduling a session involves reserving a time specifically for you, a minimum of 24 hours’ notice is required for rescheduling or canceling an appointment. Please note that you will be charged the full fee for missed sessions without such notification.
Fees: Your fee is discussed and set during our initial phone conversation. It is customary to pay for services at the time they are rendered, unless other arrangements have been made. If you wish to pay by check, please make it payable to: Maggie Lavey. To avoid wasting your valuable session time, please have your check made out and ready before your session. I also accept credit cards (VISA or MasterCard).
Therapist & Telephone/Internet Accessibility: Should you need to speak with me between sessions, please call (805) 320-4077. If I am unavailable to answer your call, my telephone is answered by confidential voice mail that I monitor periodically throughout the day. I will make every effort to return your call the same day you make it. In the event that a lengthy telephone contact is required, (more than 5 minutes), you will be charged at the session rate. Whenever I am out of town, you will be given a referral to an alternate therapist who will cover my cases on an emergency basis. It is my policy to not accept clients as friends on Facebook. I will correspond with clients through email and text but know that this will be part of your confidential clinical record and information to guide your treatment.
Confidentiality: The information that you share with me during your therapy session and through email/text messaging is strictly confidential. This means that I cannot release any information about you, including the fact that you are a client, without your prior written consent. If a reason to share information with another party arises, you will be asked to sign a form authorizing me to do so. You may revoke this authorization at any time by written notice. Confidential information will not be revealed to a third-party payer without your permission.
Exceptions to Confidentiality: There are a few specific limitations to confidentiality. In certain instances, the law requires or permits the release of confidential information without your authorization. Disclosure of confidential information is legally required when abuse or neglect of a child, elder adult or dependent adult is suspected, and when a client makes a serious threat of physical violence to an identifiable victim. Disclosure may also be required in certain legal proceedings. Disclosure of confidential information is permitted when a client presents an imminent danger of self-harm or harm to another, if such disclosure is necessary to ensure safety. You should also be aware that you may be waiving your right to confidentiality if you enter your emotional status as an issue in any legal proceeding (e.g., a child custody evaluation, a workers compensation claim, etc.).
Safety: California law states that a therapist has a legal duty to take reasonable steps to prevent threatened suicide, with the least possible violation of the client’s privacy and self-determination. If a client makes a serious threat of physical violence to an identifiable victim, the therapist is required by law to notify the police and the intended victim. If a therapist has reason to suspect that a child, elderly adult or dependent adult is being abused or neglected, the therapist is mandated by law to make a report to the appropriate agency.
Confidentiality for Minors: Parents of minors have a legal right to access information about their child’s treatment, unless otherwise stated by law. This right must be balanced with the minor’s right to a confidential therapeutic relationship. The confidences of minors will be respected as deemed clinically appropriate.
Professional Conduct: It is the therapist’s responsibility to avoid intentional or reckless harm to the client and to maintain appropriate boundaries. Sexual contact with a client is both a civil and a criminal offense and should be reported to the California State Board of Behavioral Sciences.
Termination of Services: The client’s professional relationship with the therapist continues as long as the therapist is providing professional services, and until either the client informs the therapist that he or she wishes to terminate therapy, or the therapist notifies the client that therapy is being terminated. Assistance in making appropriate arrangements for continuation of services will be provided when necessary. I would recommend that when termination is considered, you discuss this with me, so that we can create a plan for termination to minimize any possible negative effects. If you don’t show-up for 3 consecutive scheduled appointments, your treatment will be considered canceled and terminated and you will be financially responsible for the fees of the missed sessions. A letter will be sent to you acknowledging the termination along with a closing bill for any unpaid balance.
Insurance Reimbursement: The client is responsible for payment of all therapy charges at the time of service. You may check with your insurance company to determine whether therapy costs are covered and to what extent. “Managed Health Care” PPO 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. While a lot can be accomplished in short-term therapy, some clients feel that they need more services after insurance benefits end. Seeking treatment after your insurance benefits end is your option to pursue and charges for services will be based on my current private pay rate. I will be providing you a monthly invoice, (including diagnostic code(s) and psychotherapeutic service code), which you can submit to your insurance carrier for reimbursement. If needed, I will be happy to complete forms needed to help you seek reimbursement from your insurance carrier. You should be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis and may ask for treatment plans or summary of treatment. Please note that most insurance carriers do not reimburse for missed or canceled sessions.
Your signature below indicates that you have read the information in this document, provided accurate information, and agree to abide by the terms during our professional relationship.
I acknowledge that I have received a copy of my authorization for my own records.
Print Name Signature Date
Additional Client Signature (Spouse/Partner/Friend/Family Member) Date
Signature of Psychological Services Provider Date
