RISKS AND BENEFITS OF PSYCHOTHERAPY

Most individuals receiving psychotherapy are experiencing psychological problems that are causing internal (emotional) distress, behavioral problems, and/or problems in their relationships. The goal of psychotherapy is reduction of such problems and an improvement in your wellbeing. Failure to obtain needed psychotherapy often results in an exacerbation of such problems. However, it is not uncommon that the individual engaged in therapy will feel, and possibly behave, worse before feeling better. Moreover, the possible exacerbation of problems/symptoms is usually temporary and it is considered as a part of the healing process.

These symptoms/problems might include increase in anxiety, depression, sadness, sleep disturbances, eliminatory disorders, intrusive thoughts, flashbacks, self-destructive or angry impulses/behaviors, behavioral problems, social problems, academic problems, and problems in family relationships among others. Hospital care or residential treatment may be required in some cases and it will be fully discussed with client and caregiver, as well as the referral to a psychiatrist for psychotropic medication evaluation.

 In most cases, therapy eventually improves your sense of well-being, self-esteem, behaviors and relationships. However, in some cases, you might obtain little or no benefit from therapy. It is not possible to predict the outcome of treatment for an individual.

CONTACTING MY OFFICE

You may leave messages (voice or text) for me at any time at my office number:  619-797-6595. This is a Google Voice line that only I have access to but is subject to the interception of third parties. I will return your message as soon as possible within 24 hours of your call. I check my messages at the end of my working day during the weekdays and I return calls up until 6 p.m. Messages left after 6 p.m. Monday through Thursday are returned the following day, and those left after 4 p.m. on Friday are returned the following weekday.  It is important that you leave your phone number when you call as I may not have your number available at the time I respond to your message. It is also important that the phone message you leave is a discreet one in order to maintain your own confidentiality. If your message is urgent, please specify it.

 RISKS OF OPTING FOR IN-PERSON SERVICES - COVID 19 

You understand that by coming to the office, you are assuming the risk of exposure to the coronavirus (or other public health risk). To obtain services in person, you agree to take certain precautions which will help keep everyone (you, me, our families and other clients) safe from exposure and sickness.

My practice has taken steps to reduce the risk of spreading the coronavirus within the office and follows all current CDC protocols.

You understand that I am committed to keeping you, me, and all of our families safe from the spread of coronavirus. If you show up for an appointment and I believe that you have a fever or other symptoms, or believe you have been exposed, I will have to require you to leave the office immediately. We can follow up with services by telehealth as appropriate.

If I test positive for the coronavirus, I will notify you so that you can take appropriate precautions. 

LENGTH AND FREQUENCY OF OUR SESSIONS

The therapy schedule (the length and frequency of your sessions) will depend upon many factors, including your level of distress, individual preference, time limitations, and financial concerns. We will determine an initial plan and make adjustments as we go along, modifying the schedule as needed. I offer 55 minute sessions on a twice-a-week, once-a-week and every-other-week basis. I will discuss with you my treatment’s frequency recommendation. If you are late, we will end the session on time. If I am late, you will still receive 55 minutes of my time for the session. This may be provided during that same session period, or added to another session at a later date.

EMERGENCY PROCEDURES

If you are experiencing an emergency please call 911 or go to the nearest emergency room hospital. If you experience a crisis call or text 988 or the San Diego Crisis line at 1.888.724.7240 at any time.

Please note that my office is not an emergency facility and my contact number is not designated to be used in the case of an emergency.

TREATMENT MODALITIES

The following are some treatment modalities I may integrate into our sessions in order to alleviate psychological problems and achieve your therapy goals:

Insight-oriented Therapy, Play Therapy, Sandplay Therapy, Therapeutic Art, SoulCollage®, Conflict Resolution & Communication Skills, Cognitive Behavioral Therapy, Anger Management, Trauma Processing,Relationship Skills, Writing Therapies (journal-writing, poetry, etc.), Bibliotherapy, Incorporation of Client’s Spiritual Base, Psychodrama and Role-play, Therapeutic Homework, Assertiveness, Grief Work, Relaxation Exercises, EMDR, Parenting Coaching.

FEE

I offer a discounted rate of $160 for 55 minute sessions if you pay by cash, Zelle or Venmo. $170 if you pay by credit card, debit card or HSA card.

