Susan P. Sidway, LMFT

Sidway Counseling, LLC

76 Westbury Park Rd., Suite 303E

Watertown, CT 06795

Phone: 203-525-2091 Fax: 860-417-6099

CONSENT TO TREATMENT

Please read and ask questions. When your questions have been answered, sign on the reverse side.

My Credentials

I received my Master of Science degree from Central Connecticut State University in Marriage and Family Therapy (MFT). I am a licensed MFT in Connecticut. I have been providing outpatient mental health services since 2008. I am a Clinical Member of the Connecticut and American Associations of Marriage and Family Therapists.

Services

I provide outpatient assessment and treatment of mental health and relationship problems for individuals, couples, families and groups. I cannot prescribe or provide medication nor perform any medical procedure. I can coordinate care with your primary care physician and/or psychiatrist.

Fees

You are expected to pay the appropriate fee at the time of each session or for non-session related fees upon request.

If you do not pay your fees, I reserve the right to use an attorney or collection agency in order to secure payment.

Diagnostic & Evaluation Session (1st visit- 60 mins)$___160

Regular Office Visits (45 minutes)$___120

Late Cancellation Fee per missed visit$____50

Outside Office Work (inpatient visits, court, school visits, etc.) pro-rated $ 3/min.

Written Reports/Letters pro-rated at$ 3/min.

Returned Check Fee per check$____20

Appointments

Appointments are typically scheduled on a weekly basis and are 45 minutes long. More frequent sessions are available if determined appropriate by me. If you must cancel or reschedule your appointment, you must call the office at 203-525-2091 at least 24 hours in advance to avoid a late cancelation fee. If you miss your appointment three times without cancelling in advance, treatment will be considered terminated.

Insurance

I accept Aetna, Anthem, CIGNA, HealthyCT and Husky. For other insurers, I can provide you with a monthly statement which you can submit for out of network benefits after you have paid me directly. Please check with your insurer to find out if you have out of network benefits and their terms.

Emergencies

Since my phone is turned off most of the time I’m in the office, I check for messages at least twice a day. I will return urgent phone calls within 24 hours. If you have a life threatening emergency, call 911 or go to your nearest emergency room.

The Therapeutic Process

Therapy is a chance for you to get to know yourself, and values better. You may also better understand significant others and find new ways of interacting with them. Therapy can also provide a safe space for healing past trauma so that it no longer greatly disrupts your everyday life. There are several phases to the therapeutic process. First I will get to know you and how you view yourself and the problem(s) you bring to therapy. I will also want to know about your interactions with the significant people in your life. I may want to include some of these significant people in some of your sessions. Next we will jointly determine specific goals for our work together and how we will know when the goals have been achieved. From time to time during your treatment I may send you e-mail requests to provide information via my patient portal. These are typically objective measures of symptoms and are useful to assess progress in treatment and will be included in your clinical record. Please complete the request prior to your next appointment.

Risks

In addition to the potential benefits of therapy, the effort to change may also involve experiencing significant discomfort. Remembering and therapeutically resolving unpleasant events can arouse intense feelings of fear, anger, sadness and others. Seeking to resolve these issues between family members, marital partners and other person can similarly lead to discomfort, as well as relationship changes that may not be originally intended.

Your Rights as a Client

You have a right to:

  1. ask questions about any procedures used during therapy.
  2. decide not to receive therapeutic assistance from me. My goal is to provide the most effective therapeutic experience available to you. If at any time you have any misgivings about our work together, please let me know so that we can address the issue quickly and directly. If you and I decide that other services would be more appropriate, I will provide names of other qualified professionals whose services you may prefer.
  3. end therapy at any time without any moral, legal or financial obligations other than those already accrued.
  4. review your records in the files at any time.
  5. request any part of your record in the files be released to any person or agency you designate. I will tell you at the time whether or not I think releasing the information might be harmful to you in any way.
  6. confidentiality. Information revealed by you during therapy will be kept strictly confidential and will not be revealed to any other person or agency without your written permission. There are certain exceptions to this right where I am required by law to reveal information without your permission. Examples of this are:
  • If you threaten to harm yourself or another person
  • If I receive a subpoena from a court of law
  • If information revealed leads me to suspect child or elder abuse or neglect

CONSENT TO TREATMENT: By signing this Consent To Treatment, I acknowledge that I have read, understand and agree to the terms and conditions contained in this form. I have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me. I am voluntarily agreeing to receiving mental health assessment, treatment and services for me (or my child if said child is the client), and I understand that I may stop such treatment or services at any time.

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Signature – ClientDate

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Printed Name of Client

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TherapistDate

I authorize the payment of medical benefits to the provider of services.

X
CLIENT/GUARDIAN SIGNATURE / DATE

I authorize appointment reminders to be sent to me via: (choose one)

☐ e-mail at this address: ______

☐ Voice message at this phone #: ______

☐ text at this phone #: ______