DEDUCTIBLES AND COPAYS: Please call the number on the back of your  insurance card to be certain therapy services are covered. If you have a deductible, you have to pay all your medical costs until your deductible is reached. After that, you then only pay the copay. Psychotherapy covered by Blue Cross/Wellmark is $195 for the intake appointment (the first appointment), $164 for appointments after that. If you can’t afford the cost of therapy, please talk to us about a payment plan. Services provided outside of scheduled appointments such as completing forms for you, treatment summaries, telephone therapy, etc. is prorated at $40 per 15-minute increment. Sessions need to be paid before you can reschedule. We keep a credit/debit card on file for billing.

HOW DOES THERAPY WORK? In the first 2 to 3 sessions, we  will meet with your child to identify the main problems, set goals for change, and develop a treatment plan. Therapy typically lasts around 20 sessions (typically once a week at first but sometimes goes longer) and always works toward goals. Therapy is a medical intervention and more than just a place to vent about problems. We only want your child to come to therapy when it is helpful. If your child is not benefiting from therapy, we can discuss what to do and come up with a plan, e.g., try a different treatment strategy, end therapy, refer you to another provider, seek medication, or other options.

 

MISSED OR CANCELED APPOINTMENTS: Please notify us as soon as possible if you need to cancel or reschedule your appointment. Unless you give me 48-hour notice, and without exception, missed or canceled appointments will incur a $50 fee for the first appointment and the full fee for any appointments after that. Sessions will not be rescheduled until all balances are paid.

 

HOW CAN WE DO THERAPY? If you are paying out-of-pocket for therapy (not using insurance), we can do therapy by telephone, by video, or in-person. If you are using insurance, you can do therapy by video or in-person. Insurance often does not reimburse telephone therapy appointments. You will be responsible for any out-of-pocket expenses not covered by insurance for Teletherapy.

 

TELETHERAPY: If engaging in Teletherapy, the laws that protect the confidentiality of your medical information also apply to Teletherapy. Please be aware there are risks affiliated with Teletherapy. Some (but not all) include the possibility that, despite responsible efforts, the transmission of your medical information could be disrupted or distorted by technical failures and the storage of your medical information could be accessed by unauthorized persons.

 

EMERGENCIES: We will try our  best to help your child during a crisis but we do not provide emergency services. The services you are receiving are outpatient therapy and not emergency services. If your child has a crisis that requires immediate attention or thoughts of suicide, please reach out for help using one of the following: dial 911, go to your local hospital ER, or dial the suicide hotline at 1-800-273-8255.

 

Parental/Custodial Rights
To authorize mental health treatment for a minor, you must have either sole or joint legal custody/guardianship of the minor. If you are separated or divorced from the other parent, please notify us immediately. Evergreen Therapy Center asks that you provide a copy of the most recent custody decree that establishes custody rights for you and the other parent or otherwise demonstrates that you have the right to authorize treatment for your child.

 

If you are separated or divorced from the child’s other parent, and your child is under 14 years old, please be aware that it is our policy to notify the other parent that we are meeting with your child. We  believe that all parents have the right to know, unless there are truly exceptional circumstances, that their child is receiving mental health evaluation or treatment.

 

By signing this agreement, you agree that you are the legal guardian of the child you are bringing to therapy and you have the legal right to enroll this child in psychotherapy services. You agree that you have permission from any other custodial parent (if he/she is not signing this form) to enroll your child into psychotherapy (if under the age of 14).

 

Confidentiality for Adolescents (Age 11 and Older)
Before beginning treatment, you need to understand our approach to working with your child and agree to some rules about your child’s confidentiality during the course of his/her treatment.

 

Therapy is most effective when a trusting relationship exists between the therapist and a child. Privacy is especially important in securing and maintaining that trust. Children must establish a “zone of privacy” with their therapist that allows them to feel free to discuss personal matters. Therefore, it is our policy to provide you with general information about the treatment of your child, but we will not share with you what your child has disclosed without your child’s consent. However, if we ever believe that your child has been abused or is at serious risk of harming him/herself or another, we will inform you. This “zone of privacy” extends to the information contained in treatment records as well. By signing this agreement, you are waiving your right of access to your child’s treatment records. We will be happy to provide a written treatment summary upon request.

 

Adolescence is a time when children need to develop a greater sense of independence and autonomy. If your child is an adolescent, he/she may reveal sensitive information during therapy sessions regarding sexual contact, alcohol and/or drug use, or other potentially problematic behaviors. For me to effectively work with your child, we must maintain confidentiality about these behaviors unless they involve imminent risk of harm to self or others, such as driving while under the influence of alcohol or drugs. We will also inform you if your child does not attend sessions or if it is necessary to refer your child to another mental health professional.

