The Center for Connection

DEBORAH BUCKWALTER, PhD

PSY17676

THE CENTER FOR CONNECTION

275 E. California Boulevard, Suite A

Pasadena, CA 91106

626.644.1454

INFORMED CONSENT FOR OUTPATIENT SERVICES AND TREATMENT

Welcome to my practice. This document contains important information about my professional services and business policies. I want to ensure that you understand your rights as a client as well as the guidelines and limits of services. Please read this document carefully and note any questions you have so that we can discuss them. This signed document will represent an agreement between us.

PSYCHOLOGICAL SERVICES

Making the decision to seek professional help is not always easy, but I commend you for considering this important investment in yourself and/or the people you care about. I provide a variety of psychological services including psychological and neuropsychological consultation, evaluation/testing, and treatment.

Psychological treatment is not easily described. It varies depending on a number of factors, including the unique personalities of the client(s) and psychologist, particular goals identified during treatment, and the treatment modalities your psychologist uses. The duration of treatment may range from a single consultation to extended sessions, depending on your specific challenges and goals.

There are a number of different methods I may use to assist with the issues you wish to address. Psychological treatment calls for active effort for both the Client(s) and Psychologist. In order for therapy to be most successful, it is important that you come to therapy ready to discuss your issues and to work toward your goals between sessions.

Psychological treatment can have benefits and risks. Since psychotherapy often involves discussing aspects of life you wish to change, you may experience uncomfortable feelings like sadness, guilt, anger, or helplessness. While uncomfortable, such feelings may be important components of your healing. Psychotherapy has been shown to have benefits for people who use this healing process. Better relationships, solutions to specific problems, and significant reductions in feelings of distress often result. But there are no guarantees of what you will personally experience.

INTAKE AND TREATMENT

Therapy involves a commitment of valuable resources, including time, money, and energy, so it is important for you to carefully select your therapist. When you first come for psychological treatment services, I interview you and evaluate your presenting concerns; this may last from 1 to 4 sessions. You will also have the opportunity to interview me about my professional qualifications and my policies and procedures. I will offer some initial impressions of what our work will include. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. We will decide together if I am the best person to provide the services you seek. If this doesn’t seem like a good therapeutic fit, I will be happy to help you locate another mental health professional for a second opinion or referral.

If we decide to proceed with treatment, we will decide together how often to meet (typically weekly) and how long our sessions will be (typically 45-60 minutes, or 90 minutes for couples). Some sessions may be longer or more frequent to accomplish treatment goals. When you come for your appointment, I recommend arriving in the waiting room 10 minutes before your appointment in order to gather your thoughts and prepare yourself for our session; some people find it helpful to write down some thoughts and/or feelings during the waiting time. Once in session, we are both responsible for honoring the therapy time frame as a matter of good boundaries and respect for each other’s schedules.

Ending Therapy. From the very beginning of your therapy we will keep on eye on the ending of therapy. Ideally this occurs when we both agree that the goals of therapy have largely been met, and it is time to end our professional relationship. Of course, you may stop treatment at any time, for any reason. Your goals may change or something might come to light in therapy that would make you better suited to work with another professional. You may come to a point where time and/or money are not available to continue your work with me. When it is time to end therapy, it is important to have one or more “wrap up” sessions where wecan review the progress of your treatment, discussrecommendations going forward, and experience a “good goodbye”. Learning and practicing healthy closure is especially important for people who have a difficult time ending relationships and/or saying goodbye.

If you do not show for your sessions and you do not contact me within a reasonable amount of time, or I am unable to contact you, this will also be considered termination. You could conceivably return to see me, but for legal and ethical reasons you would not be considered to be under my professional care until signing another informed consent.

