Informed Consent to Telehealth Treatment

Consent for Telehealth Appointment

Thriving Center of Psychology (Thriving Mind Psychology, PLLC (Massachusetts, Minnesota, Nevada, New York Psychology Services,Oregon, Washington D.C, Illinois), LA Performance Psychology, PC (Nebraska, Texas, Washington, California Psychology Services), Thriving Center of Psychology, LLC (Florida), Thriving Center for Psychology NJ, LLC (New Jersey), Thriving Center of Psychology NM, LLC (New Mexico), Thriving Mind Psychiatry, PLLC (New York Psychiatry), Thriving Center of Psychiatry, PC (California Psychiatry)

CONSENT FOR TELEHEALTH SESSION

I understand that my healthcare provider wishes me to engage in a telehealth appointment.
I understand that the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.
I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my healthcare provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

By signing this form, I certify:

That I have read or had this form read and/or had this form explained to me.
That I fully understand its contents including the risks and benefits of the procedure(s).
That I have been given ample opportunity to ask questions and any questions have been answered to my satisfaction.

BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD, AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

Thriving Center of Psychology (Thriving Mind Psychology, PLLC (Massachusetts, Minnesota, Nevada, New York Psychology Services,Oregon, Washington D.C, Illinois), LA Performance Psychology, PC (Nebraska, Texas, Washington, California Psychology Services), Thriving Center of Psychology, LLC (Florida), Thriving Center for Psychology NJ, LLC (New Jersey), Thriving Center of Psychology NM, LLC (New Mexico), Thriving Mind Psychiatry, PLLC (New York Psychiatry), Thriving Center of Psychiatry, PC (California Psychiatry)

CONSENT FOR TELEHEALTH SESSION

I understand that my healthcare provider wishes me to engage in a telehealth appointment.
I understand that the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.
I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my healthcare provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

By signing this form, I certify:

That I have read or had this form read and/or had this form explained to me.
That I fully understand its contents including the risks and benefits of the procedure(s).
That I have been given ample opportunity to ask questions and any questions have been answered to my satisfaction.

BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD, AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

Informed Consent for Psychotherapy and Psychiatry

Thriving Center of Psychology (Thriving Mind Psychology, PLLC (Massachusetts, Minnesota, Nevada, New York Psychology Services,Oregon, Washington D.C, Illinois), LA Performance Psychology, PC (Nebraska, Texas, Washington, California Psychology Services), Thriving Center of Psychology, LLC (Florida), Thriving Center for Psychology NJ, LLC (New Jersey), Thriving Center of Psychology NM, LLC (New Mexico), Thriving Mind Psychiatry, PLLC (New York Psychiatry), Thriving Center of Psychiatry, PC (California Psychiatry)

Informed Consent for Psychotherapy, Psychiatry, and Medication Management

General Information: The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

The Therapeutic Process: You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may at times result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

By signing this document you understand that as a client of Thriving Center of Psychology you are eligible to receive a range of services. The type and extent of services that you will receive will be determined following an initial consultation and thorough discussion with your Thriving Center of Psychology clinician. The goal of the consultation process is to determine the best course of treatment for you. Typically, treatment is provided over the course of several weeks or months.

Confidentiality: The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.
If a client threatens grave bodily harm or death to another person.
If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
Suspected neglect of the parties named in items #3 and # 4.
If a court of law issues a legitimate subpoena for information stated on the subpoena.
If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

Occasionally, I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of our therapy sessions.

FOR CLIENTS UNDER THE AGE OF 18

This form documents that we, (the “parents”) give our consent and agreement to Thriving Center of Psychology (Thriving Mind Psychology, PLLC (Massachusetts, Minnesota, Nevada, New York Psychology Services,Oregon, Washington D.C, Illinois), LA Performance Psychology, PC (Nebraska, Texas, Washington, California Psychology Services), Thriving Center of Psychology, LLC (Florida), Thriving Center for Psychology NJ, LLC (New Jersey), Thriving Center of Psychology NM, LLC (New Mexico), Thriving Mind Psychiatry, PLLC (New York Psychiatry), Thriving Center of Psychiatry, PC (California Psychiatry) to provide psychotherapeutic treatment to our child and to include us, the parents, as necessary, as adjuncts in the child’s treatment. While the parents can expect benefits from this treatment for the child, they fully understand that no particular outcome can be guaranteed. The parents understand that they are free to discontinue treatment of the child at any time but that it would be best to discuss with the psychotherapist any plans to end therapy before doing so. The parents have fully discussed with the psychotherapist what is involved in psychotherapy and understand and agree to the policies about scheduling, fees and missed appointments. The discussion about therapy has included the psychotherapist’s evaluation and diagnostic formulation of the child’s problems, the method of treatment, goals and length of treatment, and information about record-keeping. The parents have been informed about and understand the extent of treatment, its foreseeable benefits and risks, and possible alternative methods of treatment.