 

Confidentiality for Children (10 Years and Younger)
Unlike therapy with adolescents, when meeting with children under the age of 10 years, it may be beneficial to meet with parents and discuss in more detail what happened in therapy. We will use our clinical judgment to keep you involved in the therapy process in a way that is helpful as well as respects your child’s privacy.

 

Confidentiality Will Not Be Maintained When:

• Child patients disclose plans to cause serious harm or death to themselves, and we believe they have the intent and ability to carry out this threat very soon. We must take steps to inform a parent or guardian or others of what the child has told me and how serious we believe this threat to be and to try to prevent the occurrence of such harm. 
• Child patients disclose they plan to cause serious harm or death to someone else, and we believe they have the intent and ability to carry out this threat very shortly. In this situation, we must inform a parent, guardian, or others, and we may be required to inform the person who is the target of the threatened harm and the police. 
• Child patients are doing things that could cause serious harm to them or someone else, even if they do not intend to harm themselves or another person. In these situations, we will need to use our professional judgment to decide whether a parent or guardian should be informed. 
• Child patients disclose or we otherwise learn that it appears that a child is being neglected or abused--physically, sexually, or emotionally--or that it appears that they have been neglected or abused in the past. In this situation, we are required by law to report the alleged abuse to the Iowa Department of Human Services. 
• We are ordered by a court to disclose information. 

 

Risks and Benefits
Counseling for adolescents/children can have benefits and risks. Since therapy often involves discussing unpleasant aspects of one’s life, your child may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. Working through difficult emotions can sometimes lead to an increase in difficult behaviors before the adolescent/child can utilize new skills or fully integrate their experiences. On the other hand, counseling has been shown to have benefits for individuals who go through it. Therapy can lead to better relationships, solutions to specific problems, significant reductions in feelings of distress, and improved self-esteem. But there are no guarantees of how an adolescent/child will respond. Adolescents/children are unique and holistic beings that sometimes require assistance and support to grow and develop to their fullest potential. Counseling can often be beneficial for adolescents/children and their families.

 

Divorce
Both parents have the right to be made aware of the child’s progress in treatment. Confidentiality can be maintained while still allowing for both parents to understand treatment goals, intervention strategies, and successes. We cannot withhold your child's appointment information from the other parent as long as they have parental rights. Both parents can contact the therapist to discuss the child's treatment, goals, and progress. We do not release treatment notes to either parent (see Release of records/progress notes policy). Children do have the same rights to confidentiality as adults.

 

Ending Therapy
One risk of child therapy involves disagreement among parents and/or disagreement between parents and a therapist regarding the best interests of the child. If such disagreements occur, we will strive to listen carefully and try to understand your perspectives, while fully explaining mine. We can resolve such disagreements or we can agree to disagree, so long as this enables your child’s therapeutic progress. If either parent decides that therapy should end, we ask that you allow me the option of having a few closing sessions with your child to appropriately end the treatment relationship.

 

If conflicts arise between parents, you understand and agree that my role is strictly limited to providing psychotherapy for the benefit of your child. This means, among other things, that you will treat anything said in session as confidential and you will not attempt to gain an advantage in any legal proceeding from my involvement with your child. You agree that you will not involve me in any legal dispute, especially a dispute concerning custody or visitation arrangements. You will not ask me to testify in court, either in person or by affidavit. You also agree to instruct your attorneys not to subpoena us or to refer to any court filing to anything we have said or done.

 

Legal Involvement
If a court appoints an evaluator, mediator, or guardian ad litem, we will provide information as needed, if appropriate releases are signed or a court order is provided. We are ethically bound not to give my opinion about either parent’s custody or visitation suitability. If for any reason, We are required to participate in a legal dispute, the party responsible for our participation agrees to reimburse me at the rate of $350/hour for time spent testifying, being in attendance at hearings, or any case-related costs. Additional fees will be incurred for preparing reports, telephoning, and travel time.

 

Payment
The parent who brings the child to therapy will be responsible for paying for services.

 

Your Understanding
Thank you for your understanding and cooperation. Your signature indicates a legally-binding agreement with the terms set forth in this contract. 

This consent will be valid until the minor reaches the age of 18, but can be revoked at any time by written notification.

By signing this agreement, you state that you have read this contract for outpatient psychotherapy services and are voluntarily enrolling your child in psychotherapy.