Linda J. Cooke, LCSW, BCD

General Informed Consent for Clients

  1. I use a voice mail system. Any messages left for me are confidential and can be left for me at any time at (207) 467-9092. I check my messages regularly. If you can not wait for a return call, or are experiencing a mental health emergency, please dial 911, call crisis response services @ (207) 282-6136, or go to your local emergency room. Leave me a message that you have done so and I will contact you as soon as possible.
  2. Appointments are 45 minutes long. Please arrive on time but not more than five minutesbefore your appointment time. Please plan to stay for the entire 45 minutes.
  3. Please turn off your cell phones in the waiting room and in the therapy office during your sessions, unless there is an emergency pending.
  4. Your demographic and insurance information is forwarded to the billing service I use so that they may perform billing operations for my practice. They are mandated to keep all private health information confidential
  5. I use a local bank, so if you don’t want to be associated with my name, please make payments in cash. All payments are due at the time of service unless otherwise arranged.
  6. I reserve the right to not reschedule clients who do not show for their first or second scheduled appointment, or who cancel or no-show frequently.
  7. I participate in several peer consultation groups and receive individual consultation. No private health information is given during consultation.
  8. There are times when I may request your permission to videotape sessions for review in professional consultation for the purpose of enhancing your care. Private health information remains confidential in all circumstances.
  9. I am not an expert witness and do not agree to participate in any legal matters you may have. If I am mandated to go to court on your behalf, I charge a $2,500 retainer and an hourly fee of $200 per hour of my time in preparation, court time, travel time, or for any time that I spend in regard to your court case.
  10. You have a right to review your record unless it is determined that such a review would be detrimental to your treatment. You have a right to review information that is revealed to your insurance company for purpose of authorization review. You also have a right to request that certain information not be included in your record. However, if I determine that documentation of such information is necessary to your treatment or to comply with federal or state laws, it may need to be documented despite your opposition.
  11. You have a right to make changes to your record. Certain exceptions apply:

You can not put information that is untrue or falsify information documented.

Your changes do not erase information that is already documented.

Information in your record from someone other than myself can not be changed.

  1. You have a right to request reasonable restrictions on uses and disclosures of private health information, except when it does not comply with state or federal laws.
  2. You have a right to have your treatment and other information kept private. Only in an emergency, or if required by law, can your record be released without your permission.
  3. You have a right to make reasonable requests for what information is communicated in confidential communications, except when it does not comply with state or federal laws.
  4. You have a right to be treated with dignity, respect, and to fair treatment. This is regardless of race, religion, gender, ethnicity, age, disability, or source of payment.
  5. You have a right to information in a language that you can understand and to have an easy to understand explanation of your condition and treatment.
  6. You have a right to know all about your treatment choices, no matter what the cost is or whether the treatment options are covered by your insurance or not.
  7. You have the right to information about your providers.
  8. You have a right to file a complaint with Office for Civil Rights or with me if you feel that you have not been treated fairly.
  9. Disclosure of Information

You have a right to know who or where your records are sent. Records of disclosure are kept for 6 years. Your records are kept for 7 years.

Your requests for information must be fulfilled within 60 days.

Copying of records or collection of information will be charged a minimum fee of $25per record, andis payable prior to release of records.

  1. You have a right to know about State and Federal Laws relating to your rights and responsibilitiesin the treatment process.

Your Responsibilities as a Client

1. You have a responsibility to give accurate information about yourself for proper care.

2. You have a responsibility to let me know when the treatment plan is not working for you.

Please ask me questions about your care so that you understand your role in your care.

3. You have a responsibility to follow your medication plan. You must tell me whenever

Changes are made to your medication regime.

  1. You have a responsibility to treat me with dignity and respect.You may not take actions that could harm me or anyone else in this office.
  2. You have a responsibility to keep appointments and to contact me as soon as you know that you are unable to keep your appointment. You are responsible for payment of fees (as defined in your service agreement). Appointments that are missed or cancelled within 24 hours of your scheduled appointment time are charged to you and due prior to your next appointment time. Certain exceptions can be made under special circumstances.
  3. You have a responsibility to pay all copayments, missed or canceled appointment charges and appointment fees at the time of the session. If you are unable to comply with the payment agreement, it is your responsibility to discuss this with me so that payment arrangements can be made.Overdue accounts are charged 15% interest.
  4. You are responsible to keep the privacy of anyone that you see in my office, whether they are waiting for an appointment, or when leaving an appointment.
  5. Please do not come more than 5 minutes before an appointment so as to ensure the privacy of the clients before you.
  6. You have a responsibility to be on time for your appointments and to be available for the entire session time scheduled, unless there is an emergency.
  7. You have a responsibility to follow the plans and instructions of your care, which are determined by both you and myself.