INFORMATION, AUTHORIZATION, &
CONSENT TO TREATMENT
Welcome to CENTER FOR PSYCHOLOGICAL PERFORMANCE, INC. We are very pleased that you selected our facility for your psychological needs and we are sincerely looking forward to assisting you. This document is designed to inform you about what you can expect from your therapist, policies regarding confidentiality and emergencies, and several other details regarding the psychological services you receive here at CENTER FOR PSYCHOLOGICAL PERFORMANCE, INC. Although providing this document is part of an ethical obligation to our profession, more importantly, it is part of our commitment to you to keep you fully informed of every part of your therapeutic experience. Please know that your relationship with your therapist is a collaborative one, and we welcome any questions, comments, or suggestions regarding the psychological services you receive.
Background Information, Theoretical Views, & Client Participation
Information regarding your therapist's educational background and experience may be found on our website under their name. Please feel free to view that information at www.psychperformance.com. Psychological services provided at CENTER FOR PSYCHOLOGICAL PERFORMANCE, INC. include psychotherapy and psychological and/or psychoeducational evaluation.
Psychotherapy is not easy to describe as it varies depending on the particular problems that clients bring, the training of the therapist, and the personalities of the clients and the therapist. Unlike a visit to a medical doctor, psychotherapy requires active effort and hard work on your part. In order to be successful, you will need to put in a lot of effort into your session and the time between sessions. Generally, the more of yourself you are willing to invest, the greater the return.
Psychotherapy has both benefits and risks. Research has shown that two-thirds to three-quarters of clients find therapy quite helpful. Psychotherapy often leads to a significant reduction of distress, better relationships, resolution of specific problems, and an increased ability to address challenges in the future. Unfortunately, since psychotherapy is not an exact science, there can be no guarantee about what your experience will be.
The risks of psychotherapy include feelings of vulnerability, frustration, fear, anger, and sadness. At times, you may have to talk about things that are difficult to discuss and result in considerable discomfort. Psychotherapy will also probably involve making some changes in your habitual ways of doing things and this may feel difficult at first. Your therapy may involve recalling unpleasant aspects of your life and life history. Also, you may have new insights into yourself and others that may initially feel uncomfortable.
If you have questions, doubts, or problems with any part of your therapy, please bring these to your therapist’s attention in session as soon as possible. It is essential that your concerns are discussed, explored, and resolved. Sometimes, your therapist may be able to modify their procedures so that they work better for you. Sometimes, greater explanation will help you understand why they do certain things and why they may be helpful. Research has shown that the most important predictor of therapy success is a good working relationship between client and therapist. Since therapy involves a large commitment of time, money, and energy, it is important that client and therapist work together to establish good teamwork. However, if your doubts, concerns, or problems about therapy persist, your therapist will be happy to assist you in meeting with another mental health professional or providing a referral for a different therapist. Your personal development is our number one priority. We encourage you to let your therapist know if you feel that transferring to another therapist is necessary at any time. Our goal is to facilitate healing and growth, and all of our therapists are very committed to helping you in whatever way seems to produce the maximum benefit. If at any point you are unable to keep your appointments or we don't hear from you for one month, we will need to close your chart. However, reopening your chart and resuming treatment is always an option.
A psychological or psychoeducational evaluation involves a battery of instruments that assess five main areas: intellectual potential, academic functioning, processing skills, attention/concentration, and social-emotional functioning. Background history, teacher input, and previous records provide additional information to assist in the diagnosis. These evaluations involve approximately six hours of testing, a two hour feedback session, and an hour of billable time to complete the written report. A copy of the report will be provided within a few weeks of the feedback session given that all necessary information has been provided. Collaboration with schools, tutors, psychiatrists, or other third-party providers may be beneficial and will be provided upon request and with completion of a release of information form.
Confidentiality & Records
Your communications with your therapist will become part of a clinical record of treatment, and it is referred to as Protected Health Information (PHI). While you are an active client, your PHI will be kept in a file stored in a locked cabinet in our locked office. Once your file has been closed and/or you are no longer an active client, your PHI will be kept on our password protected computer system in an encrypted file format.
There are a few other people who may also have access to your PHI. The practice owner, Lindsey Swanson Schriefer, Ph.D., may review your case with your therapist in the interest of providing you with the best possible care. As a licensed clinician, Lindsey Swanson Schriefer, Ph.D. is also required to keep all information about clients confidential. Additionally, one of our administrative assistants or our business manager may need to access your chart on occasion for business purposes only. This might be to check for dates of services to file an insurance claim (if applicable), to ascertain that all of the HIPAA required documentation is located in the chart (occasional audit of charts), or some other absolutely necessary business practice. However, please know this would never include reading any of your clinical notes. Additionally, each business associate has signed a HIPAA enforced confidentiality contract which spells out how confidential records must be handled.
