Below is information you will need to read as you progress through therapy. At your next appointment with your therapist, you will be required to sign a form saying that you have reviewed and understand the following. Please feel free to make copies for yourself. You will have the opportunity to ask questions before signing the release form.

About Our Practice

Welcome to our practice. I appreciate your giving me the opportunity to be of help to you.

This brochure answers some questions clients often ask about any therapy practice. It is important to me that you know how we will work together. I believe our work will be most helpful to you when you have a clear idea of what we are trying to do.

This brochure talks about the following in a general way:

·         What the risks and benefits of therapy are.

·         What the goals of therapy are, and what my methods of treatment are like.

·         How long therapy might take.

·         How much my services cost, and how I handle money matters.

·         Other important areas of our relationship.

After you read this brochure we can discuss, in person, how these issues apply to your own situation. This brochure is yours to keep and refer to later. Please read all of it and mark any parts that are not clear to you. Write down any questions you think of, and we will discuss them at our next meeting. When you have read and fully understood this brochure, I will ask you to sign it at the end. I will sign it as well and make a copy, so we each have one.

About Psychotherapy

Because you will be putting a good deal of time, money, and energy into therapy, you should choose a therapist carefully. I strongly believe you should feel comfortable with the therapist you choose, and hopeful about the therapy. When you feel this way, therapy is more likely to be very helpful to you. Let me describe how I see therapy.

My theoretical approach is based on cognitive behavioral theory.

We often believe that our behaviors and feelings are caused by what happens in the real world. However, this is not quite true. When we have any kind of experience, it does not affect us directly. Rather, we first give it a meaning through our beliefs about it. For example, if I hear a sound in the kitchen and believe it is made by my spouse, I am not bothered at all. But if I believe I am alone in the house, the same sound can bother me a great deal. Here we see that feelings and behaviors (my actions about the sound) flow from the active process of thinking about or adding meaning to the actual event (the sound).

I think of my approach to helping people with their problems as an educational one. Anyone can learn to recognize irrational beliefs, dispute them, and replace them with more rational beliefs. We can, with practice, unlearn these beliefs and become happier persons who function better in the world. This is what I mean by an educational approach.

I want you to be able to use cognitive-behavior therapy without me. I encourage you to learn more about what methods are used; how well it works, and what possible problems or side effects it may have. I can lend you books and articles that explain how it works. Please return them when you no longer need them so I can lend them to other clients. I may also give you copies of articles or handouts that are yours to keep.

I usually take notes during our meetings. You may find it useful to take your own notes, and also to take notes outside the office. You could also tape-record our meetings to review at your leisure at home.

By the end of our first or second session, I will tell you how I see your case at this point and how I think we should proceed. I view therapy as a partnership between us. You define the problem areas to be worked on; I use some special knowledge to help you make the changes you want to make. Psychotherapy is not like visiting a medical doctor. It requires your very active involvement. It requires your best efforts to change thoughts, feelings, and behaviors. For example, I want you to tell me about important experiences, what they mean to you, and what strong feelings are involved. This is one of the ways you are an active partner in therapy.

I expect us to plan our work together. In our treatment plan we will list the areas to work on, our goals, the methods we will use, the time and money commitments we will make, and some other things. I expect us to agree on a plan that we will both work hard to follow. From time to time, we will look together at our progress and goals. If we think we need to, we can then change our treatment plan, its goals, and its methods.

An important part of your therapy will be practicing new skills that you will learn in our sessions. I will ask you to practice outside our meetings, and we will work together to set up homework assignments for you. I might ask you to do exercises, to keep records, and perhaps to do other tasks to deepen your learning. You will probably have to work on relationships in your life and make long-term efforts to get the best results. These are important parts of personal change. Change will sometimes be easy and quick, but more often it will be slow and frustrating, and you will need to keep trying. There are no instant, painless cures and no “magic pills.” However, you can learn new ways of looking at your problems that will be very helpful for changing your feelings and reactions.