CONFIDENTIALITY (Consistent with HIPAA)

In general, the privacy of all communications between a patient and a psychologist is protected by law. As your psychologist, I can only release information to others about you with your written permission. There are, however, circumstances under which information might/will be disclosed without your prior consent:

Limits of Confidentiality:

a. If I believe you intend to harm yourself or someone else, it may be my duty to disclose that information and/or take protective actions. These actions may include notifying any potential victims, contacting the police, seeking hospitalization for you, and/or contacting family members or others who can help provide protection.

b. In situations of suspected child, dependent adult, or elder abuse, it is my legal duty to notify medical, legal or other authorities and/or file a report with the appropriate state agency.

c. In most legal proceedings, you have the right to prevent me from providing information about your treatment. However, if you are involved in a legal action or proceedings, your records may be subject to subpoena or lawful directive from a court.

d. In some proceedings involving child custody and those in which your emotional condition is at issue, a judge may order my testimony if he/she determines that the issues demand it.

e. If/when we communicate via wireless phone and/or Internet, privacy problems may occur due to the nature of technology capable of capturing broadcast conversations and transmissions.

These situations have rarely occurred in my practice. If something does occur during your treatment, I will make every effort to discuss it with you before taking any action.

Additional Situations in Which Your Information May Be Discussed:

Consultation with Other Professionals: I occasionally consult with other professionals outside of the Center for Connection about a case. During a consultation, your identity is not revealed. The consultant is also legally bound to keep the information confidential.

Insurance Coverage Reporting Requirements: If you access reimbursement from your health insurance, most insurance companies require that I provide them with a clinical diagnosis; sometimes additional clinical information is required.

Conjoint/Couples Therapy Confidentiality: When more than one person is involved in the therapy process, in order for information to be released, both members of the couple must provide their written authorization. Since the couple is the client, one member’s desire to have information released is not sufficient. Secondly, if we decide that some individual sessions may help the process of couples therapy, what you say in those individual sessions will be considered part of the couples therapy. Therefore, be advised that this information will be discussed in our joint sessions.

Affiliation and Case Consultation at The Center for Connection (CFC):

I am privileged to work with a group of independent professionals at CFC. The Center for Connection itself does not provide or perform therapeutic, psychological, or other professional services for which a license is required. Rather, CFC brings together carefully selected independent expert practitioners from various fields—psychology, social work, marriage and family therapy, pediatrics, neuropsychology, educational therapy, occupational therapy, parent education, and so on—with each practitioner offering treatment grounded in the science of interpersonal neurobiology. As your psychologist, I am completely independent in providing you with clinical services and I alone am fully responsible for those services. My professional records are separately maintained and no member of the group can have access to them without specific, written permission.

I also want you to know that one of the strengths of working in this environment is my ability to consult with the multidisciplinary treatment team at CFC, each member of whichprovides consistent, well informed, relationally based treatment aimed at helping our clients thrive. Confidentiality is strictly maintained within the group. This approach is particularly beneficial when clients are accessing more than one professional in the group (e.g. individual therapy and family therapy) and it is beneficial to have the background support of a connected team of professionals. You also have the choice to decline consultation of your therapy with the CFC team. Please initial your choice below:

______Dr. Buckwalter has my consent to consult with theCFC Treatment Team

______I do NOT want Dr. Buckwalter to consult with any other professionals in CFC

While this summary of exceptions to exclusive confidentiality should prove helpful, it is important that we discuss any questions/concerns you may have. If you need specific advice, formal legal advice may be needed because the laws governing confidentiality are complex, and I am not an attorney.

PROFESSIONAL RECORDS

The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of the records unless I believe that seeing them would not be in the best interest of your emotional well-being, in which case I will be happy to send them to a licensed mental health professional of your choice. Because these are professional records, they can be complex, misinterpreted and/or upsetting to untrained readers. If you have concerns about your records, I recommend that you review them in my presence so that we can discuss the contents. Clients will be charged an appropriate fee for any time spent in preparing information requests or reviewing records.

MINORS

If you are under 18, the law may give your parents the right to examine your records. It is my policy to ask parents to agree to give up access to your records and instead to accept general information about your treatment. If I feel there is a risk of you harming yourself or someone else, since your safety is most important, I will notify them of my concern. If possible, before giving them information, I will discuss the matter with you.

PROFESSIONAL FEES: TYPICAL SERVICES

Initial Consultation: 60 minutes - $240

Psychotherapy: 45-50 minute appointment- $200

55-60 minute appointment- $240

75-minute appointment- $300

90-minute appointment- $360 (recommended for conjoint therapy)

Evaluation/Assessment fees vary depending on the type and complexity of the evaluation and the type and complexity of documentation of results you will need. I will be happy to discuss my fee schedule with you when we discuss your specific needs.

