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PSYCHOLOGICAL SERVICES AGREEMENT
New Leaf Psychological Services is simply the name given to the services provided by Dr. Torie Carlson. It is not a formal entity or organization at this point in time. Dr. Carlson offers a variety of services including individual and couples therapy as well as psychological assessment, professional consultation, training and supervision. The evidence-based treatment approaches employed have been demonstrated in clinical studies to be efficient and effective, while assessment methods yield accurate results and practical recommendations. The evidenced-based practices ensure that the psychological services provided are of the highest professional standard. This form contains information about New Leaf’s professional services and business policies. The intention is to keep you well informed as to the nature of the services we provide. Then, you can make a good decision about whether New Leaf can meet your individual psychological needs. Upon reading this document, your signature will be requested, which will represent an agreement between you and your therapist to enter into a therapeutic relationship. You may revoke this agreement in writing at any time.
Thoughts About Therapy
Entering therapy takes courage. People often come to therapy for help with a specific issue or when they are at a crossroads in their lives. The path that they have been on has not taken them where they want to go and they come to therapy in search of help and direction. In order for change to take place, the therapist must join with them at the crossroads and together, embark on a voyage of discovery. Research convincingly demonstrates that the success of the journey depends on the relationship that develops between the therapist and client and therefore it is important for the therapist to: create an atmosphere that is collaborative, relaxed, safe and focused; instill hope; create a shared meaning; listen to the client’s story; gather information; and work together with the client to establish realistic and attainable goals. Therapy entails making meaningful connections between affective experiences, cognitions, and behavior. The experiences of each person in therapy will be different, because what happens in therapy depends on you and your needs. How you choose to use each session, your particular therapist’s approach and experience, and your own knowledge, insight, experience, and motivation will help determine the course and outcome of therapy. Therapy requires an active effort on your part. In order for therapy to be most successful, you will have to work on things we talk about both during our sessions and during the week.
Psychotherapy can have benefits and risks. Insight and inner awareness often creates a state of disequilibrium and decreased satisfaction in therapy. Since therapy most often involves discussing unpleasant aspects of your life and your family history, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. At times you may feel worse before you begin to feel better. Therefore it is helpful to understand that a sense of disequilibrium can be a desirable step in your healing process. Research has shown that psychotherapy has many benefits as it can lead to improved relationships, solutions to specific problems, increased awareness, and a significant reduction in feelings of distress. Although there are no guarantees of what you will experience during the process of therapy, your active participation in the therapy process is necessary for progress to be made. Thus, we encourage you to attend all scheduled sessions.
Psychotherapy will be rendered in a professional manner consistent with accepted ethical standards. Please note that it is impossible to guarantee any specific results regarding your counseling goals. However, together we will work to achieve the best possible results.
Your First Appointment
The initial appointment is an approximate 50 minute face to face meeting with Dr. Carlson. It is an opportunity to share information about your personal history and current situation and receive an evaluation of your needs. By the end of the appointment, Dr. Carlson will be able to offer his first impressions/recommendations of how best to proceed. If you decided to continue with therapy, your goals for therapy and a tentative plan to achieve these goals will be discussed. During the initial appointment, Dr. Carlson will also provide you information about his qualifications and practice orientation. You should evaluate this information and decide if you feel comfortable working with him. Therapy involves a large commitment of time, money, and energy so it is important to select a therapist with whom you are comfortable. The initial appointment is also a good time to ask questions and address any concerns you may have about therapy. If at the end of the initial meeting some alternative treatment seems indicated, information and/or an appropriate referral will be made.
Limits of Confidentiality
The law protects the privacy of all communication between a client and a psychologist. In most situations, information about your treatment can only be released if you sign a written authorization form that meets certain legal requirements imposed by the Personal Information Protection Act and/or Alberta law. However, in the following situations, no authorization is required:
· Dr. Carlson may occasionally find it helpful to consult other health and mental health professionals about a client. During consultations, your therapist will make every effort to avoid revealing your identity. Other professionals are legally bound to keep the information confidential. If you have no objections, your therapist will not inform you of a consultation unless it is important to your work together. All consultations will be noted in your Clinical Record. Your therapist will also need to communicate client information to his/her colleague who is providing emergency coverage if your therapist is not unavailable.
· If a coroner or medical examiner requests information in the performance of that individual’s duties, Dr. Carlson may be required to provide it for them.
· If a client files a complaint or lawsuit against their therapist, relevant information regarding that client may be disclosed in order of the agency to defend itself.