Most of my clients see me once a week for 3 to 4 months. After that, we meet less often for several more months. Therapy then usually comes to an end. The process of ending therapy, called “termination,” can be a very valuable part of our work. Stopping therapy should not be done casually, although either of us may decide to end it if we believe it is in your best interest. If you wish to stop therapy at any time, I ask that you agree now to meet then for at least one session to review our work together. We will review our goals, the work we have done, any future work that needs to be done, and our choices. If you would like to take a “time out” from therapy to try it on your own, we should discuss this. We can often make such a “time out” be more helpful.

I will send you a brief set of questions about 6 months after our last session. These questions will ask you to look back at our work together, and sending them to you is part of my duty as a therapist. I ask that you agree, as part of entering therapy with me, to return this follow-up form and to be very honest about what you tell me then.

The Benefits and Risks of Therapy

As with any powerful treatment, there are some risks as well as many benefits with therapy. You should think about both the benefits and risks when making any treatment decisions. For example, in therapy, there is a risk that clients will, for a time, have uncomfortable levels of sadness, guilt, anxiety, anger, frustration, loneliness, helplessness, or other negative feelings. Clients may recall unpleasant memories. These feelings or memories may bother a client at work or in school. In addition, some people in your community may mistakenly view anyone in therapy as weak, or perhaps as seriously disturbed or even dangerous. Also, clients in therapy may have problems with people important to them. Family secrets may be told. Therapy may disrupt a marital relationship and sometimes may even lead to a divorce. Sometimes, too, a client’s problems may temporarily worsen after the beginning of treatment. Most of these risks are to be expected when people are making important changes in their lives. Finally, even with our best efforts, there is a risk that therapy may not work out well for you.

While you consider these risks, you should know also that the benefits of therapy have been shown by scientists in hundreds of well-designed research studies. People who are depressed may find their mood lifting. Others may no longer feel afraid, angry, or anxious. In therapy, people have a chance to talk things out fully until their feelings are relieved or the problems are solved. Clients’ relationships and coping skills may improve greatly. They may get more satisfaction out of social and family relationships. Their personal goals and values may become clearer. They may grow in many directions—as persons, in their close relationships, in their work or schooling, and in the ability to enjoy their lives.

I do not take on clients I do not think I can help. Therefore, I will enter our relationship with optimism about our progress.

Consultations

If you could benefit from a treatment I cannot provide, I will help you to get it. You have a right to ask me about such other treatments, their risks, and their benefits. Based on what I learn about your problems, I may recommend a medical exam or use of medication. If I do this, I will fully discuss my reasons with you, so that you can decide what is best. If you are treated by another professional, I will coordinate my services with them and with your own medical doctor.

If for some reason treatment is not going well, I might suggest you see another therapist or another professional in addition to me. As a responsible person and ethical therapist, I cannot continue to treat you if my treatment is not working for you. If you wish for another professional’s opinion at any time, or wish to talk with another therapist, I will help you find a qualified person and will provide him or her with the information needed.

What to Expect from Our Relationship

As a professional, I will use my best knowledge and skills to help you. This includes following the standards of the American Psychological Association, or APA. In your best interests, the APA puts limits on the relationship between a therapist and a client, and I will abide by these. Let me explain these limits, so you will not think they are personal responses to you.

First, I am licensed and trained to practice psychology—not law, medicine, finance, or any other profession. I am not able to give you good advice from these other professional viewpoints.

Second, state laws and the rules of the APA require me to keep what you tell me confidential (that is, private). You can trust me not to tell anyone else what you tell me, except in certain limited situations. I explain what those are in the “About Confidentiality” section of this brochure. Here I want to explain that I try not to reveal who my clients are. This is part of my effort to maintain your privacy. If we meet on the street or socially, I may not say hello or talk to you very much. My behavior will not be a personal reaction to you, but a way to maintain the confidentiality of our relationship.

Third, in your best interest, and following the APA’s standards, I can only be your therapist. I cannot have any other role in your life. I cannot, now or ever, be a close friend or socialize with any of my clients. I cannot be a therapist to someone who is already a friend. I can never have a sexual or romantic relationship with any client during, or after, the course of therapy. I cannot have a business relationship with any of my clients, other than the therapy relationship.

Even though you might invite me, I will not attend your family gatherings, such as parties or weddings.

As your therapist, I will not celebrate holidays or give you gifts; I may not notice or recall your birthday; and may not receive any of your gifts eagerly.