Typically, complex psychodiagnostic evaluations range from $1600 to $3800.

Typically, complex neuropsychological evaluations range from $4100 to $5200. Screenings that are less complex are also available at a reduced fee.

My fee is $240 per 60-minute hour (pro-rated for portions of the hour) for other professional services you may need. These include between-session telephone conversations, text/email exchanges initiated by you lasting longer than 05 minutes, telephone consultations or meetings/conferences with other professionals you have authorized; preparation of reports, records, letters, or treatment summaries requested by you, and the time spent performing any other service you may request of me.

PROFESSIONAL FEES: PSYCHOLEGAL SERVICES

If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party involving you. Because of the complexity of legal involvement, I charge $450 per hour for preparation for and attendance at any legal proceeding including but not limited to legal records review, depositions, and testimony.

BILLING AND PAYMENTS

Evaluate Your Resources:

Professional evaluation and/or treatment for the difficulties you are experiencing, and for the personal growth and development you wish to do, is an important investment in your health and well-being. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment.

Payment for psychotherapy:

Payment is due at the time of service. Please arrive at your session with the correct cash, check (payable to Deborah Buckwalter), or credit card. Dealing with the fees and “business” aspect at the beginning of each treatment session enables us to end your session with what we have worked on freshest in your mind. I request that you keep a credit card on file with me to cover costs of services and/or missed sessions.

Insurance reimbursement

Dr. Buckwalter is an out-of-network provider.

If you have medical insurance and would like to access out-of-network reimbursement, you will pay for services at the time they are provided and I will provide you with a statement you may submit to your insurance company. Please note that you (not your insurance company) are responsible for full payment of my fees. It is important that you find out exactly what mental health services your insurance policy covers. If you decide to access insurance benefits, it is important for you to know that most insurance companies require that I provide them with a clinical diagnosis. On some occasions, additional clinical information such as treatment plans, summaries, or copies of the entire record are required. This information becomes part of insurance company records.

Financial Hardship/Sliding Scale:

In circumstances of unusual financial hardship, I may be able to negotiate a fee adjustment or payment installment plan. But in general, like most small businesses, I will not be in a position to reduce fees or carry a balance for you.

Payment for psychological or neuropsychological Testing/Assessment:

Payment is due on the (first) day of evaluation unless we agree otherwise. Some Clients prefer to pay a retainer at the time the evaluation is scheduled and payment of the balance on the day(s) of the evaluation.

Collections:

If your account has not been paid for more than 60 days (and arrangements for payment have not been agreed upon), I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, the costs of the action will be included in the claim. In most collection situations, the only Client information I release is name, contact information, the nature of services provided, and the amount due.

CONTACTING ME

You may contact me by telephone, mail, text, or email. When I am unavailable, my telephone is answered by secured voice mail that I monitor frequently (except on rare occasions that I am in a poor reception area). I will make every effort to return your call within 24 hours, with the exception of weekends and holidays. When you leave a message, please leave your phone number even if you think I already have it. You may also contact me by text or email to make/reschedule an appointment or for brief communication about treatment logistics. Please keep in mind that communication via text or email carries risk and is less secure with respect to confidentiality.

In an emergency, particularly if you feel that you are in imminent danger of hurting yourself or another person, dial 911. In other circumstances that feel urgent to you: if you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist [psychiatrist] on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary.

Feel free to contact me with any questions or concerns you may have. And thank you for wading through this lengthy document. I look forward now to working with you to address your concerns and move toward your goals!

INFORMED CONSENT

Your signature(s) below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.

I, ______/ ______authorize and request that

(Individual)(Couple)

• Deborah Buckwalter, Ph.D. provide psychological services to include consultation, evaluation, and/or treatment, which now or during the course of my care as a Client is advisable. The frequency and type of treatment will be decided between Dr. Buckwalter and me.
• I understand that upon request the purpose of these policies and procedures will be explained to me and be subject to my verbal and/or written agreement.
• I understand that there is an expectation that I will benefit from psychological evaluation and/or treatment but there is no guarantee that this will occur.

STATEMENT OF UNDERSTANDING