You are expected to pay the agreed fee on the day of your session, unless other payment arrangements have been made between us. 

INSURANCE

If you are utilizing insurance to pay for your treatment, you are responsible for any applicable deductibles, co-shares and co-payments at the time of service. By signing this contract, you agree that if you have obtained all necessary authorizations from your insurance. If you are using your health insurance: co-payments and co-insurances are also due on the day of your session. Many plans have high deductible rates, meaning the insurance will only cover the cost of the session once the deductible has been met, until then you will pay me my negotiated rate with the insurance company (typically between $120-$180 depending on the insurance) until you reach your deductible allowance. 

You should also be aware that insurance companies require you to authorize me to provide them with a clinical diagnosis.  Sometimes I have to provide additional clinical information such as treatment plans or summaries.  This information will become part of the insurance company files and will probably be stored in a computer.   I will provide your insurance company with only the information required in order to meet their administrative needs.  If you don’t want a diagnosis sent to the insurance company, you can chose to pay for sessions out of pocket. 

By signing this consent form, you agree that if your insurance payment is denied for any reason you are responsible for the payment of therapist’s full fee, even if the insurance determination is made after the services are rendered. If payments are not made, I reserve the right to utilize a collections agency for the means of collecting the payment. In the event of a returned check for insufficient funds, you will be charged $20 in addition to the amount of the check to cover banking fees. Please do not hesitate to notify me if any problem arises during the course of therapy regarding your ability to make timely payments. It is essential that financial difficulties not prevent you from obtaining the help you need. Although I provide a portion of my work at a reduced fee, these arrangements are in high demand. If I am unable to accommodate your financial limitations, I will assist you in finding alternatives for the continuity of your mental health treatment.

CANCELLATION POLICY 

When client and therapist decide to work together they both commit to that appointment time. That means that I will reserve that portion of my limited working hours exclusively for you. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation (unless we both agree that you were unable to attend due to circumstances beyond your control). It is important to note that insurance companies do not provide reimbursement for cancelled sessions.  If it is possible, I will try to find another time to reschedule the appointment. If we can’t reschedule for the same week, the full session fee will be charged. 

PHONE CALLS TO CLIENT OR COLLATERAL CONTACTS

If you have a quick question you can call me and I will be available to speak for a maximum of 10 minutes. Calls over 10 minutes will be charged $10 per every 5 additional minutes. If more time is needed to discuss the issues presented, an additional session might need to be scheduled. The fee for this meeting will be the same as your psychotherapy fee.

TELEHEALTH

Online teletherapy includes consultation, treatment, transfer of medical data, emails, telephone conversations and education using interactive audio, video, or data communications. Teletherapy also involves the communication of medical/mental information, both orally and visually.

The laws that protect the confidentiality of your medical information also apply to teletherapy. Information disclosed during the course of teletherapy is generally confidential, however, there are limits and exceptions to confidentiality just as there are with in person sessions.

Potential risks and limitations of telehealth may include: technical failures; interruption by unauthorized persons; unauthorized access to transmitted and/or stored confidential information; and decreased availability of the therapist in the event of a crisis.

I am currently using a HIPAA compliant platform that requires Google Chrome or Safari browsers. Client will provide the necessary computer, telecommunications equipment and internet access for teletherapy sessions and will arrange a location with sufficient lighting and privacy that is free from distractions or intrusions.

Teletherapy based services and care may not be as complete as face-to-face services. Teletherapy does not provide emergency services. If you are experiencing an emergency situation, please call 911; or proceed to the nearest hospital emergency room for help or call the San Diego Access and Crisis Line at 1.888.724.7240 for free 24 hour hotline support. 

TREATMENT SUMMARIES

The writing of simple treatment summaries for individual or conjoint treatment will include solely the information regarding number of session attended, frequency of sessions, current treatment goals and treatment progress. The fee is: $100 paid in advance.

LITIGATION LIMITATION

Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to the many matters which may be confidential, it is agreed that should there be legal proceedings (for example, divorce custody disputes, lawsuits, injuries, divorce, etc.), neither yourself, nor your attorney, nor anyone else acting on your behalf will call me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.

