PSYCHOTHERAPY PROFESSIONAL DISCLOSURE STATEMENT AND INFORMED CONSENT

Carthage Therapy, LLC

Helping You Live Better

Coaching, Counseling, & Tele-therapy

Welcome to Carthage Therapy, LLC. We appreciate the opportunity to be of help to you. This document answers some questions regarding the practice of counseling/psychotherapy. At Carthage Therapy, LLC, it is important that you know how we will work together. After you read this, a therapist will discuss, in person, how these issues apply to your own situation.

Psychotherapy requires your very active involvement. It will be important for you to be honest with your therapist about your feelings, emotions, and experiences. Therapy is most effective when you feel trust in our therapeutic partnership, and are open to change and the uncomfortable feelings that may be associated with stepping outside your typical way of viewing life, yourself and others.

Client and therapist will plan the work together and agree on a plan that both parties will work hard to achieve. In our treatment plan, we will list the areas to work on, our goals and the methods we will use. From time to time, we will look together at our progress and goals and if we think we need to, we can make changes.

Many different techniques will be utilized in order to work towards increasing your self-awareness and personal growth. Techniques may include dialogue, education, relaxation strategies, reframing negative thoughts, art and writing exercises, or role-playing, and positive communication techniques. An important part of your therapy will be practicing the new skills you learn. You will be asked to practice outside our meetings, and we will work together to set up homework assignments for you. You can expect the unfamiliar feelings often associated with change to dissipate as you begin to incorporate the various techniques into your life.

Change will sometimes be easy and quick, or it may be slow and frustrating. There are no instant cures and no “magic pills.” However, you can learn new ways of looking at your problems that will be very helpful in developing more positive ways of coping with your current situation.

You may be referred to other professionals, such as doctors, nutritionists, or other supportive services if it is felt that you would benefit from additional resources. You may, as with all aspects of your treatment, decline such recommendations.

The process of ending therapy, called “termination,” can be a very valuable part of our work. Stopping therapy should not be done casually, although either client or therapist may decide to end it if either believe it is in client’s best interest. If you wish to stop therapy early, we ask that you agree now to meet for at least one additional session to review our work together. We will review our goals, the work we have done, any future work that needs to be done, as well as our choices moving forward.

The following are two exceptions to this joint decision to end therapy. (1) If the therapist is, in his/her professional judgment, not able to help you, because of the nature of your presenting concerns/diagnosis/medical illness or because his/her training and skills are, in his/her judgment, not appropriate, you will be informed of this fact and referred to another therapist who may meet your needs. (2) Verbal or physical threats, harassment, and violence towards therapist, his/her family, or his/her co-workers may result in an immediate and unilateral termination of treatment. If you are terminated from therapy, you will receive referrals to other sources of care, but it cannot be guaranteed that they will accept you for therapy.

The Benefits and Risks of Therapy

As with any treatment, psychotherapy involves some potential risks. Making changes in your beliefs or behaviors can be scary, and sometimes disruptive to the relationships you already have. You may find your relationship with the therapist to be a source of strong feelings. Sometimes, too, a client’s problems may temporarily worsen after the beginning of treatment. Most of these risks are to be expected when people are making important changes in their lives. It is important that you consider carefully whether these risks are worth the benefits to you of changing. Most people who take these risks find that therapy is helpful.

While you consider these risks, you should also know that the benefits of therapy have been shown in hundreds of well-designed research studies to be beneficial for many people. For example, people who are depressed may find their mood lifting. In this therapeutic partnership, you will have a chance to talk things out fully. You may find that your relationships and coping skills improve greatly. You may experience more satisfaction from social and family relationships, work, school or a renewed sense of hope.

About Confidentiality

In all, but a few rare situations, you have the absolute right to the confidentiality (privacy) of your therapy. We cannot and will not tell anyone else what you have shared in sessions, or even that you are in therapy without your prior written permission, with a few rare exceptions described below in this document. You may direct Carthage Therapy, LLC to share information with whomever you chose, and you can change your mind and revoke that permission at any time. Under the provisions of the Health Care Information Act of 1992, we will always act so as to protect your privacy even if you do release us in writing to share information about you. You are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA). This law insures the confidentiality of all electronic transmission of information about you. You will be given a copy of Carthage Therapy, LLC’s Notice of Privacy Practices and you will be asked to sign a client consent for the use and disclosure of protected health information.

