Informed Consent

Consent for Treatment

This informed consent will provide a clear framework for my treatment at Women’s Wellness, LLC. Please read this information and review our office policies. Although these documents are long and sometimes complex, it is important these policies are understood. Filling in the checkbox at the end of this document represents an agreement between the client, clinician and practice.

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 provide clear expectations and understanding of rights and responsibilities.

The decision to enter treatment is a positive step and we are glad you are here. The outcome of treatment depends largely on the client’s willingness to engage in the therapeutic process, which may, at times, result in considerable discomfort. Because the process of psychotherapy often requires discussing the unpleasant aspects of your life, risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness. However, psychotherapy has also been shown to have benefits such as a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. There are no guarantees about what will happen. The therapeutic relationship is an important factor and you have the right to choose a therapist who meets your needs. Each clinician has their own style, educational background and follows the ethical guidelines of their discipline.

Consent for Treatment with Provisionally Licensed Clinician (if applicable, for clinicians with LMSW, LPCA, LMFTA)

Qualifications – A Provisionally Licensed Clinician in the State of Connecticut receives direct supervision under a fully licensed clinician at Women’s Wellness, LLC. A provisionally licensed clinician has completed a Master’s degree, clinical internship experience and is receiving supervision to obtain their full licensure.

Confidentiality – Information gathered in the sessions will be held with the same confidentiality laws of all clients at Women’s Wellness, LLC. Session details may be discussed with a supervisor for the purpose of feedback and support. Exceptions to this confidentiality are subject to the same guidelines outlined in the Notice of Privacy Practices.

Response to Concerns – If for any reason I have questions about counseling or I am dissatisfied, I have the right to meet with my therapist, supervisor or practice owners.

Fees and Office Procedures – Payment for services with a provisionally licensed clinician varies by insurance plan.

You may see my clinician’s supervisor listed on insurance documents.

I have read and agree to the “Consent for Treatment with Provisionally Licensed Clinician” (initial below):

Telehealth Consent

What is Telehealth – Telehealth is a service that uses online, interactive videoconference software to provide mental health services from a distance. Telehealth does not include the use of fax, audio-only telephone, e-mail, or videotelephony products such as FaceTime and Skype.

Benefits of Telehealth – Less limited by geographical location and transportation concerns. Decrease in travel time and ability to meet virtually during inclement weather conditions. Ability to participate in treatment from your own home or other environment that may feel safe, secure and comfortable.

Potential Risks of Telehealth – Technological failures such as unclear video, loss of sound, poor internet connection or loss of internet connection. Nonverbal cues might be more difficult to observe and interpret during clinician and client interactions.

Eligibility – Women’s Wellness, LLC is able to provide Telehealth services to clients located in Connecticut where clinicians hold valid licenses. If a client is traveling out of state, the clinician may not provide services unless they are licensed in the state where client is physically located. Telehealth may not be the most effective form of treatment for certain individuals or presenting problems. If clinician assessment indicates that Telehealth is not appropriate, an alternative recommendation will be made.

Privacy and Confidentiality – The current laws that protect privacy, confidentiality and mental health information/records also apply to Telehealth services. Telehealth services are provided through HIPAA compliant, secure software. No permanent video or voice recordings are kept from telemental health sessions. Clients may not record or store video from sessions.

Client Expectations During Telehealth Sessions – Client should have a device with camera, microphone and speakers and stable internet connection. The client shall ensure proper lighting and seating to ensure a clear image of each party’s face. Dress and environment should be appropriate to an in-office visit. Engage in sessions in a private location where you cannot be heard by others. If you will be in a car during session, you must be parked in a safe and secure location. Only agreed upon participants will be present. Client must disclose the physical address of their location at the start of the session. Failure to meet any of these requirements will be cause for termination of the session.

I have read and agree to the “Telehealth Consent” (initial below):

Fees and Attendance

Women’s Wellness appreciates your cooperation and welcomes questions regarding fees or payments. Patients will be provided with a copy of this form upon request.

I understand that it is an office policy of Women’s Wellness, LLC that a credit card must be kept on file. Charges for co-pays, deductibles, or fees will be charged to my card on file. I agree to notify billing or clinician prior to or before the end of session if I would like to use a different form of payment.

If I need to cancel or reschedule an appointment, I will provide 24 business hours advance notice, otherwise I will be charged $75. In the rare case of an emergency situation, cancellations made with less than 24 hours notice, may be accepted at the discretion of clinician and/or practice owners.