The parents understand that therapy can sometimes cause upsetting feelings to emerge, and that the child’s problems may worsen temporarily before improving. The parents understand that the psychotherapist cannot provide emergency service. The psychotherapist has told the parents whom to call if an emergency arises and the psychotherapist is unavailable.

The parents have access to a copy of this form and a HIPAA Notice of Privacy Practices. A copy can be provided if the parents do not have access to the internet. The parents understand that information about psychotherapy is almost always kept confidential by the psychotherapist and not revealed to others besides the parents unless a parent authorizes such release. There are a few exceptions as noted in the HIPAA Notice of Privacy Practices. Details about certain of those exceptions follow:

The psychotherapist is required by law to report suspected child abuse or neglect to the proper authorities.
If a child tells the psychotherapist that he or she intends to harm another person, the psychotherapist must try to protect the endangered person, including by telling the police, the person and other health care providers. Similarly, if a child threatens to harm him or herself, or a child’s life or health is in any immediate danger, the psychotherapist will try to protect the child, including, as necessary, by telling the police and other health care providers, who may be able to assist in protecting the child.
If a child is involved in certain court proceedings the psychotherapist may be required by law to reveal information about the child’s treatment. These situations include child custody disputes, cases where a patient’s psychological condition is an issue, lawsuits or formal complaints against the psychotherapist, civil commitment hearings, and court-ordered treatment.
If the parents’ and child’s health insurance or managed care plan will be reimbursing or paying the psychotherapist directly, they will require that confidentiality be waived and that the psychotherapist give them information about the child’s treatment.
The psychotherapist may consult with other healthcare professionals about the child’s treatment, but in doing so will not reveal the child’s name or other information that would identify the child unless specific consent to do so is obtained from a parent. Further, when the psychotherapist is away or unavailable, another psychotherapist might answer calls and so will need to have access to information about the child’s treatment.
If an account with the psychotherapist becomes overdue and responsible parties do not work out a payment plan, the psychotherapist will have to reveal a limited amount of information about a patient’s treatment in taking legal measures to be paid. This would include the child’s and parents’ names, social security number, address, dates and type of treatment and the amount due.

In all of the situations described above, the psychotherapist will try to discuss the situation with a parent before any confidential information is revealed, and will reveal only the least amount of information that is necessary.

The parents, as legal guardians of the child, have rights to general information about what takes place in the child’s therapy, to information about the child’s progress in therapy, to information about any dangers the child might present to self or others, and, upon request, to obtain copies of the child’s treatment record (with certain qualifications and exceptions). The parents understand that it is usually best not to ask for specific information about what was said in therapy sessions because this might break the trust between the child and the psychotherapist, especially for children over the age of 12.

The parents agree that in the event custody of, or visitation with, the child is contested in a legal proceeding, each of the parents and their attorneys will not require the psychotherapist to testify at any of the proceedings, because to do so would hurt the child’s treatment, because the psychotherapist’s role is a therapeutic and not evaluative one, and because other forensic professionals would be better able and more appropriate to conduct any necessary evaluation. Because of these limitations, the psychotherapist also will not be able to give any opinion regarding custody, visitation or any other legal issue. If such a proceeding does occur, the parents agree that the psychotherapist’s role will be limited to providing to a mental health professional appointed to perform such an evaluation, and/or to the attorneys, law guardian, if any, and the judge involved in the legal proceeding, written information regarding, and/or the record of, the child’s treatment; the psychotherapist will provide these either as required by law or upon the authorization of either parent.

The psychotherapist has explained to the parents that children with two parents have the best chance to benefit from therapy if both parents are involved and cooperate with each other and the psychotherapist. If both of a child’s parents are consenting to therapy:

Each of us agrees that he or she will not end the child’s therapy without the agreement of the other parent, and that if we disagree about the child’s continuing in therapy, we will try to come to an agreement, by counseling if necessary, before ending the child’s therapy.
We each agree to cooperate with the treatment plan of the psychotherapist for the child and understand that without mutual cooperation, the psychotherapist may not be able to act in the child’s best interests and may have to end therapy.
We agree that each of us has and shall continue to have the right to information about the child’s treatment and to the treatment records of the psychotherapist regarding the child, and agree that the psychotherapist may release information or records to either of us without any additional authorization of the other.