FEES FOR DEPOSITIONS, COURT APPEARANCES OR OTHER TESTIMONY: 

In the case of depositions, court appearances or testimony by the therapist in proceedings, whether requested by you or others, will accrue the following fees:  

1.  $800 (eight hundred dollars), for up to four hours of the therapist’s time in preparing for the deposition, court appearances or testimony, which fee shall be paid at least two weeks in advance of the appearance date.
2.  $800 (eight hundred dollars), for up to four hours of the therapist’s time in attending or testifying in person at a Deposition or court appearance, which fee shall be paid at least two weeks in advance of the appearance datE.
3. $200 (two hundred dollars) for up to one hour of the therapist’s time in being available on call or testifying by telephone, which fee shall be paid at least two weeks in advance of the appearance date.
4. Time expended by the therapist in excess of the above, shall accrue fees of $200 (two hundred dollars) per hour or fraction of it.
5. All fees shall be earned regardless of whether the therapist is actually called to testify or whether the Deposition or Court proceeding is cancelled or rescheduled.

PREPARATION OF WRITTEN DOCUMENTS IN ANY LEGAL PROCEEDINGS

Any written reports or other documents that I as the therapist am required to prepare in connection with proceedings regarding yourself, whether requested by you or others, will accrue the following fees:

1. $350 (three hundred and fifty dollars) for up to two hours of the therapist’s time in preparing the report, which shall be paid in advance.
2. Time expended by the therapist in excess of the above, shall accrue fees of $160 (one hundred and sixty dollars) per hour or fraction of it.
3.  All fees shall be earned regardless of whether the request for the report is later cancelled or whether the report is used.

ELETRONIC COMMUNICATION

The U.S. Department of Health and Human Services (HHS) Office for Civil Rights announces a final rule that implements a number of provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009, to strengthen the privacy and security protections for health information established under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

HIPAA Omnibus Rulemaking: (page 5634) —  We clarify that covered entities are permitted to send individuals unencrypted emails if they have advised the individual of the risk, and the individual still prefers the unencrypted email… If individuals are notified of the risks and still prefer unencrypted email, the individual has the right to receive protected health information in that way, and covered entities are not responsible for unauthorized access of protected health information while in transmission to the individual based on the individual’s request. Further, covered entities are not responsible for safeguarding information once delivered to the individual.

I inform that in my private practice I use an email system, Gmail, which is considered by HIPAA regulations as not secure.  Often my clients, or their legal representatives and I also communicate by text messaging - which is also considered by HIPAA as a not secure means of communication. I inform you that by using these means of communication, despite my email accounts and office cell phone being confidential and password protected, there may be some risk that the information shared by email or text message could be read by a third party. If you wish to communicate with me by electronic means, please be advised of the risks involved. By signing this document, you accept the risks explained and give Shirla de Magalhães, permission to communicate with you by email and text messages. Please indicate in written if you wish to not utilize electronic means of communication.

TREATMENT CONSISTENCY

Therapy is a process that requires time, effort and consistency. The treatment’s frequency and client’s attendance to sessions directly impacts treatment goals and treatment outcomes. 

TERMINATION OF TREATMENT

You and I will continually communicate and evaluate treatment progress and goals through the course of our work together. It is important that you understand that the termination of treatment should be planned and that you need time to transition to this last phase of treatment. You should have the opportunity to finish current issues we might be working on and to have the proper time to process the end of the therapeutic relationship established with the professional therapist. Given that it is essential that you communicate with me the intention of terminating your treatment as soon as it arises. Together we will plan for a positive and healthy end of treatment.

PROFESSIONAL RECORDS AND CONFIDENTIALITY

The laws of California and the standards of my profession require that I keep treatment records.  The information in your medical record may include your personal history, reasons you are seeking treatment, problems, complaints, symptoms or needs, diagnoses and treatment plan. Progress Notes – after each session I write down how you are doing, observations and things you tell me as well as records provided to me from others who have treated or evaluated you such as psychological evaluations and any other information provided to me including information about medications taken, legal matters and billing and insurance information. Process Notes includes pictures of sandtrays, art or play that I have taken during or after session, as well as notes to myself to test hypothesis, help me recall content, etc. Process notes can rarely be accessed by other parties, it requires my permission, which I would only give if I felt it wouldn’t be detrimental to the therapeutic relationship and confidentiality of the client. A separate signed authorization from you would also be required.

When you understand what is in your record and what it is used for, you can make better decisions about who, when and why others should have this information.