About Confidentiality

I will treat with great care all the information you share with me. It is your legal right that our sessions and my records about you be kept private. That is why I ask you to sign a “release-of-records” form before I can talk about you or send my records about you to anyone else. In general, I will tell no one what you tell me. I will not even reveal that you are receiving treatment from me.

In all but a few rare situations, your confidentiality (that is, your privacy) is protected by state law and by the rules of my profession. Here are the most common cases in which confidentiality is not protected:

1.  If you were sent to me by a court or an employer for evaluation or treatment, the court or employer expects a report from me. If this is your situation, please talk with me before you tell me anything you do not want the court or your employer to know. You have a right to tell me only what you are comfortable with telling.

2.  Are you suing someone or being sued? Are you being charged with a crime? If so, and you tell the court that you are seeing me, I may then be ordered to show the court my records. Please consult your lawyer about these issues.

3.  If you make a serious threat to harm yourself or another person, the law requires me to try to protect you or that other person. This usually means telling others about the threat. I cannot promise never to tell others about threats you make.

4.  If I believe a child has been or will be abused or neglected, I am legally required to report this to the authorities.

5.   Psychologists are state mandated to report driving impairments.

There are two situations in which I might talk about part of your case with another therapist. I ask now for your understanding and agreement to let me do so in these two situations.

First, when I am away from the office for a few days, I have a trusted fellow therapist “cover” for me. This therapist will be available to you in emergencies. Therefore, he or she needs to know about you. Of course, this therapist is bound by the same laws and rules as I am to protect your confidentiality.

Second, I sometimes consult other therapists or other professionals about my clients. This helps me in giving high-quality treatment. These persons are also required to keep your information private. Your name will never be given to them, and they will be told only as much as they need to know to understand your situation.

For the purpose of these consultations, I may want to make audio or video recordings of our sessions. I will review the recordings with my consultant to assist with your treatment. I will ask your permission to make any recording. I promise to destroy each recording as soon as I no longer need it, or, at the latest, when I destroy your case records. You can refuse to allow this recording, or can insist that the recording be edited.

Except for the situations I have described above, my office staff and I will always maintain your privacy. I also ask you not to disclose the name or identity of any other client being seen in this office.

My office staff makes every effort to keep the names and records of clients private. My staff and I will try never to use your name on the telephone, if clients in the office can overhear it. All staff members who see your records have been trained in how to keep records confidential.

If your records need to be seen by another professional, or anyone else, I will discuss it with you. If you agree to share these records, you will need to sign a release form. This form states exactly what information is to be shared, with whom, and why, and it also sets time limits. You may read this form at any time. If you have questions, please ask me.

It is my office policy to destroy clients’ records 15 years after the end of our therapy. Until then, I will keep your case records in a safe place.

If I must discontinue our relationship because of illness, disability, or other presently unforeseen circumstances, I ask you to agree to my transferring your records to another therapist who will assure their confidentiality, preservation, and appropriate access.

If we do family or couple therapy (where there is more than one client), and you want to have my records of this therapy sent to anyone, all of the adults present will have to sign a release.

As part of cost control efforts, an insurance company will sometimes ask for more information on symptoms, diagnoses, and my treatment methods. It will become part of your permanent medical record. I will let you know if this should occur and what the company has asked for. Please understand that I have no control over how these records are handled at the insurance company. My policy is to provide only as much information as the insurance company will need to pay your benefits.

You can review your own records in my files at any time. You may add to them or correct them, and you can have copies of them. I ask you to understand and agree that you may not examine records created by anyone else and sent to me.

In some very rare situations, I may temporarily remove parts of your records before you see them. This would happen if I believe that the information will be harmful to you, but I will discuss this with you.

About Our Appointments

The very first time I meet with you, we will need to give each other much basic information. For this reason, I usually schedule 1 hour for this first meeting. Following this, we will usually meet for a 50-minute session once or twice a week, then less often. We can schedule meetings for both your and my convenience. I will tell you at least a month in advance of my vacations or any other times we cannot meet. Please ask about my schedule in making your own plans.

