Informed Consent

AGREEMENT FOR PSYCHOTHERAPY SERVICES
Conducted By Counseling Relationships Online Therapists
John E. Turner, LCSW, LMFT or Sally Connolly, LCSW, LMFT

THE PROCESS OF THERAPY/EVALUATION

Benefits:
Participation in therapy can result in a number of benefits to you, including better relationships, solutions to specific problems and significant reduction in feelings of distress; but there are no guarantees for what you will experience.

Working toward these benefits requires effort on your part. We will ask you to work in and between sessions in order to change your thoughts, feelings and/or behavior. We will ask for your feedback and views on your therapy, its progress and other aspects of the therapy and we will expect you to respond openly and honestly.

Possible Side Effects:
Occasionally remembering or talking about unpleasant events, feelings or thoughts can result in your experiencing discomfort or strong feelings of anger, sadness, worry, fear, etc. or experiencing anxiety, depression, insomnia, etc.

Attempting to resolve issues that brought you into therapy in the first place, such as personal or interpersonal relationships may result in changes that were not originally intended. At times a decision that is positive for you may be viewed quite negatively by others in your family.

Change will sometimes happen quickly, but more often it will take time and patience on your part. During the course of therapy, we will utilize various therapeutic approaches according, in part, to the problem that is being treated and by our assessment of what will best benefit you. These approaches include but are not limited to behavioral, cognitive-behavioral, solution-focused, system/family, developmental (adult, child, family) or psycho-educational.

DISCUSSION OF TREATMENT PLAN

During the first session and throughout this process, we will discuss with you your understanding of the problem, treatment plan, therapeutic objectives and your view of the possible outcomes of treatment. If you have unanswered questions about any of the procedures used in the course of your therapy, their possible risks, our expertise in employing them or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits. If you could benefit from any treatment that we do not provide, we have an ethical obligation to assist you in obtaining those treatments.

Minors
We will not treat minors with our written permission from their parents.

DUAL RELATIONSHIPS

Not all dual relationships are unethical or avoidable. However, sexual involvement between therapist and client is never part of the therapy process, nor are any other actions or dual relationship situations that might impair the therapist’s objectivity, clinical judgment, or therapeutic effectiveness or that could be exploitative in nature. In addition, we will never acknowledge working therapeutically with anyone without his/her written permission. In some instances, even with permission, we will preserve the integrity of our working relationship. For this reason we will not accept any invitations via social networking sites nor will we respond to blogs written by clients or accept comments on our blog from clients. 

TERMINATION

During the initial intake process and the first couple of sessions, we will assess if we can be of benefit to you. If you have requested online counseling, our assessment will include your suitability to psychotherapy delivered via technology. We do not accept clients who, in our opinion, we cannot help. In such a case, we will give you a number of referrals that you may contact.

If at any point during psychotherapy, we assess that we are not effective in helping you reach your therapeutic goals, we are obligated to discuss this with you, up to and including termination of treatment. In such a case, we would give you a number of referrals that may be of help to you. You have the right to terminate therapy at any time. If you choose to do so, we will offer to provide you with names of other qualified professionals whose services you might prefer.

PRIVACY & CONFIDENTIALITY

All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law. Likewise, you are expected to keep our communications confidential and you understand that all records of communication between client and therapist remain the property of John E. Turner, LCSW, LMFT and/or Sally Connolly, LCSW, LMFT. Most of the provisions explaining when the law requires disclosure were described to you in the Notice of Privacy Practices that you received with this form.

When Disclosure Is Required By Law: Some of the circumstances in which disclosure is required by the law include 1) when there is a reasonable suspicion of child, dependent or elder abuse or neglect; 2) when a client presents a danger to self, to others, to property or is gravely disabled (for more details see also Notice of Privacy Practices form).

When Disclosure May be Required: Disclosure may be required pursuant to a legal proceeding. If you are involved in a custody dispute or if you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by one of us. In couples and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. we will use our clinical judgment when revealing such information. We will not release records to any outside party unless we are authorized to do so by all adult family members who were part of the treatment or unless compelled to do so by law or a valid court order.

Harm to Self or Others: If there is an emergency during our work together or in the future after termination we become concerned about your personal safety, the possibility of you injuring someone else or about you receiving proper psychiatric care, we will do whatever we can within the limits of the law to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, we may also contact law enforcement, hospital or an emergency contact whose name you have provided.