I understand that continued late cancelations or no showed appointments will negatively impact my care and understand that 3 missed sessions may result in discharge.

If additional information is requested of me from the billing department (such as Coordination of Benefits, new insurance card, expired/invalid credit card info, etc.) I will respond in a timely manner. I understand that failure to provide this information may result in a pause in therapeutic sessions until my account is up to date. Payment plans can be arranged on a case by case basis.

I understand that I am responsible for informing my clinician about my insurance, secondary plans or a change of insurance.

I understand that I am responsible for payments that my insurance does not cover.

I understand and agree that I will be charged $20 for a return check fee.

I have read and agree to the “Fees and Attendance” Section (initial below):

Non-Clinical and Paperwork Requests

Insurance typically covers clinical sessions associated with billable insurance CPT codes for therapy/treatment services. At times, your treatment may indicate professional services outside the clinical session which are not reimbursable by your insurance. These services may be billed to the client directly. Examples of these services include but are not limited to: attending meetings (such as IEP meetings, 504 meetings, treatment meetings, court appearances, etc.), writing clinical letters, filling out paperwork, writing treatment reports or summaries. Additionally, collaboration with other providers such as: primary care physicians, pediatricians, psychiatrists, APRN’s, other therapists, school staff if applicable, etc. can be part clinical care and may become a billable service if/when a task is requiring extended time in a clinician’s schedule. Requests for these professional services will be at the discretion of the clinician and supervisor (if applicable) and charges will be discussed with the client in advance. Clients will be billed at the rate of $100 per hour for these services.

Completion of paperwork for benefits – As the therapeutic relationship and proper assessment of functioning take time to fully develop, clinicians at Women’s Wellness do not complete paperwork related to benefits (i.e. Social Security, FMLA, Workman’s Compensation, etc.) in the early stage of treatment (first 90 days). After this time, if a request is made by the client for this type of documentation, it is at the clinician’s discretion if they are able to provide the information. In addition, a Treatment Summary letter may be offered. We encourage clients to utilize medical providers for such requests whenever possible.

I have read and agree to the “Non-Clinical and Paperwork Requests” Section (initial below):

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:

1. 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.
2. If a client threatens grave bodily harm or death to another person.
3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, oractual victim of physical, emotional or sexual abuse of children under the age of 18 years.
4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
5. Suspected neglect of the parties named in items #3 and #4.
6. If a court of law issues a legitimate subpoena for information stated on the subpoena.
7. 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.

Additional Information about how Protected Health Information (PHI) is disclosed is listed in the Notice of Privacy Practices.

I understand the limits of confidentiality (initial below):

Consent for Communication

It may become useful during the course of treatment to communicate by email, text message (e.g. “SMS”) or other electronic methods of communication. Receiving receipts for services by email or text message fall into this category as well. Be informed that these methods, in their typical form, are not confidential means of communication. If I use these methods to communicate, there is a reasonable chance that a third party may be able to intercept these messages. Some of the potential risks you might encounter using these methods of communication include: People in my home or other environments who access your phone, computer or other devices that you use might read your email or text messages. Loss of cellular phone, computer, or other devices. Email accounts can be hacked. Text messages and emails are stored on servers. Inaccurate delivery of email to an incorrectly typed address. Third parties on the Internet such as server administrators who monitor Internet traffic might intercept your communication. To protect your confidentiality, your clinician will limit interactions on social networking websites (Facebook, etc.). I agree to limit the use of electronic communications to issues related to scheduling. I agree to wait until scheduled sessions to discuss other matters or review concerns about my treatment. I agree not to use electronic communication for emergencies.

I consent to email and text communication (initial below):

Emergency Protocols

Emergency Protocols – Client is to provide the name and contact information for a local emergency contact. In the case of a mental health emergency during an in person or Telehealth session where a client is at imminent risk of harming themselves or someone else, clinicians will contact the local emergency services to the office or client’s location.

In the event of a true medical or psychiatric emergency, I will call 911 or go to my local emergency department. I understand that neither my clinician nor the practice provide crisis or on-call services. For non-emergency situations or urgent needs between sessions, I may reach out to my clinician and I understand that they may not be readily available.

I understand emergency protocols (initial below):

Questions, Concerns or Complaints

If a client is unhappy with their treatment for any reason, we encourage this should be discussed with clinician or practice owners so that it may be resolved. If I have any questions, concerns or complaints, I can notify the Women’s Wellness office and/or practice owners by calling 203.951.9949 or emailing [email protected].

I understand how to address if I have questions, concerns or complaints (initial below):