An appointment is a commitment to our work. We agree to meet here and to be on time. If I am ever unable to start on time, I ask your understanding. I also assure you that you will receive the full time agreed to. If you are late, we will probably be unable to meet for the full time, because it is likely that I will have another appointment after yours.

A cancelled appointment delays our work. I will consider our meetings very important and ask you to do the same. Please try not to miss sessions if you can possibly help it. When you must cancel, please give me at least a week’s notice. Your session time is reserved for you. I am rarely able to fill a cancelled session unless I know a week in advance. If you start to miss a lot of sessions, I will have to charge you for the lost time unless I am able to fill it. Your insurance will not cover this charge.

I will reserve a regular appointment time for you into the foreseeable future. I also do this for my other patients. Therefore, I am rarely able to fill a cancelled session unless I have several weeks’ notice. You will be charged the full fee for sessions cancelled with less than 24 hours’ notice, for other than the most serious reasons.

I request that you do not bring children with you if they are young and need babysitting or supervision, which I cannot provide. I do not have toys, but I can provide reading materials suitable for older children.

Fees, Payments, and Billing

Payment for services is an important part of any professional relationship. This is even more true in therapy; one treatment goal is to make relationships and the duties and obligations they involve clear. You are responsible for seeing that my services are paid for. Meeting this responsibility shows your commitment and maturity.

Telephone consultations: I believe that telephone consultations may be suitable or even needed at times in our therapy. If so, I will charge you our regular fee, prorated over the time needed. If I need to have long telephone conferences with other professionals as part of your treatment, you will be billed for these at the same rate as for regular therapy services. If you are concerned about all this, please be sure to discuss it with me in advance so we can set a policy that is comfortable for both of us. Of course, there is no charge for calls about appointments or similar business.

Extended sessions: Occasionally it may be better to go on with a session, rather than stop or postpone work on a particular issue. When this extension is more than 10 minutes, I will tell you, because sessions that are extended beyond 10 minutes will be charged on a prorated basis.

Reports: I will not charge you for my time spent making routine reports to your insurance company. However, I will have to bill you for any extra-long or complex reports the company might require. The company will not cover this fee.

Other services: Charges for other services, such as hospital visits, consultations with other therapists, home visits, or any court-related services (such as consultations with lawyers, depositions, or attendance at courtroom proceedings) will be based on the time involved in providing the service at my regular fee schedule. Some services may require payment in advance.

I realize that my fees involve a substantial amount of money, although they are well in line with similar professionals’ charges. For you to get the best value for your money, we must work hard and well.

I will assume that our agreed-upon fee-paying relationship will continue as long as I provide services to you. I will assume this until you tell me in person, by telephone, or by certified mail that you wish to end it. You have a responsibility to pay for any services you receive before you end the relationship.

Because I expect all payment at the time of our meetings, I usually do not send bills. However, if we have agreed that I will bill you, I ask that the bill be paid within 5 days of when you get it.

If you think you may have trouble paying your bills on time, please discuss this with me. I will also raise the matter with you so we can arrive at a solution. If your unpaid balance becomes too high, I will notify you by mail. If it then remains unpaid, I must stop therapy with you. Fees that continue unpaid after this may be turned over to small-claims court or a collection service.

If there is any problem with my charges, my billing, your insurance, or any other money-related point, please bring it to my attention. I will do the same with you. Such problems can interfere greatly with our work. They must be worked out openly and quickly.

If You Have Traditional (or “Indemnity”) Health Insurance Coverage

Because I am a licensed psychologist, many health insurance plans will help you pay for therapy and other services I offer. These plans include Blue Shield and most Major Medical plans. Because health insurance is written by many different companies, I cannot tell you what your plan covers. Please read your plan’s booklet under coverage for “Outpatient Psychotherapy” or under “Treatment of Mental and Nervous Conditions.” Or call your employer’s benefits office to find out what you need to know.

If your health insurance will pay part of my fee, I will help you with your insurance claim forms. However, please keep two things in mind:

1.  I had no role in deciding what your insurance covers. Your employer decided which, if any, services will be covered and how much you (and I) will be paid. You are responsible for checking your insurance coverage, deductibles, payment rates, copayments, and so forth. Your insurance contract is between you and your company; it is not between me and the insurance company.

