Informed Consent Form for Psychotherapy
Informed Consent Statement for Psychotherapy and Counseling
Therapy is a relationship that works in part because of clearly defined rights and responsibilities held by each person. As a client in psychotherapy, you have certain rights that are important for you to know about because this is your therapy, whose 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, too.
My Responsibilities to You as Your Therapist
With the exception of certain specific exceptions 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. Under the provisions of the Health Care Information Act of 1992, I may legally speak to another health care provider or a member of your family about you without your prior consent, but I will not do so unless the situation is an emergency. I will always act so as 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 chose, and you can change your mind and revoke that permission at any time. You may request anyone you wish to attend a therapy session with you. You are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA).
If you elect to communicate with me by email at some point in our work together, I am willing to respond briefly by return email, but please be aware that email and other electronic media are not completely confidential. I do not use an encrypting program on email at this time.
The following are legal exceptions to your right to confidentiality. I would inform you of any time when I think I will have to put these into effect.
- 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 your intended victim.
- If I have good reason to believe that you are abusing or neglecting a child or vulnerable adult, or if you give me information about someone else who is doing this, I must inform Child Protective Services within 48 hours and Adult Protective Services immediately.
- If I believe that you are in imminent danger of harming yourself, I may legally break confidentiality and call the police or the county crisis team. 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 the crisis team.
- 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 keep brief records of each session noting the dates we meet, the topics we cover, progress reports from the client’s perspective, interventions and impressions from the therapist and next steps. My records are kept private and not shared with others, in accordance with HIPPA requirements.
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 in order to be paid. Diagnoses are technical terms that describe the nature of your problems and something about whether they are short-term or long-term problems. If I do use a diagnosis, I will discuss it with you.
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 can request that I refer you to someone else if you decide I’m not the right therapist for you. You are free to leave therapy at any time, although I recommend finding a way to give me advance notice so that I can help you end treatment well and consolidate gains (please see section below on Ending Therapy.)
Because I have a limited practice, I do not have 24 hour emergency or “on call” coverage. If you believe you will need a therapist with 24 hour coverage I will be happy to make a referral. If you experience a psychiatric emergency, you should call 911 or go to the nearest hospital emergency room rather than waiting for me to call you back. If I am out of town for an extended period of time I will give you the name of a colleague you can contact in case of an urgent need.
As of 1/1/18: Individual therapy or couples therapy is $185 per 45-50 minute session. You will be asked to pay for each session at the time of the session. Payment can be by check, cash, or credit card. An email statement of the month’s sessions will be furnished to you on the first of each month for the previous month’s sessions and payments as a pdf attachment. You can use the statement for tax purposes or for reimbursement. If you prefer to receive the statement in another way, let Lynn know.
There is no direct billing with any insurance company, including Medicare. Psychotherapy with Lynn Grodzki operates on an “opt-out” basis with Medicare. As such, Lynn Grodzki will not bill Medicare nor accept reimbursement from Medicare.
Clients work via a private contract and informed consent with Lynn Grodzki and are liable for charges of her services without any limits that would otherwise be imposed by Medicare or any other insurance company.
Medicare Opt Out Policy:
Lynn does not participate with Medicare. She has an opt-out policy, as shown below.
• Client agrees to give up all Medicare coverage and payment for services furnished by the clinical social worker for two years and will not bill Medicare nor ask the clinical social worker to bill Medicare.
• Client is liable for charges of the clinical social worker without any limits that would otherwise be imposed by Medicare.
• Client acknowledges that Medigap will not make payment for services and other supplementary insurers may not pay either. Acknowledges that he has the right to receive services from a clinical social worker or other practitioner for whom Medicare coverage and payment would be available.
• Client will receive a copy of the private contract that states the effective and expiration dates of the opt-out period.
• The contract will be retained by the clinical social worker and made available to the Centers for Medicare and Medicaid Services (CMS) upon request.
• The clinical social worker will not submit any claims to Medicare during the two year period beginning on the date the affidavit is signed. The clinical social worker will not receive any Medicare payment for any services provided to Medicare beneficiaries.
Note from Lynn: Ending Therapy Well
I want to make your therapy as successful as possible. For that reason, it works best to find a rhythm and structure to the beginning stages with sessions that meet regularly. To support your leaving, I request several weeks of notice prior to your actual leaving to allow you to have an experience of leaving well, with a sense of completion. If I initiate terminating you from our therapy, it will be because I feel that I am not able to be helpful to you any longer. My ethics and license requires that I offer quality service and have my clients’ needs as paramount in my treatment planning. If I no longer feel that I am the best or right practitioner for you, I will offer referrals to other sources of care, but cannot guarantee that they will accept you for therapy or how they will approach your treatment.
My Training and Approach to Therapy
I have an MSW Clinical Social Work earned in 1988 at Maryland University in Baltimore. I am a Licensed Certified Clinical Social Worker in Maryland State. My areas of special training and expertise include: psycho-dynamic therapy, cognitive behavioral approaches and the use of a coaching style and approach. I am trained and certified in and use a variety of techniques in therapy, including EMDR, psychological interpretation, cognitive reframing, self-awareness exercises, self-monitoring, and guided visualization. I have a MCC (Master Coach Certification) which is the highest level of coach certification offered through the International Coach Federation. I have been in practice as a psychotherapist since 1988 and graduated with an MSW form University of Maryland. I have been working as a life/business coach since 1996.
I may suggest that you get involved in additional or adjunctive forms of support, such as additional counseling or a support group as part of your work with me. If another health care person is working with you, I may request a release of information from you so that I can communicate freely with that person about your care.
I am away from the office several times in the year for extended vacations or to attend professional meetings. If I am not taking and responding to phone messages during those times I will have someone cover my practice. I will tell you well in advance of any anticipated lengthy absences.
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 45-50 minutes. If you are late, we will end on time and not run over into the next person’s session. If you miss a session without canceling, or cancel with less than forty-eight (48) hours notice within business hours (Monday-Friday), you will be charged for that session, unless I can reschedule with you within the same calendar week.
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. Please see sections on this page re: ending therapy.
Client Consent to Psychotherapy
You will be given a copy of this Informed Consent to sign in the office. Starting therapy with Lynn Grodzki signals agreement with these policies.
To set up a session with Lynn, simply email:
firstname.lastname@example.org or call: 301 434 0766