I use the information given to me to plan your treatment and keep a record of the significant issues that we address in treatment. I also use the information to coordinate your treatment with other professionals or to provide information to significant others or family members; information is only provided to those that you have given me permission in writing to communicate with regarding your treatment.  You have the right to limit which kind of information I share with others. I will keep our agreement except if it is against the law, or an emergency.

I will maintain treatment records for ten years following termination of treatment.  After ten years treatment records will be destroyed in a manner that preserves confidentiality.

EXCEPTIONS TO CONFIDENTIALITY

I am legally required to disclose confidential information in certain situations listed below. While it is my legal responsibility to report these incidents, I will support you through this challenging time.

Legal exceptions to confidentiality include the following: 

1. When there is risk of imminent danger to you or your child or another person, I am required to take the necessary steps to prevent such danger. e.g.; imminent risk of suicide or violence to others, destruction of property that could endanger others, and grave disability e.g.: inability to provide for one’s own food, shelter, and clothing, or to obtain this help from others.In case of a serious threat of violence, I must also attempt to warn intended victims.
2. When there is reasonable suspicion that a child, elder (65+) or disabled adult has been neglected, sexually or physically abused or is at risk of abuse, I am mandated to report to Child Protection, and/or law enforcement based on information provided by the client or collateral sources. This also includes child behavior suggesting exposure to inappropriate sexual material or activity and exposure to addictive drugs at birth.
3. Sexual intercourse involving a minor is reported to authorities when a minor is under 14 and another party is 14 or older, or if a minor is under 16 and another party is over 21.
4. Emotional abuse and exposure of children to domestic violence may also be reported.
5. Past physical abuse or sexual abuse of the child must be reported.
6. I am also obligated under the law to report to the appropriate authorities any instance where a client discloses that she/he has accessed, streamed, or downloaded material where a child is engaged in an obscene sexual act.  I must also report electronic images of children that depict obscene sexual conduct.   

Psychotherapists often consult with other professionals on cases, and teach or write about the therapy process, but disguise identifying information when doing so, to protect client’s confidentiality. Please indicate in writting if you wish to make restrictions on consultation, teaching or writing related to your case.

ART & SANDTRAY PICTURES FOR EDUCATIONAL & TRAINING PURPOSES 

By signing this consent form you authorize me to use your artwork and sandtray photos for educational or professional consultation purposes. Your name and personal information will remain confidential. If you do not want your artwork or sandtray pictures to be used for consultation or training purposes, please let me know in writing. 

OTHER EXCEPTIONS TO CONFIDENTIALITY

Some exceptions to confidentiality include billing account management, managed care, worker’s compensation claims, and disclosure to insurance and collection agencies. If you plan to bill health insurance to reimburse you for your therapy, please be aware that many companies require private information about you, such as diagnosis, symptoms, treatment and response to treatment. This carries a certain amount of risk to privacy and to future capacity to obtain health or life insurance.

Another exception to confidentiality is if the client is involved in a litigation process. These situations are rare in my practice, but I want you to be aware that if your records are ever requested by the court, you will be notified, and I will claim privilege on your (client’s) behalf. However, if a valid Court order is issued for release of health records I am bound by law to comply with such request.  In this case, only the essential information will be disclosed. It is important for you to know that if you place your mental status issue in a litigation process initiated by you, the defendant may have the right to obtain your therapy records as well, and/or my testimony.

Emergency situations may also be an exception to confidentiality. If there is an emergency with you or your child during our work together where I become concerned about your personal safety, I may contact the person whose name you have provided as the Emergency Contact on my caregiver’s information form.

If a situation occurs that requires that I share information without your written permission, I will make every effort to fully discuss it with you before taking any action.  In most situations, in order to release any information to another party, I will ask that you sign an Authorization to Release Information. You may revoke your authorization at any time.

No Secrets Policy: In Family Therapy, or when different family members are seen individually by the same therapist, confidentiality and privilege do not apply between the parties.

In the event of my incapacitation, disability or death, I have authorized my colleague, Isabelle George, LMFT to have access to my client files and my appointment book.  As a licensed marriage and family therapist, she is bound by confidentiality as well. Ms. George can be reached at 619-784-3884

OUR PROFESSIONAL RELATIONSHIP AND SOCIAL MEDIA

Our relationship is professional and therapeutic. In order to preserve this relationship, it is imperative that we not have any other type of relationship. If I encounter you in a public setting, in order not to reveal your identity, I will not acknowledge your presence unless addressed by you first.