2.  You—not your insurance company or any other person or company—are responsible for paying the fees we agree upon. If you ask me to bill a separated spouse, a relative, or an insurance company, and I do not receive payment on time, I will then expect this payment from you.

To seek payment from your insurance company, you must first obtain a claim form from your employer’s benefits office or call your insurance company. Complete the claim form. Then attach my statement to the claim form and mail it to your insurance company. My statement already provides the information asked for on the claim form.

If You Have a Managed Care Contract

If you belong to a health maintenance organization (HMO) or have another kind of health insurance with managed care, decisions about what kind of care you need and how much of it you can receive will be reviewed by the plan. The plan has rules, limits, and procedures that we should discuss. Please bring your health insurance plan’s description of services to one of our early meetings, so that we can talk about it and decide what to do.

I will provide information about you to your insurance company only with your informed and written consent. I may send this information by mail or by fax. My office will try its best to maintain the privacy of your records, but I ask you not to hold me responsible for accidents or for anything that happens as a result.

If You Need to Contact Me

I cannot promise that I will be available at all times. Although I am in the office most weekdays, I usually do not take phone calls when I am with a client. You can always leave a message on my answering machine, and I will return your call as soon as I can. Generally, I will return messages daily except on Sundays and holidays.

If you have an emergency or crisis, tell this to the answering service who will try to contact me. If you have a behavioral or emotional crisis and cannot reach me or my answering immediately by telephone, you or your family members should seek assessment and treatment at the nearest hospital emergency room.

If I Need to Contact Someone about You

If there is an emergency during our work together, or I become concerned about your personal safety, I am required by law and by the rules of my profession to contact someone close to you—perhaps a relative, spouse, or close friend. I am also required to contact this person, or the authorities, if I become concerned about your harming someone else. Please write down the name and information of your chosen contact person in the blanks provided:

Name: ____________________________________________________________

Address: ___________________________________________________________

Phone: ________________________ Relationship to you:____________________

Other Points

If you ever become involved in a divorce or custody dispute, I want you to understand and agree that I will not provide evaluations or expert testimony in court. You should hire a different mental health professional for any evaluations or testimony you require. This position is based on two reasons: (1) My statements will be seen as biased in your favor because we have a therapy relationship; and (2) the testimony might affect our therapy relationship, and I must put this relationship first.

Doing follow-up and outcome research is always educational. As a professional therapist, I naturally want to know more about how therapy helps people. To understand therapy better, I must collect information about clients before, during, and after therapy. Therefore, I am asking you to help me by filling out some questionnaires about different parts of your life-relationships, changes, concerns, attitudes, and other areas. I ask your permission to take what you wrote on these questionnaires and what I have in my records and use it in research or teaching that I may do in the future. If I ever use the information from your questionnaire, it will always be included with information from many others. Also, your identity will be made completely anonymous. Your name will never be mentioned, and all personal information will be disguised and changed. After the research, teaching, or publishing project is completed all the data used will be destroyed.

If, as part of our therapy, you create and provide to me records, notes, artworks, or any other documents or materials, I will return the originals to you at your written request but will retain copies.

Statement of Principles and Complaint Procedures

It is my intention to fully abide by all the rules of the American Psychological Association (APA) and by those of my state license.

Problems can arise in our relationship, just as in any other relationship. If you are not satisfied with any area of our work, please raise your concerns with me at once. Our work together will be slower and harder if your concerns with me are not worked out. I will make every effort to hear any complaints you have and to seek solutions to them. If you feel that I, or any other therapist, has treated you unfairly or has even broken a professional rule, please tell me. You can also contact the state or local psychological association and speak to the chairperson of the ethics committee. He or she can help clarify your concerns or tell you how to file a complaint. You may also contact the state board of psychologist examiners [note that this name differs across states], the organization that licenses those of us in the independent practice of psychology.

In my practice as a therapist, I do not discriminate against clients because of any of these factors: age, sex, marital/family status, race, color, religious beliefs, ethnic origin, place of residence, veteran status, physical disability, health status, sexual orientation, or criminal record unrelated to present dangerousness. This is a personal commitment, as well as being required by federal, state, and local laws and regulations. I will always take steps to advance and support the values of equal opportunity, human dignity, and racial/ethnic/cultural diversity. If you believe you have been discriminated against, please bring this matter to my attention immediately.