Treatment Records:
The laws and standards of our profession require that we do keep treatment records of the professional services that we provide. You are entitled to receive a copy of the records unless I believe that seeing them would be emotionally damaging, in which case, I will be happy to send them to a mental health professional of your choice.

Because these are professional records, they can be misinterpreted and/or upsetting to the untrained readers. I recommend that you review them with me so that we can discuss the contents. (I am sometimes willing to conduct a review meeting without charge. Patients will be charged an appropriate fee for any time spend n preparing information requests.

Confidentiality of E-mail and Chat, Cell Phone and Fax Communication: Therapeutic email and chat exchanges are delivered via HushMail. You agree to work with us online using HushMail or another encrypted email/chat service determined to be suitable by this therapist. If you choose to email me from your personal email account, please limit the contents to housekeeping issues such as cancellation or change in contact information. we will not respond to personal and clinical concerns via regular email. If you call us, please be aware that unless we are both on land line phones, the conversation may not be confidential. Likewise, text messages may not be confidential. If you send a fax to us, my fax line is in a secure location. Any computer files referencing our communication are maintained using secure and encrypted measures. If you wish to use email as a way to “journal” information between sessions, you understand that we may not have the opportunity to review your journal emails until our next scheduled session. You understand that emails between sessions that contain confidential information will be sent utilizing encryption.

We make every effort to keep all information confidential. Likewise, if we are working online together, we ask that you determine who has access to your computer and electronic information from your location. This would include family members, co-workers, supervisors and friends. We encourage you to only communicate through a computer that you know is
safe, i.e. wherein confidentiality can be ensured. Be sure to fully exit all online counseling sessions and emails. If we are unable to connect or are disconnected during a session due to a technological breakdown, please try to reconnect within 10 minutes. If reconnection is not possible, email to schedule a new session time.

Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) nor your attorney, nor anyone else acting on your behalf will call on John Turner or Sally Connolly to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.

Consultation: I consult regularly with other professionals regarding our clients; however, the client’s name or other identifying information is never disclosed. The client’s identity remains completely anonymous and confidentiality is fully maintained.

Considering all of the above exclusions, if it is still appropriate, upon your request, we will release information to any agency/person you specify unless I conclude that releasing such information might be harmful in any way.

TELEPHONE & EMERGENCY PROCEDURES

If you need to speak with me between sessions to alert me of an emergency, please call John Turner at 502-451-4628 or Sally Connolly at 502-473-0766. Your call will be returned as soon as possible. Messages are checked daily (but never during the night time). Messages are checked less frequently on weekends and holidays. If an emergency situation arises that requires immediate attention, you may call the emergency National Suicide Hotline at 800-784-2433 or dial 911. If a life-threatening crisis should occur, you agree to contact a crisis hotline, call 911 or go to a hospital emergency room.

PAYMENTS

Session payments via credit or debit card can be processed through Visa, Discover or MasterCard. Sessions are generally purchased in 30 and 60 minute increments. Therapeutic email exchanges can be purchased one at a time or as a package.

FEES

Current rates for therapeutic services are posted on my website.

MEDIATION & ARBITRATION

All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of Sally Connolly, LCSW, LMFT or John E. Turner, LCSW, LMFT and the client. The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in accordance with the rules of the American Arbitration Association that are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, I can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitrator will determine that sum.

CANCELLATION

Since scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours notice is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification.

You as the client understand that phone and email sessions have limitations compared to in-person sessions, among those being the lack of “personal” face-to-face interactions, the lack of visual and audio cues in the therapy process, and the fact that most insurance companies will not cover this type of therapy. You understand that telephone/online psychotherapy with us is not a substitute for medication under the care of a psychiatrist or doctor. You understand that online and telephone therapy is not appropriate if you are experiencing a crisis or having suicidal or homicidal thoughts. As stated previously, if a life-threatening crisis should occur, you agree to contact a crisis hotline, call 911, or go to a hospital emergency room. You also understand that we follow the laws and professional regulations of the State of Kentucky (USA) and the psychotherapy treatment will be considered to take place in the state of Kentucky (USA).

Your signature below indicates that you have reviewed the information available on my website and have read and understand this Informed Consent and the HIPAA Notice of Privacy Practices.


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Signature                                                                Date


We will discuss this Informed Consent during our first session. If our sessions are scheduled online please fax or mail this form with your signature. Fax number will be provided over the phone or by email. MAIL: 2054 Douglass Boulevard, Louisville, KY 40205.

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