In an emergency where your life or health is in danger, and we cannot get your consent, we may give another professional or a family member some information to protect your life.

The following are legal exceptions to your right to confidentiality.

We will inform you of any time when we think we will have to put these into effect. In any of these situations, we will reveal only the information that is needed to protect you or the other person.

a) Child Neglect: If we have good reason to believe that you are abusing or neglecting a child or vulnerable adult, or if you give us information about someone else who is doing this,

we must inform Child Protective Services.

b) Danger to Self: If we believe that you are in imminent danger of harming yourself, we may legally break confidentiality and call the police. We are not obligated to do this, and would explore all other options with you before taking this step. However, if at that point you were unwilling to take steps to guarantee your safety, we would call the police.

c) Danger to Others: If we have good reason to believe that you will harm another person, we must attempt to inform that person and warn them of your intentions. We must also contact the police and ask them to protect your intended victim.

d) Court Order: If your records are subpoenaed by court order, we may be required to disclose confidential information.

Couples Therapy: The next is not a legal exception to your confidentiality. However, it is a policy you should be aware of if you are in couples therapy at Carthage Therapy.

If you and your partner decide to have some individual sessions as part of the couple’s therapy, what you say in those individual sessions will be considered to be a part of the couples therapy, and can and probably will be discussed in our joint sessions. Do not tell your therapist anything you wish kept secret from your partner. You will be reminded of this policy before beginning such individual sessions.

Children and families create some special confidentiality questions.

a. Confidentiality also extends to parents. Other than the exceptions listed above,

we will not share with you specifics of what your child said or did during a session unless your child gives me permission to do so. We will, however, talk with you on a regular basis about your child’s therapeutic progress, treatment goals, your expectations for therapy, and your concerns and hopes for your child.

b. In cases where we treat several members of a family (parents and children or other relatives), the confidentiality situation can become very complicated. We may have different duties toward different family members. At the start of our treatment, we must all have a clear understanding of our purposes, any limits on confidentiality that may exist and my role.

c. We also request that you respect the right of confidentiality of others that you may see at this practice. We ask our clients to not disclose the identity of those they may see coming or going, as each individual has the right to decide with whom they share this information.

Carthage Therapy only accepts private pay at the time of service. We will provide a statement for you to file with your insurance company to reimburse you.

Will my insurance company pay for counseling?

Many insurance plans reimburse for a portion of therapy. Please direct questions about reimbursement amounts and timeliness to your insurance company. Carthage Therapy, LLC therapists are not contracted (preferred provider or in-network) with any insurance company. Out-of-network benefits vary from plan to plan. For details, contact your insurance carrier and ask about “out-of-network” benefits for “outpatient mental health services.” Upon request, we are happy to provide you with a statement for therapy that you may submit to your insurance company for reimbursement.

Why doesn’t Carthage Therapy accept insurance?

Choice: You and your counselor are in charge of goals, length of treatment, and therapeutic choices.

Savings: You pay less because we don’t spend valuable time on insurance paperwork.

Privacy: Insurance companies require a diagnosis to authorize treatment and may request additional information to process your claims. Your files are not shared with anyone outside of our organization without your permission, except for the provisions outlined above in the section entitled About Confidentiality. If insurance claims are filed, confidential information must be disclosed.

Therapist’s Role in the Therapeutic Partnership

Your therapist can only be your therapist. He/she cannot have any other role in your life. Your therapist cannot, now or ever, be a close friend or socialize with any of his/her clients. He/she cannot be a therapist to someone who is already a friend. He/she can never have a sexual or romantic relationship with any client during, or after, the course of therapy. He/she cannot have a business relationship with any of my clients other than the therapy relationship.

