The purpose of this document is to inform you, the client, an adult, 18 years or older whom resides in the state of Ohio about aspects of technology assisted counseling services via Online or Phone. Please read this entire document, sign, and submit.
RIGHTS WITH RESPECT TO ONLINE/PHONE THERAPY
The laws that protect the confidentiality of my personal information also apply to online/phone therapy. As such, I understand that the information disclosed by me during the course of my sessions is generally confidential. You may decline any service at any time without jeopardizing your access to future care.
Confidentiality is a fundamental principle of psychotherapy. Anything you discuss with the therapist and the information contained in your file will remain completely confidential with the exception of the following circumstances: if you present a serious danger to yourself or another person, if you report physical or sexual abuse of a minor, or exploitation of an incapacitated adult, if a valid subpoena is received for your records, or your records are otherwise subject to a court order or other legal process requiring disclosure.
RISKS AND BENEFITS
Psychotherapy 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 psychotherapy often requires discussing unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals 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 of any positive outcome. Psychotherapy requires active effort on your part. In order to be most successful, you will have to work outside of sessions on matters discussed with your therapist.
Technology assisted counseling may not be appropriate for many types of clients including those who have numerous concerns over the risks of internet counseling, clients with active suicidal or homicidal thoughts, and clients who are experiencing active manic/psychotic symptoms. An alternative to receiving services online or by phone would be to receive services in person. You will be given a referral that would be more practical or beneficial for you.
I accept that technology assisted counseling does not provide emergency services. I understand that I can call 911 or proceed to the nearest hospital emergency room for help. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) for free 24-hour hotline support.
PRIVACY OF THE THERAPIST
The therapist has a right to privacy and restricts the use of any phone or video copies or recordings by the client.
Fees for online/phone therapy is the same. Online therapy or telephone sessions are paid in advance and payments are made via Square Registrar. I understand that I must pay for each service prior to receiving the services.
You must give 24 hours notice in order to cancel your therapy/phone session or you will be charged the full fee. I understand that I am responsible for all charges incurred, for no shows, missed appointments or failure to give 24 hour cancellation notice. You will not be expected to pay for the session if you have major problems with your connection.
NO SECRETS POLICY & LIMITATIONS ON CONFIDENTIALITY OF COUPLES COUNSELING
This form is intended to notify couples about the limitations of confidentiality during the treatment process. During couples counseling, the Center views the couple as the ‘client’ unit. Because more than one person is involved with couples counseling, confidentiality of private information often becomes complicated. Unless required by law counseling-related information will not be released to third parties (i.e., outside the Center) unless written informed consent is received by the couple. At times an individual member of the couple may request that information from couples counseling be released to a third party. A written consent form must be signed by both members of the couple in order for the information to be released. If records are subpoenaed, I will assert the therapist‐client privilege on behalf of the client (the treatment unit).
However, at some points during treatment members of the couple may be counseled individually while couples counseling is continuing. These individual counseling sessions are viewed as part of or adjunct to the couples counseling. Therefore, information learned in these individual sessions may potentially be shared with the other member of the couple as part of the unit’s treatment. I will exercise clinical judgment regarding the need to bring information gained in individual sessions into couple sessions.
When possible, I will first give individuals the opportunity to make disclosures during couples counseling themselves. If a client believes that it is important to talk about information which absolutely must not be disclosed to the other member of the couple that client is encouraged to discuss the information with another therapist not serving the couple.
This “no secrets policy” is intended to allow me to continue to treat the client (the couple) by preventing, to the extent possible, a conflict of interest to arise where an individual’s interests may not be consistent with the interests of the unit being treated. For instance, information learned in the course of an individual session may be relevant or even essential to the proper treatment of the couple during their therapy.
If I am not free to exercise clinical judgment regarding the need to bring this information to the couple during their therapy, I might be placed in a situation to have to terminate treatment of the couple. The policy is intended to prevent the need for such termination.
“We have read and we understand that the statements above are an explanation of confidentiality during couples counseling. Our signature indicates that we give free and full informed consent for the clinician to discuss client concerns/issues in either couple or individual sessions.”
CONSENT TO PSYCHOTHERAPY
I have read and understand the information provided above regarding online/phone therapy, have discussed it with my therapist, and all of my questions have been answered to my satisfaction. I have read this document carefully and understand the risks and benefits related to the use of online/phone therapy services and have had my questions regarding the procedure explained. I hereby give my informed consent to participate in the use of online/phone therapy services for treatment under the terms described herein.
I have read a copy of the Notice of HIPPA Privacy Practices, Client Rights, and Payment Polices & Fee Agreement PART 1 - documents.
By my signing & submitting this document, you indicate that you have read, understood, and agree to the terms of this document.