There are situations in which Dr. Carlson is legally obligated to take actions, which are believed to be necessary in an attempt to protect others from harm and we may have to reveal some information about a client’s treatment. These situations are unusual in this practice.
· If there is reason to believe that a child is a victim of child abuse or neglect, the law requires that a report be filed with the appropriate government agency, usually the local child protection service. Once such a report is filed, Dr. Carlson may be required to provide additional information.
· If there is reason to believe that someone is an endangered adult, the law requires that a report be filed with the appropriate government agency, usually the adult protective services unit. Once such a report is filed, the center may be required to provide additional information.
· If a client communicates an actual threat of physical violence against an identifiable victim, or evidences conduct or makes statements indicating imminent danger that the client will use physical violence or other means to cause serious personal injury to others, Dr. Carlson may be required to disclose information in order to take protective actions. These actions may include notifying the potential victim, contacting the RCMP, or seeking hospitalization for the client.
· If a client communicates an imminent threat of serious physical harm to him/herself, Dr. Carlson may be required to disclose information in order to take protective actions. These actions may include initiating hospitalization or contacting family members or others who can assist in providing protection.
The Alberta Personal Information Protection Act (effective January 1, 2004) and the Federal Personal Information Protection and Electronic Documents Act (effective January 1, 2005) are designed to protect the privacy of client information, provide for the electronic and physical security of health and client medical information, and simplify billing and other electronic transactions by standardizing codes and procedures. These Acts, create a minimum standard for the use and disclosure of Protected Health Information (PHI) by health care organizations.
At New Leaf, Dr. Carlson is committed to maintaining your confidentiality and the privacy of psychological and medical records and will continue to adhere to psychologist’s ethical guidelines, as well as, provincial and federal law. Furthermore, Dr. Carlson will make every effort to discuss confidentiality procedures with you before taking any action and will limit disclosure to what is necessary. 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 might have now or in the future. The laws governing confidentiality can be quite complex and in situations where specific advice is required, formal legal advice may be needed.
Minors and Parents
Clients 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. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is New Leaf’s policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, they will be provided only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. When therapy is complete, a summary of their child’s treatment will be provided if requested. Any other communication will require the child’s authorization, unless it is the therapist’s judgment that the child is in danger or is a danger to someone else, in which case parents will be notified. Before giving parents any information, all matters will be discussed with the child, if possible, an objections he/she may have handled accordingly.
Professional Fees
The fees for services are listed below. Each payment must be paid to Dr. Carlson at each session unless alternative arrangements are made. Payment can be made by cash or check (made payable to Dr. Torie Carlson). If a check does not clear at the bank, you may be asked to pay for future services in cash. There is a $15.00 fee charged for each returned check in addition to the amount of the check. If there is an unpaid balance on your account, you will receive a bill at the end of each month that will indicate the amount required to pay. Payment is due at the time your bill is received. If you find the cost prohibitive, please feel free to discuss this with your therapist to determine what options are available.
The following fees are typically covered by insurance policies:
Intake Assessment (1st appointment only) / ………………....$200.00Individual Psychotherapy / …………………$180.00 per 45-50 min. session
…………………$100.00 per 30 min. session or
each additional 30 min.
Couple/Family Therapy / …………………$200.00 per 45-50 min. session
…………………$300.00 per 90 min. session
The following fees are NOT typically covered by insurance:
Telephone Consultations / …………………..$145.00 per 45-50 min. session…...……………...$ 80.00 per 30 min. session
Cancelled appointments without 24 hr. notice / …………………..$ 75.00
Court Appearances and Testimony / …………………..$200.00 per hour
Consultations with Professional in the Community / …………………..$115.00 per 45-50 min. session
Supervision of Psychologists in the Community / ..…………………Negotiable
Insurance Reimbursement
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. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. Dr. Carlson will provide you with whatever assistance he can in helping you receive benefits to which you are entitled; however, you, not your insurance company, are responsible for full payment of fees. It is very important that you find out about mental health services your insurance policy covers. If you have questions about the coverage, call your plan administrator. We will provide you with whatever information we can and will call the company on your behalf to clear up any confusion.
Due to the rising cost of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. Some plans require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel that they need more services after insurance benefits end. Some plans will not allow your therapist to provide services to you once your benefits cease. If this is the case, we will do our best to find another provider who will help you continue your psychotherapy.
Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for our services yourself to avoid the problems described above [unless prohibited by contract].