Please note the following information you are about to read is the informed consent I, Dr. Liesl, asks incoming referrals to sign when an initial appointment takes place. The Informed Consent will be reviewed in the initial appointment. At that time, any further questions about my terms of services can be addressed.
INFORMED CONSENT FOR TREATMENT
Any patient who comes to see Dr. Liesl authorizes and requests Dr. Liesl to provide psychological examinations, assessment, interventions and/or diagnostic procedures that now or during the course of treatment are advisable. The frequency and type of assessment will be decided between therapist and patient.
The purpose of these procedures and treatments will be explained and be subject to verbal agreement.
It is understood that there is an expectation that the patient will benefit from this assessment and/or interventions but there is no guarantee that this will occur.
It is understood that maximum benefit will occur with consistent attendance and that at times the patient may feel conflicted about therapy as the process can sometimes be uncomfortable.
CONFIDENTIALITY: All information disclosed within sessions, including minors, is confidential and may not be revealed to anyone without written permission except where disclosure is permitted or required by law. Disclosure may be required in the following circumstances:
Where is a reasonable suspicion of abuse to a child, dependent or elder adult.
When there is a reasonable suspicion of knowledge of knowingly downloading, streaming and accessing through electronic or digital media, materials of a child engaged in an act of obscene sexual conduct.
When the client or credible third person communicates a serious threat of bodily injury to others.
When the therapist has a reasonable belief that the client may be a danger to him or herself, others or property of others.
When disclosure is otherwise required by law.
I receive regular professional consultation. In such cases, neither your name or any identifying information about you is revealed.
If you have a life threatening emergency please call 911. I am not able to provide 24 hour availability. I usually return calls within 24 hours or the next business day. When I am out of town or otherwise unavailable, a qualified professional will cover for me by checking my telephone voicemail.
PAYMENT: Payment is due at the end of each session unless other arrangements are made. Please notify me if any problem arises during the course of your therapy regarding your ability to make timely payment. My fee is $150 per 50 minute session. I reserve the right to periodically adjust this fee. I will give you prior notice of fee increases.
In the case of using insurance, you are responsible for making your co-payment at each session unless other arrangements have been made. You are responsible for informing your therapist of any change in your insurance during the course of treatment. If your policy is cancelled and you do not have further coverage, you will be responsible for the full fee of the session.
In addition to my fee for sessions, I charge for other professional services such as report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals, preparation of records or time spent providing any other service requested by patients.
A scheduled appointment means that time is reserved only for you. If an appointment is missed or cancelled with less than 24 hours’ notice, you will be billed according to the scheduled fee or according to the rules of the patient’s health plan.
If your account becomes delinquent (past 30 days) our office may begin collection procedures. We will attempt to contact you directly. However, if your account remains delinquent we may utilize the services of an outside collection agency, we may retain an attorney, or small claims court action may be taken.
If I am required to attend a deposition, hearing or other legal proceeding in the capacity of your current or past therapist, you will be billed at $300 per hour for my time, including preparation and travel time as well as the time I spend at the legal proceeding. If you are a current or past client, my testimony will not include forensic opinions.
I strongly advise that you not involve me in any litigation as it is outside of my role as your therapist and is not in the best interest of your therapy.
EMAIL or TEXT
Other than scheduling appointments, I will not accept, review or respond to emails or texts from you or someone on your behalf. Please limit email or text communication to scheduling only.
TERMINATION OF THERAPY SERVICES
I may terminate therapy services at my discretion. I may consider termination if:
I do not believe that I can provide you with effective treatment
Your needs are outside the scope of my experience or training
You desire to terminate treatment or we mutually agree it is time to terminate treatment
You fail to comply with my treatment recommendations
A conflict of interest develops
You fail to pay my fee on a timely basis
You or I believe it is in your best interest
If either you or I decide to terminate therapy services, I recommend at least one closure session.
Please advise me if you change your address, telephone number, place of employment or insurance coverage of companies.
ACKNOWLEDGMENT AND AGREEMENT FOR INFORMED CONSENT
I have read and fully understand this Consent for Treatment form