I do not accept friend or contact requests from current or former clients on any social media site. Adding clients as friends or contacts on these sites can compromise confidentiality and privacy of both the therapist and the client and can blur the boundaries of the professional relationship.

BUSINESS REVIEW SITES

You may find my therapy practice on sites such as Yelp, Healthgrades, Yahoo Local, Bing, Google or other places which list businesses.  Some of these sites include forums in which users rate their providers and add reviews.  Many of these sites comb search engines for business listings and automatically add listings regardless of whether the business has added itself to the site.  If you should find my listing on any of these sites, please know that my listing is not created by me and is NOT a request for a testimonial, rating, or endorsement from you as my client.

Of course, you have a right to express yourself on any site you wish, but due to confidentiality, I cannot respond to any review on any of these sites whether it is positive or negative.  I urge you to take your own privacy as seriously as I take my commitment of confidentiality to you.  You should also be aware that if you are using these sites to communicate indirectly with me about your feelings about our work, there is a good possibility that I may never see it so I encourage you to always talk to me personally about anything that might not be working well for you

PROFESSIONAL RECORDS

You are entitled to receive a copy of your medical record unless I believe that receiving that information would be emotionally damaging.  Because these are professional records, they can be misinterpreted or upsetting to untrained readers.  If you wish to see your records or receive a copy of your records, I require written notice to that effect, and I would expect to discuss your request with you in person.  I typically provide a treatment summary when there is a request for records.  If I deny you access to your records, you can request to speak with an independent mental health professional about the situation.  Your request for independent review of your original request for records should also be made in writing.  If you are provided with a copy of your medical record information, I may charge a fee for any costs associated with that request.

If you believe that the information I have about you is incorrect or incomplete, you may ask me to amend that information.  It is my practice to accept this sort of request in writing, and that any information you may wish to add to your record also be provided to me in written form.  

You have the right to request a restriction or limitation on the health information I disclose about you for treatment, payment, or health care operations. As noted above, I will not release your confidential information without your written permission. Any restrictions to your Authorization To Release Information should be specified on the Authorization. 

You have the right to request that I communicate with you only in certain ways.  For example, you can ask that I not leave a telephone message for you, or that I only contact you at work or by mail.

You have the right to a paper copy of this document. I reserve the right to change my policies as outlined in this document-if they change you will be informed of that change and will be provided with a copy of the updated form.

MEDIATION & ARBITRATION

By signing this office policy contract, you are agreeing that all disputes arising 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 our mutual agreement, and the costs of such mediation 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 San Diego County, California in accordance with the rules of the American Arbitration Association which is in effect at the time the demand for arbitration is filed. Lawsuits are something that no one anticipates and everyone hopes to avoid.

The method of resolving disputes by arbitration is one of the fairest systems for both parties and psychotherapists. Arbitration agreements between health care providers and their patients have long been recognized and approved by the California Courts. You may still call witnesses and present evidence. Each party selects one arbitrator, who then select a third, neutral arbitrator. These three arbitrators hear the case. This agreement typically helps to limit the legal costs for both parties and psychotherapists. Further, both parties are spared some of the rigors of trial and the publicity that may accompany judicial proceedings. My goal, of course, is to provide psychotherapy care in such a way as to avoid any such dispute. I know most problems begin with communication. Therefore, if you have any questions about your care, please ask.

QUESTIONS OR COMPLAINTS

The Board of Behavioral Sciences receives and responds to complaints
regarding services provided within the scope of practice of (marriage and family therapists, licensed educational psychologists, clinical social workers, or
professional clinical counselors). You may contact the board online at
www.bbs.ca.gov, or by calling (916) 574-7830.

Please feel free to ask me any questions you have before signing below. Your signature indicates that you have fully read and understood the information listed on the Informed Consent, Office Policy and Legal Engagement for Shirla de Magalhães, LMFT, you agree to abide by its terms during our professional relationship and thereafter, and that you authorize Ms. Magalhães to provide assessment, evaluation and treatment for yourself.

Acknowledgement

I have reviewed this Informed Consent, Office Policy and Legal Engagement. I likewise understand my Client's Rights set in this form.

I accept this agreement and consent to therapeutic services.