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Office Policies & General Information Agreement for Psychotherapy Services & Informed Consent for Psychotherapy
This form provides you, the client/patient/patient, with information that is additional to that detailed in the Notice of Privacy Practices and it is subject to HIPAA preemptive analysis.
CONFIDENTIALITY:All information disclosed within sessions and the written records pertaining to those sessions are confidentialand may not be revealed to anyone without your written permission except where disclosure is required by law.
WHEN DISCLOSURE IS REQUIRED OR MAY BE REQUIRED BY LAW: Some of the circumstances where disclosure is required or may be required by law are: where there is a reasonable suspicion of child, dependent, or elder abuse or neglect; where a client/patient presents a danger to self, to others, to property, or is gravely disabled; or when a client/patient's family members communicate to Progressive Mind Center, PLLC that the client/patient presents a danger to others. Disclosure may also be required pursuant to a legal proceeding by or against you. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony from Progressive Mind Center, PLLC. In couples and family therapy, or when different family members are seen individually, even over a period of time, confidentiality and privilege do not apply between the couple or among family members, unless otherwise agreed upon. Progressive Mind Center, PLLC will use clinical judgment when revealing such information. Progressive Mind Center, PLLC not release records to any outside party unless they are authorized to do so by alladult parties who were part of the family therapy, couples therapy, or other treatment that involved more than one adult client/patient.
EMERGENCY:If there is an emergency during therapy, or in the future after termination, where Progressive Mind Center, PLLC becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, they will do whatever they can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, they may also contact the person whose name you have provided on the biographical sheet.
HEALTH INSURANCE & CONFIDENTIALITY OF RECORDS: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process claims. If you so instruct Progressive Mind Center, PLLC, will provide only the minimum necessary information to be communicated to the carrier. Progressive Mind Center, PLLC has no control over, or knowledge of, what insurance companies do with the information submitted or who has access to this information. You must be aware that submitting a mental health invoice to your insurance company for reimbursement carries a certain amount of risk to confidentiality, privacy or to future capacity to obtain health or life insurance or even a job. The risk stems from the fact that mental health information is likely to be entered into big insurance companies' computers and is likely to be reported to the National Medical Data Bank. Accessibility to companies' computers or to the National Medical Data Bank database is always in question as computers are inherently vulnerable to hacking and unauthorized access. Medical data has also been reported to have been legally accessed by law enforcement and other agencies, which also puts you in a vulnerable position.
LITIGATION: Sometimes patients become involved in litigation while they are in therapy or once therapy has been completed. Sometimes patients or the opposing attorney in a legal case wants the records disclosed to the legal system. Due to the nature of the psychotherapeutic process and the fact that it often involves making a full disclosure with regard to many matters, client/patients’ records are generally confidential and private in nature. Patients should know that very serious consequences can result from disclosing therapy records to the legal system. Such disclosures may negatively affect the outcome of custody disputes or other legal matters and may negatively affect the therapeutic relationship. If you or the opposing attorney are considering requesting Progressive Mind Center, PLLC’s disclosure of the records, Progressive Mind Center, PLLCwilldo their best to discuss with you the risks and benefits of doing so. As noted in this document, you have the right to review your own psychotherapy records anytime. (See also relevant section above: "WHEN DISCLOSURE IS REQUIRED OR MAY BE REQUIRED BY LAW"
CONSULTATION: Progressive Mind Center, PLLC consults regularly with other professionals regarding their clients/patients; however, each client/patient's identity remains completely anonymous and confidentiality is fully maintained.