If you ever become involved in a divorce or custody dispute, you should understand and agree that Carthage Therapy, LLC therapists will not provide evaluations or expert testimony in court. You should hire a different mental health professional for any evaluations or testimony you require. This position is based on two reasons: (1) Our statements will be seen as biased in your favor because we have a therapy relationship; and (2) the testimony might affect our therapy relationship, and we must put this relationship first.

About Our Appointment

Initially, appointments are usually once a week, then less often. The frequency of sessions will be a joint decision. An appointment is a commitment to our work. If you are late, we will be unable to meet for the full time. You will be billed for the full scheduled appointment.

If you miss a session without canceling, or cancel with less than 48 (forty-eight) hours notice, for non-emergency reasons, you will be charged $100. We cannot bill these sessions to your insurance, nor will your insurance reimburse you for missed sessions.

We request that you do not bring children that are young and need babysitting or supervision, as it would be difficult for you to fully devote your attention to therapy while also attending to a small child. The exception is of course for children involved in the therapy.

Fees and Payment

Carthage Therapy, LLC agrees to provide psychotherapy services in return for a fee of $100 for an initial intake session and $100 per each subsequent session. Group Therapy Sessions are billed at $50 for each session. Payment for each session will be collected at the start of the session. Cash, personal checks, or credit cards are acceptable methods of payment. Please make out your check before each session begins. We will provide you with a receipt for all fees paid.

If there is any problem with our charges, billing, your insurance, or any other money-related point, please bring it to our attention. Such problems can interfere greatly with our work. If you think you may have trouble paying your bills on time, please discuss this with us. There will be a $35 charge for all returned or bounced checks. Please be aware that following the second returned or bounced check or debit/credit card charge, you will be required to pay all fees in cash. If you eventually refuse to pay your debt, Carthage Therapy, LLC reserves the right to give your name and the amount due to a collection agency and must end therapy at that time.

Consultation

During the course of treatment, consultation may be a required and/or necessary part of your care. Payment for such will be required on the date of service. Time spent in phone consultation or attendance at school conferences, such as IEP meetings, will be billed at $100.00 an hour. Any requested administrative work, beyond what it is provided at the end of each session, will be charged an administrative fee of $25.00 for 1-20 minutes. Each additional 20 minute increment will be billed at$25.00.

If a court appearance is required by a court ordered subpoena, a rate of $500.00 will be retained. This retainer must be received prior to any action being taken by your therapist. Each subsequent hour, including such actions as time spent in travel, preparation, document preparation, and consultation with attorneys or other professionals will be billed at a rate of $150.00 per hour.

Client Consent to Psychotherapy

I acknowledge that I, the client (or his or her parent or guardian), have received, have read (or have had read to me), and understand the “Informed Consent”. I have discussed those points I did not understand, and have had my questions, if any, fully answered. I understand that after therapy begins I have the right to withdraw my consent to therapy at any time, for any reason. Furthermore, I am aware that an agent of my insurance company or other third-party payer may be given information about the type(s), cost(s), date(s), and providers of any services or treatments I receive, if I request that this information be provided in order from me to receive any reimbursement of fees paid. I understand that if payment for the services I receive here is not made, the therapist may stop my treatment.

I, or as the legal guardian of ______________________________________________, do hereby seek and consent to take part in psychotherapy services provided by Carthage Therapy therapists. I understand that no specific promises have been made to me by Carthage Therapy, LLC or it’s therapists about the results of treatment, the effectiveness of the procedures used by its therapists, or the number of sessions necessary for therapy to be effective.

My signature below shows that I understand and agree with all of the statements contained in this document.

__________________________________________________________ _______________

Signature of client or legal guardian Date

I, R.T. Estes, LPC, LMFT, on behalf of Carthage Therapy, LLC, have met with this client (and/or his or her parent or guardian), and have informed him or her of the issues raised in this document. I have responded to all of his or her questions. I believe this person fully understands the issues, and I find no reason to believe this person is not fully competent to give informed consent to treatment. I agree to enter into therapy with this client, as shown by my signature.

__________________________________________________________ _______________

Signature of therapist Date

____ Copy given to client ____ Copy kept by therapist