THERAPY CONSENT, POLICIES, & AGREEMENT
PART I: THERAPEUTIC PROCESS
BENEFITS/OUTCOMES: The therapeutic process seeks to meet goals
established by all persons involved, usually revolving around a
specific complaint(s). Participating in therapy may include
benefits such as the resolution of presenting problems as well as
improved intrapersonal and interpersonal relationships. The
therapeutic process may reduce distress, enhance stress
management, and increase one's ability to cope with problems
related to work, family, personal, relational, etc.
Participating in therapy can lead to greater understanding of
personal and relational goals and values. This can increase
relational harmony and lead to greater happiness. Progress
will be assessed on a regular basis and feedback from clients
will be elicited to ensure the most effective therapeutic
services are provided. There can be no guarantees made
regarding the ultimate outcome of therapy.
EXPECTATIONS: In order for clients to reach their therapeutic
goals, it is essential they complete tasks assigned between
sessions. Therapy is not a quick fix. It takes time
and effort, and therefore, may move slower than your
expectations. During the therapy process, we identify
goals, review progress, and modify the treatment plan as needed.
RISKS: In working to achieve therapeutic benefits, clients must
take action to achieve desired results. Although change is
inevitable, it can be uncomfortable at times. Resolving
unpleasant events and making changes in relationship patterns may
arouse unexpected emotional reactions. Seeking to resolve
problems can similarly lead to discomfort as well as relational
changes that may not be originally intended. We will work
collaboratively toward a desirable outcome; however, it is
possible that the goals of therapy may not be reached.
STRUCTURE OF THERAPY:
Intake Phase - During the first session, therapeutic process,
structure, policies and procedures will be discussed. We
will also explore your experiences surrounding the presenting
problem(s).
Assessment Phase - The initial evaluation may last 2-4
sessions. During this assessment phase, I will be getting
to know you. I will ask questions to gain an understanding
of your worldview, strengths, concerns, needs, relationship
dynamics, etc. During this relationship building process, I
will be gathering a lot of information to aid in the therapeutic
approach best suited for your needs and goals. If it is
determined that I am not the best fit for your therapeutic needs,
I will provide referrals for more appropriate treatment.
Goal Development/Treatment Planning - After gathering background
information, we will collaborate to identify your therapeutic
goals. If therapy is court ordered, goals will encompass
your goals and court ordered treatment goals, based on
documentation from the court (please provide any court
documents). Once each goal is reached, we will sign off on
each goal and you will receive a copy.
Intervention Phase - This phase occurs anywhere from session two
until graduation/discharge/termination. Each client must
actively participate in therapy sessions, utilize solutions
discussed, and complete assignments between sessions.
Progress will be reviewed and goals adjusted as needed.
Graduation/Discharge/Termination - As you progress and get closer
to completing goals, we will collaboratively discuss a transition
plan for graduation/discharge/termination.
LENGTH OF THERAPY: Therapy sessions are typically weekly or
biweekly for minutes depending upon the nature of the
presenting challenges and insurance authorizations. It is
difficult to initially predict how many sessions will be
needed. We will collaboratively discuss from session to
session what the next steps are and how often therapy sessions
will occur.
APPOINTMENTS AND CANCELLATIONS: You are responsible for attending
each appointment and agree to adhere to the following policy: If
you cannot keep the scheduled appointment, you MUST notify our
office to cancel or reschedule the appointment prior to 24
hours of the scheduled appointment time. If you cancel or
reschedule more than once, we may re-evaluate your needs,
desires, and motivations for treatment at this time.
Psychotherapy is a uniquely personal service; therefore,
consultations may be briefly interrupted. I may
periodically take time off for vacation, seminars, and/or become
ill. Attempts will be made to give adequate notice of these
events. If I am unable to contact you directly, a colleague
may contact you to cancel or reschedule an appointment.
FEES: The fee for each therapy session is $150. Payment is
due at the time of service. Acceptable forms of payment
are: exact-amount cash, check or credit/debit card.
In the event that a scheduled appointment time is missed or
cancelled less than 24 hours in advanced, please refer to the
"Appointments and Cancellations" policy above.