E–MAILS, CELL PHONES, COMPUTERS, AND FAXES: It is very important to be aware that computers and unencrypted email, texts, and e-fax communication (which are part of the clinical records) can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. Emails, texts, and e-faxes, in particular, are vulnerable to such unauthorized access due to the fact that servers or communication companies may have unlimited and direct access to all emails, texts and e-faxes that go through them. While data on Progressive Mind Center, PLLC’slaptops are encrypted, emails, texts and e-faxes are not. It is always a possibility that e-faxes, texts, and email can be sent erroneously to the wrong address and computers. Progressive Mind Center, PLLC’s laptops are equipped with a firewall, a virus protection and a password, and they back up all confidential information from their computers on a regular basis onto an encrypted hard-drive. Also, be aware that phone messages are transcribed and sent to Progressive Mind Center, PLLC via unencrypted emails. Please notify Progressive Mind Center, PLLC if you decide to avoid or limit, in any way, the use of email, texts, cell phones calls, phone messages, or e-faxes. If you communicate confidential or private information via unencrypted email, texts or e-fax or via phone messages, we will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and staff will honor your desire to communicate on such matters. Please do not use texts, email, voicemail, or faxes for emergencies.
RECORDS AND YOUR RIGHT TO REVIEW THEM: Both the law and the standards of Progressive Mind Center, PLLC’sprofession require that they keep treatment records for at least 7years. Please note that clinically relevant information from emails, texts, and faxes are part of the clinical records. Unless otherwise agreed to be necessary, Progressive Mind Center, PLLC retains clinical records only as long as is mandated by Florida law. If you have concerns regarding the treatment records, please discuss them with Progressive Mind Center, PLLC. As a client/patient, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or whenProgressive Mind Center, PLLC assesses that releasing such information might be harmful in any way. In such a case, Progressive Mind Center, PLLC provides the records to an appropriate and legitimate mental health professional of your choice. Considering all of the above exclusions, if it is still appropriate, and upon your request, Progressive Mind Center, PLLC release information to any agency/person you specify unless Progressive Mind Center, PLLC assesses that releasing such information might be harmful in any way. When more than one client/patient is involved in treatment, such as in cases of couples and family therapy, Progressive Mind Center, PLLC only release records with signed authorizations from allthe adults (or all those who legally can authorize such a release) involved in the treatment.
TELEPHONE & EMERGENCY PROCEDURES: If you need to contact Progressive Mind Center, PLLCbetween sessions, please leave a message at the answering service (772) 213-8881 and your call will be returned as soon as possible. Progressive Mind Center, PLLC checks messages a few times during the daytime only, unless out of town. If an emergency situation arises, indicate it clearly in your message and if you need to talk to someone right away call Psychiatric Emergency Services 24-hour crisis line (Indian River County): 211 or the Police: 911. Please do not use email or faxes for emergencies. Progressive Mind Center, PLLC may not always check emails or faxes daily.
PAYMENTS & INSURANCE REIMBURSEMENT: Client/patients are expected to pay the standard fee for services before or at the beginning of each session unless other arrangements have been made. Telephone conversations, site visits, writing and reading of reports, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc., will be charged at the same rate, unless indicated and agreed upon otherwise. Please notify Progressive Mind Center, PLLC immediately if any problems arise during the course of therapy regarding your ability to make timely payments. Client/patients who carry insurance should remember that professional services are rendered and charged to the client/patient and not to the insurance companies. Unless agreed upon differently, Progressive Mind Center, PLLC will provide you with a copy of your receipt on, at least, a monthly basis that you may then submit to your insurance company for reimbursement, if you so choose. As was indicated in the section, “Health Insurance & Confidentiality of Records,”you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems that are dealt with in psychotherapy are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage. If your account is overdue (unpaid) and there is no written agreement on a payment plan, Progressive Mind Center, PLLCmay use legal or other means (courts, collection agencies, etc.) to obtain payment.
THE PROCESS OF THERAPY/EVALUATION AND SCOPE OF PRACTICE: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek treatment. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behaviors. Progressive Mind Center, PLLC asks for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach may be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts may result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. Progressive Mind Center, PLLC may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that may cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that initially brought you into therapy, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, Progressive Mind Center, PLLCis likely to draw on various treatment approaches according, in part, to the problem that is being treated and the clinician’s assessment of what will best benefit you. These approaches include, but are not limited to, behavioral, cognitive-behavioral, cognitive, psychodynamic, existential, system/family, developmental (adult, child, family), humanistic or psycho-educational. Progressive Mind Center, PLLC provides neither custody evaluation recommendationsnor legal advice, as these activities do not fall within the scope of this practice.