Our Agreement

I, the client (or his or her parent or guardian), understand I have the right not to sign this form. My signature below indicates that I have read and discussed this agreement; it does not indicate that I am waiving any of my rights. I understand I can choose to discuss my concerns with you, the therapist, before I start (or the client starts) formal therapy. I also understand that any of the points mentioned above can be discussed and may be open to change. If at any time during the treatment I have questions about any of the subjects discussed in this brochure, I can talk with you about them, and you will do your best to answer them.

I understand that after therapy begins I have the right to withdraw my consent to therapy at any time, for any reason. However, I will make every effort to discuss my concerns about my progress with you before ending therapy with you.

I understand that no specific promises have been made to me by this therapist about the results of treatment, the effectiveness of the procedures used by this therapist, or the number of sessions necessary for therapy to be effective.

I have read, or have had read to me, the issues and points in this brochure. I have discussed those points I did not understand, and have had my questions, if any, fully answered. I agree to act according to the points covered in this brochure. I hereby agree to enter into therapy with this therapist (or to have the client enter therapy), and to cooperate fully and to the best of my ability.

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and
how you can get access to this information.
Please review it carefully.

Our Commitment to Your Privacy

Our practice is dedicated to maintaining the privacy of our personal health information as part of providing professional care. We also are required by law to keep your information private. These laws are complicated, but we must give you this important information. This pamphlet is a shorter version of the full, legally required NPP and you may have a copy of this to read and refer to it for more information. However, we can’t cover all possible situations so please talk to our Privacy Officer (see the end of this pamphlet) about any questions or problems.

We will use the information about your health which we get from you or from others mainly to provide you with treatment, to arrange payment for our services, and for some other business activities which are called, in the law, health care operations. After you have read this NPP we will ask you to sign a Consent Form to let us use and share your information. If you do not consent and sign this form, we cannot treat you.

If we or you want to use or disclose (send, share, release) your information for any other purposes we will discuss this with you and ask you to sign an Authorization form to allow this.

Of course we will keep our health information private but there are some times when the laws require us to use or share it. For example:

1. When there is a serious threat to your health and safety or the health and safety of another individual or the public. We will only share information with a person or organization that is able to help prevent or reduce the threat.
2. Some lawsuits and legal or court proceedings.
3. If a law enforcement official requires to do so.
4. For Workers Compensation and similar benefit programs.

There are some other situations like these but which don’t happen very often. They are described in the longer version of the NPP.

Your Rights Regarding your Health Information

1. You can ask us to communicate with you about your health and related issues in a particular way or at a certain place which is more private for you. For example, you can ask us to call you at home and not at work to schedule or cancel an appointment. We will try our best to do as you ask.
2. You have the right to ask us to limit what we tell people involved in your care or the payment of your care, such as family members and friends.
3. You have the right to look at the health information we have about you such as your medical and billing records. You can even get a copy of these records but we may charge you. Contact our Privacy Officer to arrange how to see your records. See below.
4. If you believe the information in your records is incorrect or missing important information, you can ask us to amend your health information. You have to make this request in writing and send it to our Privacy Officer. You must tell us the reasons you want to make the changes.
5. You have the right to a copy of this notice. If we change this NPP we will post the new version in our waiting area and you can always get a copy of the NPP from the Privacy Officer.
6. You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with our Privacy Officer and with the Secretary of the Department of Health and Human Services. All complaints must be in writing. Filing a complaint will not change the care we provide to you in any way.

If you have any questions regarding this notice or our health information privacy policies, please contact us at 724/772-4949.

This notice is effective September 1, 2008.

You may have other rights which are granted to you by the state laws; these may be the same or different from the rights described above. I would be happy to discuss these situations with you now or as they arise.

______________________________________________           ___________________________

Signature                                                                                         Date

What You Should Know about Managed Care and Your Treatment

Your health insurance may pay part of the costs of your treatment, but the benefits cannot be paid until a managed care organization (MCO) authorizes this (says they can be paid). The MCO has been selected by your employer, not by you or me. The MCO sets some limits on us, and you need to know what these are before we go further.