The clinician reserves the right to terminate the counseling
relationship if more than 2 sessions are missed without proper
notification.
The clinician charges his/her hourly rate in quarter hours for
phone calls over 10 minutes in length, email correspondence,
reading assessments or evaluations, writing assessments or
letters, and collaborating with necessary professionals (with
your permission) for continuity of care. All costs for
services outside of session will be billed.
All email communication over 15 minutes will also be billed $130
prorated to the hour.
TRIAL, COURT ORDERED APPEARANCES, LITIGATION: Rarely, but on
occasion, a court will order a therapist to testify, be deposed,
or appear in court for a matter relating to your treatment or
case. In order to protect your confidentiality, I strongly
suggest not being involved in the court. If I get called
into court by you or your attorney, you will be charged a fee of
$350 per hour to include travel time, court time, preparing
documents, etc.
COPIES OF MEDICAL RECORDS: Should you request a copy of your
medical records, the cost is 1.00 per page. Payment for
your medical records will be due prior or upon receipt and can be
picked up at the office. Please allow at least 2 weeks to
prepare medical records.
PHONE CONTACTS AND EMERGENCIES: Office hours are from By
Appointment Only. If you need to contact the clinician for
any reason please call 864-406-6464, leave a voicemail, and a
return call will be made within 24 hours. In case of an
emergency, you can access emergency assistance by calling the
National Suicide Prevention Lifeline at 1-800-273-8255. If
either you or someone else is in danger of being harmed, dial
911. Mental Health America Crisis Line: (864) 271-8888
Greenville Mental Health Center: (864) 241-1040 In the event of
imminent harm or suicidal thoughts, please call 911 first, or go
to the nearest hospital emergency room.
PART II: CONFIDENTIALITY:
Anything said in therapy is confidential and may not be revealed
to a third party without written authorization, except for the
following limitations:
Child Abuse: Child abuse and/or neglect, which include but are
not limited to domestic violence in the presence of a child,
child on child sexual acting out/abuse, physical abuse,
etc. If you reveal information about child abuse or child
neglect, I am required by law to report this to the appropriate
authority.
Vulnerable Adult Abuse: Vulnerable adult abuse or neglect.
If information is revealed about vulnerable adult or elder abuse,
I am required by law to report this to the appropriate authority.
Self-Harm: Threats, plans or attempts to harm oneself. I am
permitted to take steps to protect the client's safety, which may
include disclosure of confidential information.
Harm to Others: Threats regarding harm to another person.
If you threaten bodily harm or death to another person, I am
required by law to report this to the appropriate authority.
Court Orders & Legal Issued Subpoenas: If I receive a
subpoena for your records, I will contact you so you may take
whatever steps you deem necessary to prevent the release of your
confidential information. I will contact you twice by
phone. If I cannot get in touch with you by phone, I will
send you written correspondence. If a court of law issues a
legitimate court order, I am required by law to provide the
information specifically described in the order. Despite
any attempts to contact you and keep your records confidential, I
am required to comply with a court order.
Law Enforcement and Public health: A public health authority that
is authorized by law to collect or receive such information for
the purpose of preventing or controlling disease, injury, or
disability; to a health oversight agency for oversight activities
authorized by law, including audits; civil, administrative, or
criminal investigations; inspections; licensure or disciplinary
actions; civil, administrative, or criminal proceedings or
action; limited information (such as name, address DOB, dates of
treatment, etc.) to a law enforcement official for the purpose of
identifying or locating a suspect, fugitive, material witness, or
missing person; and information that your clinician believes in
good faith establishes that a crime has been committed on the
premises.
Governmental Oversight Activities: To an appropriate agency
information directly relating to the receipt of health care,
claim for public benefits related to mental health, or
qualification for, or receipt of, public benefits or services
when a your mental health is integral to the claim for benefits
or services, or for specialized government functions such as
fitness for military duties, eligibility for VA benefits, and
national security and intelligence.