TREATMENT PLANS: Within a reasonable period of time after the initiation of treatment, Progressive Mind Center, PLLC will discuss with you the clinician’s working understanding of the problem, treatment plan, therapeutic objectives, and view of the possible outcomes of treatment. If you have unanswered questions about any of the interventions used during the course of your therapy or possible risks, Progressive Mind Center, PLLC's expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits.
TERMINATION: As set forth above, after the first couple of meetings, Progressive Mind Center, PLLC assesses if it may be of benefit to you. Progressive Mind Center, PLLC will not work with clients/patients who, in their opinion, cannot be helped by a clinician. In such a case, if appropriate, the clinician will give you referrals that you may contact. If at any point during psychotherapy Progressive Mind Center, PLLCeither assesses that they are not effective in helping you reach the therapeutic goals or you are non-compliant or non-responsive with treatment and if you are available and/or it is possible and appropriate to do so, the clinician will discuss with you the termination of treatment and conduct pre-termination counseling. In such a case, if appropriate and/or necessary, the clinician will give you a couple of referrals that may be more helpful to you. If you request it and authorize it in writing, Progressive Mind Center, PLLC will talk to the psychotherapist of your choice in order to help with the transition. If at any time you want another professional’s opinion or wish to consult with another psychiatrist/therapist, Progressive Mind Center, PLLC gives you a couple of referrals that you may want to contact, and if the clinician has your written consent, s/he will provide him or her with the essential information needed. You have the right to terminate therapy and communication at any time. If you choose to do so, upon your request and if appropriate and possible, Progressive Mind Center, PLLC provides you with names of other qualified professionals whose services you might prefer.
DUAL RELATIONSHIPS:Despite a popular perception, not all dual or multiple relationships are unethical or avoidable. Therapy never involves sexual or other dual relationships that impair Progressive Mind Center, PLLC's objectivity or clinical judgment. Progressive Mind Center, PLLC carefully assesses before entering into non-sexual or non-exploitative dual relationship with a client/patient. It is important to realize that in some communities, particularly small towns, small communities, military bases, university campuses, spiritual, and rehabilitation communities, etc., multiple relationships are unavoidable and expected. Progressive Mind Center, PLLC never acknowledges working with anyone without his/her written permission. Many clients/patients have chosen Progressive Mind Center, PLLC for psychiatric or psychotherapeutic interventions because they knew him/her before they entered a therapeutic relationship and/or are personally aware of his/her professional work and achievements. Nevertheless, Progressive Mind Center, PLLC will discuss with you the often-existing complexities, potential benefits and difficulties that may be involved in dual or multiple relationships. Dual or multiple relationships can enhance trust and therapeutic effectiveness but can also detract from it and often it is impossible to know which ahead of time. It is your responsibility to advise Progressive Mind Center, PLLC if the dual or multiple relationship becomes uncomfortable in any way. Progressive Mind Center, PLLC always listens carefully and responds to your feedback and will discontinue the dual relationship if s/he finds it interfering with the effectiveness of your treatment or welfare and, of course, you may do the same at any time.
SOCIAL NETWORKING AND INTERNET SEARCHES:At times,Progressive Mind Center, PLLC may conduct a web search on a client/patient prior to beginning of treatment or during treatment. If you have concerns or questions regarding this practice, please discuss them with us. We do not accept friend requests from current or former client/patients on social networking sites, such as Facebook. We believe that adding client/patients as friends on these sites and/or communicating via such sites can compromise privacy and confidentiality. For this same reason, we request that client/patients not communicate with us via any interactive or social networking web sites.
AUDIO OR VIDEO RECORDING: Unless otherwise agreed to by all parties beforehand, there shall be no audio or video recording of therapy sessions, phone calls, or any other services provided by Progressive Mind Center, PLLC.
CANCELLATION: Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 48 hours (2 days) notice is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification. Most insurance companies do not reimburse for missed sessions.
I have read the above Office Policies and General Information, Agreement for Psychotherapy Services or Informed Consent for Psychotherapy carefully (a total of 6 pages); I understand them and agree to comply with them:
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