Consent Form

FACE-TO-FACE THERAPY INFORMED CONSENT
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Welcome to my practice! This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.

Instructions

Please review the Agreement at the bottom of this page, fill out the Consent Form below and answer as many of the optional questions as you are comfortable responding. After you are done, please click the print button. Once printed, please bring with you to our session. You may also view the Right to Receive a Good Faith Estimate of Expected Charges Notice.

THERAPY SERVICES

Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in face-to-face therapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.

Face-to-face therapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of face-to-face therapy often requires discussing the unpleasant aspects of your life. However, face-to-face therapy has been shown to have benefits for individuals, couples and families who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Face-to-face therapy requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions.

I utilize mostly solution-focused (link to explanation) approach to therapy. We will come up with treatment goals together in our first session and continue to define them as our sessions continue. If you have questions about our therapy process, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion.

The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I require that you provide 24 hours. notice. If you miss a session without canceling, or cancel with less than a 24 hour notice, my policy is to collect the amount above for your payment unless otherwise agreed that you were unable to attend due to circumstances beyond your control. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still end on time.

If you have more than 2 cancelations during the course of therapy, we may discuss the need for continuing therapy. Should you express and wish and/or desire to continue therapy, prepayment will be required. If you cancel or miss a session with less than 24 hours notice and the session is pre-paid, it will follows the cancelation guidelines and the payment will applied to the missed session.

In the case of a disputed charge, I reserve the right to provide the needed and adequate documentation, i.e. your signature on this agreement, that outlines you acceptance of this session cancellation policy and documentation or proof of the time and date you informed me of your cancellation to your bank or Credit Card Company.

In the event that you are experiencing a crisis and you are not able to contact this therapist immediately, you can contact (in Broward County) 954-463-0911. This is for adults only. For children, please contact 954-677-3113 ext 3. Remember, if you feel you are suicidal or homicidal, please call 911 immediately.

The standard fee for the initial intake is $200.00 for couples counseling and $150.00 for individual counseling, and each subsequent session is $200.00 and $150.00 respectively. I do understand that situations arise that makes it unable to pay my regular fees. I also work on a sliding scale fee which we can discuss further. You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by check or cash or through an Internet payment found on the face-to-face therapy site. Any checks returned to my office are subject to a returned check fee of up to $75.00. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment.

In addition to weekly appointments, it is my practice to charge this amount on a prorated basis (I will break down the hourly cost) for other professional services that you may require such as report writing, telephone conversations that last longer than 15 minutes, attendance at meetings or consultations which you have requested, or the time required to perform any other service which you may request of me. If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required even if another party compels me to testify.

This therapist will ask you how you would like to be reminded of a session. I can contact you via text or email 48 hours prior to your session and the contact is not intended for therapy purposes. It is important to understand that these outside conversations are meant for appointment purposes only. If you need further assistance, we can discuss setting up an appointment to discuss any concerns you may have.

If you choose to take advantage of any of our online counseling methods, Online Therapy is technical in nature and that there may be problems with Internet connectivity, which is the fault of neither Jennifer Lagrotte DMFT nor me. Internet availability may be limited or disrupted by things such as server maintenance, upgrades, or other problems (such as software or hardware malfunction) or natural or man-made disasters (such as terrorist acts, Internet viruses, and so forth). These types of problems are beyond the control of Jennifer Lagrotte DMFT and me (client). If something like this were to occur, any scheduled appointments would be re-scheduled by your online therapist at no additional cost to you (client). Please be aware of although Jennifer Lagrotte DMFT has taken a significant number of steps to ensure the confidentiality and privacy of Online communication(s), these actions, in whole or in part, cannot guarantee the security of Internet transmissions. I permanently agree to release and indemnify Jennifer Lagrotte DMFT from all suits, claims, and other actions originating from therapy provided through Jennifer Lagrotte DMFT.

I am required to keep appropriate records of the therapy services that I provide. Your records are maintained in a secure location in the office. I keep brief records noting that you were here, your reasons for seeking therapy, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records I receive from other providers, copies of records I send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and / or upsetting to untrained readers. For this reason, I recommend that you initially review them with me, or have them forwarded to another mental health professional to discuss the contents. If I refuse your request for access to your records, you have a right to have my decision reviewed by another mental health professional, which I will discuss with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request.

My policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled Notice of Privacy Practices. You have been provided with a copy of that document and we have discussed those issues. Please remember that you may reopen the conversation at any time during our work together.

While privacy in therapy is crucial to successful progress, parental involvement can also be essential. It is my policy not to provide treatment to a child under age 13 unless s/he agrees that I can share whatever information I consider necessary with a parent. For children 14 and older, I request an agreement between the client and the parents allowing me to share general information about treatment progress and attendance, as well as a treatment summary upon completion of therapy. All other communication will require the child.s agreement, unless I feel there is a safety concern (see also above section on Confidentiality for exceptions), in which case I will make every effort to notify the child of my intention to disclose information ahead of time and make every effort to handle any objections that are raised.

I am often not immediately available by telephone. I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a message on my confidential voice mail and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters.

If you are unhappy with what is happening in therapy, I hope you will talk with me so that I can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist and are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect that I will not have social or sexual relationships with clients or with former clients.

Your electronic signature below indicates that you have read this Agreement and the Notice of Privacy Practices and agree to their terms.

You have the right to recieve a Good Faith Estimate. Please see our policy here.