Consent Form for Therapy
Urithi MentalWellness
Welcome to the therapeutic practice of URITHI MENTALWELLNESS. This document contains important information about our professional services and business policies. It also contains information about our policies and practices to protect the privacy of your health information.
Please read this document carefully and let me know if you have any questions or concerns. By signing this document, you will be stating that you were provided with this information and it will represent a binding agreement between us.
Psychotherapy Services
Psychotherapy varies depending on the therapist, the client and the client’s particular situation and goals. There are many different methods which may be used to deal with a particular situation, goals, and objectives. For the best outcome, each client must choose to invest energy in the process and work actively on relevant topics both during and between sessions.
Psychotherapy can have benefits and risks. The risks may include experiencing uncomfortable feelings like sadness, guilt, anger, anxiety or frustration when discussing aspects of life. Psychotherapy has been shown to have benefits that can include better relationships, solutions to specific problems, increased life satisfaction, improved physical health, and significant reductions in feelings of distress. However, there are no guarantees as to what each client will experience.
What to Expect
The first few sessions will involve an evaluation of your situation including needs, goals, and objectives to work toward. Psychotherapy can involve a significant investment of time, energy, and money. It is important to select a therapist with whom you are comfortable working. If at any time you have questions about therapy, please discuss them with me as they arise.
Sessions
We schedule 1 hour sessions. If you would like longer sessions, the price will be pro-rated according to the length of appointment we agree upon. If you arrive late for an appointment, the remaining time of our scheduled session is available to you if you have called to state you will be late. If you have not called, we may not be available after 15 minutes from the scheduled start time. At times, it may be appropriate to meet more or less than once per week if that is consistent with the agreed upon treatment plan.
If you need to cancel a scheduled therapy session, you must do so at least 24-hours in advance.
Professional Fees
Fees are listed on the Counseling Fees document. Package rates are available which can be found on our website (www.urithimentalwellness.com). In addition to regular sessions, it is policy to charge the therapy rate on a pro-rated basis for other professional services required. Other services include report writing, telephone conversations lasting longer than 15 minutes, attendance at meetings or consultations with other professionals which have been authorized, preparation of records or treatment summaries, and time spent performing any other professional service.
Billing and Payments
You will be expected to pay the full agreed upon fee before the time of each session. Our official payment method is via Paybill.
Official Paybill Details
Paybill: 522533
Account: 8031109
Payment schedules for other professional services will be agreed upon when/if they are requested.
Therapy Refund Policy
- Therapy session payments are generally non-refundable once payment has been made.
- If a client is unable to attend a scheduled session, the session may be rescheduled for a later date based on availability.
- Paid sessions may also be transferred or donated to another individual if the client chooses not to use them.
- Promotional or discounted therapy sessions are strictly non-refundable.
- Clients are encouraged to communicate cancellations or rescheduling requests in advance to allow proper planning.
By booking and making payment for therapy services, clients acknowledge and agree to this refund policy.
Social Media Policy
We do not interact or accept “friend” requests via social media sites (Facebook, LinkedIn, etc) because it has the potential to compromise privacy and complicate our therapeutic relationship.
Confidentiality
In general, the law protects the privacy of all communication between a client and a mental health provider. We may only release information about your treatment to others if you sign a written authorization form. You may revoke any such authorizations at any time, which must be in writing.
However, in the following situations, your authorization is not required to release your personal information:
- Therapist’s duty to warn another in the case of potential suicide, homicide or threat of imminent, serious harm to another individual.
- Therapist’s duty to report suspicion of abuse or neglect of children or vulnerable adults.
- Therapist’s duty to report prenatal exposure to illegal substances and excesses.
- Therapist’s duty to report the misconduct of mental health or health care professionals.
- Therapist’s duty to provide a spouse or parent of a deceased client access to their child or spouse’s records.
- Therapist’s duty to provide parents of minor children access to their child’s records.
- Therapist’s duty to release records if subpoenaed by the courts.
- Therapist’s obligations to contracts (e.g. to employer of client, to an insurance carrier or health plan).
Other Client Rights
- I have the right to request and receive confidential communication of my protected health information by alternate means or at alternative locations.
- I have the right to request that the therapist change information in my record. I understand I am required to make such requests in writing along with reasons for the requested changes.
- I understand I generally have the right to receive an accounting of any disclosures the therapist has made of protected health information, which did not require client authorization.
- I understand my therapist may use or disclose my health information for treatment purposes including presentation of my case in consultation with other professionals or consultants who are bound by the legal framework of privacy and confidentiality.
Safety
We strive to provide a safe environment for all. Please let me know immediately if you have concerns for your safety while at our office. You agree that if you engage in verbal, written or physical behavior that is threatening to a therapist or a therapist’s family, or any other person, any therapist may identify you to the police, explain that you are a client, and report the threatening behavior using your personally identifying information.
Acknowledgment & Consent
I understand the basic goals, ideas, and methods of this therapy. I have no important questions or concerns that the therapist has not discussed with me. I understand that reaching the agreed upon therapy goal is not guaranteed. I understand that therapy is successful for some people, moderately successful for others, and for some not successful at all.
By using our booking services and checking the agreement box, you are indicating that you have read the information in this document and agree to abide by its terms during the course of therapy.