Confidentiality

If you use your health insurance to help pay for psychotherapy, you must allow me to tell the MCO about your problem (give it a psychiatric diagnosis). You must also permit me to tell the MCO about the treatment I am recommending, about your progress during treatment, and about how you are doing in many areas of your life (functions at work, in your family, and in activities of daily living). I am not paid separately for collecting, organizing, or submitting this information, and I cannot bill you for these services. All of this information will become part of the MCO’s records, and it will be included in your permanent medical record at the Medical Information Bureau, a national data bank. The information will be examined when you apply for life or health insurance, and it may be considered when you apply for employment, credit or loans, a security clearance, or other things in the future. You will have to indicate that you were treated for a psychological condition and release this information, or you may not get the insurance, job, loan, or clearance.

All insurance carriers claim to keep the information they receive confidential, and there are federal laws about its release. The laws and ethics that apply to me are much stricter than the rules that apply at present to MCOs. There have been reports in the media about many significant and damaging breaches of confidentiality by MCOs. If you are concerned about who might see your records now or in the future, we should discuss this issue more fully before we start treatment and before I send the MCO any information. You should evaluate your situation carefully in regard to confidentiality. For some people and some problems, the privacy of their communications to their therapist is absolutely essential to their work on their difficulties. For others, their problems are not ones that raise much concern over confidentiality.

Treatment

The MCO will review the information I send it and then decide how much treatment I can provide to you. The MCO can refuse to pay for any of your treatment, or for any treatment by me. Or it may pay only a very small part of the treatment’s cost, and it can prevent me from charging you directly for treatment we agree to. Finally, it can set limits on the kinds of treatments I can provide to you. These limited treatments may not be the most appropriate for you or in your best interest. The MCO will approve treatment aimed at improving the specific symptoms (behaviors, feelings) that brought you into therapy, but it may not approve any further treatment. The MCO will almost always require you to see a psychiatrist for medication evaluations (and prescriptions), whether you or I think this is appropriate.

When it does authorize our treatment, the MCO is likely to limit the number of times we can meet. Your insurance policy probably has a maximum number of appointments allowed for outpatient psychotherapy (usually per year, though there may be a lifetime limit as well), but the MCO does not have to let you use all of those. It may not agree to more sessions, even if I believe those are needed to fully relieve your problems, or if I believe that undertreating your problems may prolong your distress or lead to relapses (worsening or backsliding).

If the MCO denies payment before either of us is satisfied about our progress, we may also need to consider other treatment choices, and they may not be the ones we would prefer. We can appeal the MCO’s decisions on payment and number of sessions, but we can only do so within the MCO itself. We cannot appeal to other professionals, to your employer, or through the courts. This state does not have laws regulating MCOs —that is, laws about the skills or qualifications of their staff members, about access to medical and psychological records by employers and others, or about the appeals process.

You should know that my contract or your employer’s contract with a particular MCO prevent us from taking legal actions against the MCO if things go badly because of its decision. My contract may prevent me from discussing with you treatment options for which the MCO will not pay. I will discuss with you any efforts the MCO makes to get me to limit your care in any way.

The particular MCO in charge of your mental health benefits can change during the course of your treatment. If this happens, we may have to go through the whole treatment authorization process again. It is also possible that the benefits or coverage for your treatment may change during the course of our therapy, and so your part of costs for treatment may change.

Lastly, even if we send all the forms and information to the MCO on time, there may be long delays before any decisions are made. This creates stressful uncertainty and may alter our earlier assumptions about the costs and nature of your treatment.

Our Agreement

If, after reading this and discussing it with me, you are concerned with these issues, you may have the choice of paying me directly and not using your health insurance. This will create no record outside of my files. This possibility depends on my contract with the MCO.

I have read and understood the issues described above and willingly enter treatment accepting these limits. I give my therapist permission to submit information in order to secure payment for the mental health services to be provided to me.

___ Yes, I want to review and/or receive copies of any written materials you send to my MCO.

___ No, that is not necessary.

__________________________          ___________________________      __________

              Signature of client                                  Printed name of client                           Date