The parents understand that they have a right to ask the psychotherapist about the psychotherapist’s training and qualifications and about where to file complaints about the psychotherapist’s professional conduct.

Consent

By signing below, I/the parents are indicating that I/they have read and understood this agreement, that I/they give consent to the psychotherapist’s treatment of myself/my child, and that I/they have the proper legal status to give consent to therapy for myself/my child.

Pre Licensed clinician

Thriving Center of Psychology (Thriving Mind Psychology, PLLC (Massachusetts, Minnesota, Nevada, New York Psychology Services,Oregon, Washington D.C, Illinois), LA Performance Psychology, PC (Nebraska, Texas, Washington, California Psychology Services), Thriving Center of Psychology, LLC (Florida), Thriving Center for Psychology NJ, LLC (New Jersey), Thriving Center of Psychology NM, LLC (New Mexico), Thriving Mind Psychiatry, PLLC (New York Psychiatry), Thriving Center of Psychiatry, PC (California Psychiatry)

Informed Consent for Psychotherapy for Adult Clients

Pre-Licensed Therapist:

I understand that I will be provided psychological services by a pre-licensed therapist, who is under the supervision of a licensed clinical psychologist, licensed marriage and family therapist, or a licensed professional counselor. The name of the licensed provider will be provided to you during your initial intake session. Pre-licensed therapists have earned their degree, are completing their final year/s of clinical supervision, and are bound by the ethics and laws of their profession. As part of supervision, they may discuss their cases with their supervisor, who is also bound by the same ethics and laws of their profession.

General Information:

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

The Therapeutic Process:

You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may at times result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

Confidentiality:

The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.
If a client threatens grave bodily harm or death to another person.
If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
Suspected neglect of the parties named in items #3 and # 4.
If a court of law issues a legitimate subpoena for information stated on the subpoena.
If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

FOR CLIENTS UNDER THE AGE OF 18

The psychotherapist is required by law to report suspected child abuse or neglect to the proper authorities.
If a child tells the psychotherapist that he or she intends to harm another person, the psychotherapist must try to protect the endangered person, including by telling the police, the person and other health care providers. Similarly, if a child threatens to harm him or herself, or a child’s life or health is in any immediate danger, the psychotherapist will try to protect the child, including, as necessary, by telling the police and other health care providers, who may be able to assist in protecting the child.
If a child is involved in certain court proceedings the psychotherapist may be required by law to reveal information about the child’s treatment. These situations include child custody disputes, cases where a patient’s psychological condition is an issue, lawsuits or formal complaints against the psychotherapist, civil commitment hearings, and court-ordered treatment.
If the parents’ and child’s health insurance or managed care plan will be reimbursing or paying the psychotherapist directly, they will require that confidentiality be waived and that the psychotherapist give them information about the child’s treatment.
The psychotherapist may consult with other healthcare professionals about the child’s treatment, but in doing so will not reveal the child’s name or other information that would identify the child unless specific consent to do so is obtained from a parent. Further, when the psychotherapist is away or unavailable, another psychotherapist might answer calls and so will need to have access to information about the child’s treatment.
If an account with the psychotherapist becomes overdue and responsible parties do not work out a payment plan, the psychotherapist will have to reveal a limited amount of information about a patient’s treatment in taking legal measures to be paid. This would include the child’s and parents’ names, social security number, address, dates and type of treatment and the amount due.

Each of us agrees that he or she will not end the child’s therapy without the agreement of the other parent, and that if we disagree about the child’s continuing in therapy, we will try to come to an agreement, by counseling if necessary, before ending the child’s therapy.
We each agree to cooperate with the treatment plan of the psychotherapist for the child and understand that without mutual cooperation, the psychotherapist may not be able to act in the child’s best interests and may have to end therapy.
We agree that each of us has and shall continue to have the right to information about the child’s treatment and to the treatment records of the psychotherapist regarding the child, and agree that the psychotherapist may release information or records to either of us without any additional authorization of the other.

Consent

Risk Disclosure

Please note that our clinicians may not review your responses to the information provided on intake forms or questionnaires for a few days. Additionally, your clinician may not check emails and voicemails immediately. If you feel unsafe, are having thoughts of hurting yourself or someone else, or are experiencing an emergency, please call 911 or the National Suicide Hotline at 800-273-8255, or go to the nearest emergency room.

By checking this box, you are signing this form and agree that you have read the disclosure above.

By checking this, you are eSigning this form.