Psychotherapy Information Disclosure Statement
Therapy is a relationship that works in part because of clearly defined rights and responsibilities held by each person. This frame helps to create the safety to take risks and the support to become empowered to change. As a client in psychotherapy, you have certain rights that are important for you to know about because this is your therapy, and the goal is your well-being. There are also certain limitations to those rights that you should be aware of. As a therapist, I have corresponding responsibilities to you.
My Responsibilities to You as Your Therapist
There are certain specific exceptions which are described below, you have the absolute right to the confidentiality of your therapy. I cannot and will not tell anyone else what you have told me, or even that you are in therapy with me without your prior written permission. I may not legally speak to another health care provider or a member of your family about you without your prior consent, and I will not do so unless the situation is an emergency. I will always act to protect your privacy even if you do release me in writing to share information about you. You may direct me to share information with whomever you choose, and you can change your mind and revoke that permission at any time.
The following are legal exceptions to your right to confidentiality. I would inform you of any instance when I will put these into effect.
1. If I have good reason to believe that you will harm another person, I must attempt to inform that person and warn them of your intentions. I must also contact the police and ask them to protect the intended victim.
2. If I have good reason to believe that you are abusing or neglecting a child or a vulnerable adult, or if you give me information about someone else who is doing this.
3. If I believe that you are in imminent danger of harming yourself, I may legally break confidentiality and call the police. I am not obligated to do this, and would explore all other options with you before I took this step. If at that point you were unwilling to take steps to guarantee your safety, I would call for help.
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 with me.
If you and your partner decide to have some individual sessions as part of the couples 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 me anything you wish kept secret from your partner. I will remind you of this policy before beginning such individual sessions.
I keep very brief records, noting only that you have been here, what interventions happened in session, and the topics we discussed. You have the right to a copy of your file at any time. You have the right to request that I correct any errors in your file. You have the right to request that I make a copy of your file available to any other health care provider at your written request. I maintain your records in a secure location that cannot be accessed by anyone else.
If a third party such as an insurance company is paying for part of your bill, I am normally required to give a diagnosis to that third party. Diagnoses are technical terms that describe the nature of your problems and whether they are short-term or long-term problems. If I do use a diagnosis, I will discuss it with you. The diagnosis comes from the DSM-V.
IV. Other Rights
You have the right to ask questions about anything that happens in therapy. I'm always willing to discuss how and why I've decided to do what I'm doing, and to look at alternatives that might work better. You can feel free to ask me to try something that you think will be helpful. You can ask me about my training for working with your concerns, and you are free to leave therapy at any time if you decide I'm not the right therapist for you.
Your Responsibilities as a Therapy Client
You are responsible for coming to your session on time and at the time we have scheduled. Sessions last for 50 minutes. If you are late, we will end on time and not run over into the next person's session. If you are more than 20 minutes late that will be considered a missed session. If you miss a session without canceling, or cancel with less than twenty-four hours notice, you must pay for that session. If you no-show for two sessions in a row and do not respond to my attempts to reschedule, I will assume that you have dropped out of therapy and will make the space available to another individual.
You are responsible for paying for your session at the time of the appointment. My rate is $150 for individuals and $180 for couples/families. If we decide to meet for a longer session, I will charge you prorated on the hourly fee. Emergency phone calls of less than ten minutes are normally free.
If you have insurance, you are responsible for providing the insurance company with the information. I will provide the necessary paperwork for you to submit..
I am not willing to have clients run a bill with me. I cannot accept trade for therapy.
If you're unhappy with what's happening in therapy, I hope you'll talk about it with me so that I can respond to your concerns. I will take such criticism seriously, and with care and respect. You are free to discuss your complaints about me with anyone you wish, and you do not have any responsibility to maintain confidentiality about our work together since you are the person who has the right to decide what to keep confidential