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Informed Consent and Practice Policies

Real Talk - Clinical Psychology

7670 Woodway Dr., Suite 270 - Houston, TX 77063 - (832) 583-7373

Informed Consent for Psychotherapy

This document is an agreement between the patient and therapist. Feel free to ask us any questions before signing it. You may revoke it in writing at any time; the revocation is binding on us unless we have taken action in reliance on it, if there are obligations imposed on us by your health insurer to process or substantiate claims made under your policy, or if you have not satisfied any financial obligations you have incurred.

Psychological Services

Psychotherapy varies depending on the psychologist and the patient. There are many different approaches to deal with psychological issues, and they all require an active effort on the patient's part. Since treatment often involves discussing unpleasant aspects of your life, you may experience temporary uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, it has also been shown to have many benefits, leading to better relationships, solutions to specific problems, and significant reductions in feelings of distress. There are no guarantees of what you will experience.

Our first few sessions will involve an evaluation of your needs. You should evaluate this information along with your own opinions of whether you feel comfortable working with us. If you have questions about our procedures, we should discuss them whenever they arise.

Session Information and contacting me

When psychotherapy begins, we will schedule 30-55 minute sessions at a time we agree on. If you miss two or more consecutive sessions or do not schedule an appointment within 60 days after your last session, it will be considered notice of termination of therapy.

Due to our work schedule, we are often not immediately available by telephone, but we will make every effort to return your call within 24 hours via phone, email, or text. There is no charge for these brief contacts. If you are experiencing a life-threatening emergency, call 911 or go to your nearest emergency room.

We use HIPAA (Health Insurance Portability and Accountability Act) compliant email, phone, and messaging systems. However, we cannot ensure the confidentiality of any form of communication through electronic media. If you prefer to communicate via email, we will do so. Due to the importance of your confidentiality and the importance of minimizing dual relationships, we do not accept friend or contact requests from current clients on any social networking site (Facebook, LinkedIn, etc.).

Limits on Confidentiality

The law protects the privacy of all communications between a patient and a psychologist. In most situations, we can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements. There are other situations that require only that you provide written, advance consent.

Your signature on this Agreement provides consent for those activities, as follows:

• We may find it helpful to consult other health and mental health professionals about a case. The other professionals are also legally bound to keep the information confidential. If you don't object, we will not tell you about these consultations unless I feel that it is important to our work together. We will note all consultations in your Clinical Record.

• We also have a privacy contract with our accountants. As required by HIPAA, we have a formal business associate contract with them, in which they promise to maintain the confidentiality of data except as specifically allowed in the contract or otherwise required by law.

• If a patient seriously threatens to harm themselves or others, we may be obligated to seek hospitalization for them or to contact others who can help provide protection. Texas law states that a professional may disclose confidential information only to medical or law enforcement personnel if the professional determines that there is a probability of imminent physical injury by the patient to the patient or others, or there is a probability of immediate mental or emotional injury to the patient.

• If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. We cannot provide any information without your (or your legal representative's) written authorization, or court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information.

• If a government agency is requesting the information for health oversight activities, we may be required to provide it for them.

• If a patient files a complaint or lawsuit against me or my company, we may disclose relevant information regarding that patient in order to defend ourselves.

• If a patient files a worker's compensation claim, we must, upon appropriate request, provide records relating to treatment or hospitalization for which compensation is being sought. There are some situations in which we are legally obligated to take actions, which we believe are necessary to attempt to protect others from harm, and we may have to reveal some information about a patient's treatment. These situations are unusual in our practice.

• If we have cause to believe that a child under 18 has been or may be abused or neglected or is a victim of a sexual offense, and if an elderly or disabled person is in a state of abuse, neglect, or exploitation, the law requires that we make a report to the appropriate governmental agency, usually the Department of Protective and

Regulatory Services. Once such a report is filed, we may be required to provide additional information.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. In situations where specific advice is required, formal legal advice may be needed.

Legal Proceedings

We do not voluntarily participate in any legal proceedings. We will not communicate with a patient's attorney and will not write or sign letters, affidavits or reports to be used in a patient's legal matters. We will not provide testimony or patient records unless compelled to do so. If you become involved in legal proceedings that require our participation, you will be expected to pay for all of our professional time, including preparation and transportation costs, even if we are called to testify by another party.

Professional Records

Your Clinical Record includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and others, you may examine and/or receive a copy of your Clinical Record if you request it in writing. If we refuse your request for access to your Clinical Record, you have a right of review, which we will discuss with you upon your request.

Pursuant to Texas law, psychological test data are not part of a patient's record, as they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them in our presence or have them forwarded to another mental health professional so you can discuss the contents.

Patient Rights

HIPAA provides you with several rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that your doctor amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and our privacy policies and procedures.

Minors and Parents

Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child's treatment records. However, if the treatment is for suicide prevention, chemical addiction or dependency, or sexual, physical, or emotional abuse, the law provides that parents may not access their child's records.

For children between 12 and 18, because privacy in psychotherapy is often crucial to successful progress, it is our policy to request an agreement from the patient and their parents that the parents consent to give up their access to their child's records. If they agree, during treatment, we will provide only with general information about the progress of the child's treatment, and their attendance at scheduled sessions. Any other communication will require the child's Authorization unless the doctor feels that the child is in danger or is a danger to someone else. If parents are separated or divorced, the parent bringing the child for treatment MUST provide a copy of the most recent divorce decree or custody agreement prior to the initial parent consultation. The therapist will not treat the child without this.

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