Upon Your Death: To a law enforcement official for the purpose of
alerting of your death if there is a suspicion that such death
may have resulted from criminal conduct; to a coroner or
medical examiner for the purpose of identifying a deceased
person, determining a cause of death, or other duties as
authorized by law.
Victim of a Crime: Limited information, in response to a law
enforcement official's request for information about you if you
are suspected to be a victim of a crime; however, except in
limited circumstances, we will attempt to get your permission to
release information first.
Court Ordered Therapy: If therapy is court ordered, the court may
request records or documentation of participation in
services. I will discuss the information and/or
documentation with you in session prior to sending it to the
court.
Written Request: Clients must sign a release of information form
before any information may be sent to a third party. A
summary of visits may be given in lieu of actual
"psychotherapy/process notes", except if the third party is part
of the medical team. If therapy sessions involve more than
one person, each person over the age of 18 MUST sign the release
of information before information is released.
Fee Disputes: In the case of a credit card dispute, I reserve the
right to provide the necessary documentation (i.e. your signature
on the "Therapy Consent & Agreement" that covers the
cancellation policy to your bank or credit card company should a
dispute of a charge occur. If there is a financial balance
on account, a bill will be sent to the home address on the intake
form unless otherwise noted.
Couples Counseling & "No Secret" Policy: When working with
couples, all laws of confidentiality exist. I request that
neither partner attempt to triangulate me into keeping a "secret"
that is detrimental to the couple's therapy goal. If one
partner requests that I keep a "secret" in confidence, I may
choose to end the therapeutic relationship and give referrals for
other therapists as our work and your goals then become
counter-productive. However, if one party requests a copy
of couples or family therapy records in which they participated,
an authorization from each participant (or their representatives
and/or guardians) in the sessions before the records can be
released.
Dual Relationships & Public: Our relationship is strictly
professional. In order to preserve this relationship, it is
imperative that there is no relationship outside of the
counseling relationship (ie: social, business, or
friendship). If we run into each other in a public setting,
I will not acknowledge you as this would jeopardize
confidentiality. If you were to acknowledge me, your
confidentiality could be at risk.
Social Media: No friend requests on our personal social media
outlets (Facebook, LinkedIn, Pinterest, Instagram, Twitter, etc.)
will be accepted from current or former clients. If you
choose to comment on our professional social media pages or
posts, you do so at your own risk and may breach
confidentiality. I cannot be held liable if someone
identifies you as a client. Posts and information on social
media are meant to be educational and should not replace
therapy. Please do not contact me through any social media
site or platform. They are not confidential, nor are they
monitored, and may become part of medical record.
Electronic Communication: If you need to contact me outside of
our sessions, please do so via phone.
Clients often use text or email as a convenient way to
communicate in their personal lives. However, texting
introduces unique challenges into the therapist-client
relationship. Texting is not a substitute for
sessions. Texting is not confidential. Phones can be
lost or stolen. DO NOT communicate sensitive information
over text. The identity of the person texting is unknown as
someone else may have possession of the client's phone.
Do not use email for emergencies. In the case of an
emergency call 911, your local emergency hotline or go to the
nearest emergency room. Additionally, e-mail is not a
substitute for sessions. If you need to be seen, please
call to book an appointment.
E-mail is not confidential. Do not communicate sensitive
medical or mental health information via email.
Furthermore, if you send email from a work computer, your
employer has the legal right to read it. E-mail is a part
of your medical record.
Sessions Outside the Office: From time to time, clients like to
meet in an alternate location (i.e. their home, in public, or
somewhere more conducive for them). We may be able to
accommodate this request, however, this can put your
confidentiality at risk.
2. I authorize the release of treatment and diagnosis
information (as described in Part III, above) necessary to process
bills for services to my insurance company, and request payment of
benefits to Jerah Sowinski, of Jerah Sowinski, LLC. I
acknowledge that I am financially responsible for payment whether
or not covered by insurance. I understand, in the event that
fees are not covered by insurance, Jerah Sowinski, of Jerah
Sowinski, LLC may utilize payment recovery procedures after
reasonable notice to me, including a collection company or
collection attorney. ="ltr">