Your therapist will always keep everything you say to him or her completely confidential, with the following exceptions: (1) you direct your therapist to tell someone else and you sign a “Release of Information” form; (2) your therapist determines that you are a danger to yourself or to others; (3) you report information about the abuse of a child, an elderly person, or a disabled individual who may require protection; or (4) your therapist is ordered by a judge to disclose information. In the latter case, your therapist’s license does provide him or her with the ability to uphold what is legally termed “privileged communication.” Privileged communication is your right as a client to have a confidential relationship with a counselor. This state has a very good track record in respecting this legal right. If for some unusual reason a judge were to order the disclosure of your private information, this order can be appealed. We cannot guarantee that the appeal will be sustained, but we will do everything in our power to keep what you say confidential. Please note that in couple’s counseling, your therapist does not agree to keep secrets. Information revealed in any context may be discussed with either partner.
Professional Relationship
Your relationship with your therapist has to be different from most relationships. It may differ in how long it lasts, the objectives, or the topics discussed. It must also be limited to only the relationship of therapist and client. If you and your therapist were to interact in any other ways, you would then have a "dual relationship," which could prove to be harmful to you in the long run and is, therefore, unethical in the mental health profession. Dual relationships can set up conflicts between the therapist's interests and the client’s interests, and then the client’s (your) interests might not be put first. In order to offer all of our clients the best care, your therapist’s judgment needs to be unselfish and purely focused on your needs. This is why your relationship with your therapist must remain professional in nature.
Additionally, there are important differences between therapy and friendship. Friends may see your position only from their personal viewpoints and experiences. Friends may want to find quick and easy solutions to your problems so that they can feel helpful. These short-term solutions may not be in your long-term best interest. Friends do not usually follow up on their advice to see whether it was useful. They may need to have you do what they advise. A therapist offers you choices and helps you choose what is best for you. A therapist helps you learn how to solve problems better and make better decisions. A therapist's responses to your situation are based on tested theories and methods of change.
There is another dual relationship that therapists are ethically required to avoid. This is providing therapy while also providing a legal opinion. These are considered mutually exclusive unless you hire a therapist specifically for a legal opinion, which is considered "forensic" work and not therapy. Our passion is not in forensic work but in providing you with the best therapeutic care possible. Therefore, by signing this document, you acknowledge that your therapist will be providing therapy only and not forensic services. You also understand that this means your therapist will not participate in custody evaluations, depositions, court proceedings, or any other forensic activities.
You should also know that therapists are required to keep the identity of their clients confidential. As much as your therapist would like to, for your confidentiality he or she will not address you in public unless you speak to him or her first. Your therapist also must decline any invitation to attend gatherings with your family or friends. Lastly, when your therapy is completed, your therapist will not be able to be a friend to you like your other friends. In sum, it is the duty of your therapist to always maintain a professional role. Please note that these guidelines are not meant to be discourteous in any way, they are strictly for your long-term protection.
Statement Regarding Ethics, Client Welfare & Safety
CENTER FOR PSYCHOLOGICAL PERFORMANCE, INC. assures you that our services will be rendered in a professional manner consistent with the ethical standards of the American Psychological Association. If at any time you feel that your therapist is not performing in an ethical or professional manner, we ask that you please let him or her know immediately. If the two of you are unable to resolve your concern, please contact Lindsey Swanson Schriefer, Ph.D. (Clinical Director) at 770.282.4946.
Due to the very nature of psychotherapy, as much as we would like to guarantee specific results regarding your therapeutic goals, we are unable to do so. However, your therapist, with your participation, will work to achieve the best possible results for you. Please also be aware that changes made in therapy may affect other people in your life. For example, an increase in your assertiveness may not always be welcomed by others. It is our intention to help you manage changes in your interpersonal relationships as they arise, but it is important for you to be aware of this possibility nonetheless. Additionally, at times people find that they feel somewhat worse when they first start therapy before they begin to feel better. This may occur as you begin discussing certain sensitive areas of your life. However, a topic usually isn’t sensitive unless it needs attention. Therefore, discovering the discomfort is actually a success. Once you and your therapist are able to target your specific treatment needs and the particular modalities that work the best for you, help is generally on the way.
For the safety of all our clients, their accompanying family members and children, and our therapists and staff, CENTER FOR PSYCHOLOGICAL PERFORMANCE, INC. maintains a zero tolerance weapons policy. No weapon of any kind is permitted on the premises, including guns, explosives, ammunition, knives, swords, razor blades, pepper spray, garrotes, or anything that could be harmful to yourself or others. CENTER FOR PSYCHOLOGICAL PERFORMANCE, INC. reserves the right to contact law enforcement officials and/or terminate treatment with any client who violates our weapons policy.
TeleMental Health Statement
In our ever-changing technological society, there are several ways we could potentially communicate and/or follow each other electronically. It is of utmost importance to us that we maintain your confidentiality, respect your boundaries, and ascertain that your relationship with your therapist remains therapeutic and professional.
TeleMental Health is defined as follows:
“TeleMental Health means the mode of delivering services via technology-assisted media, such as but not limited to, a telephone, video, internet, a smartphone, tablet, PC desktop system or other electronic means using appropriate encryption technology for electronic health information. TeleMental Health facilitates client self-management and support for clients and includes synchronous interactions and asynchronous store and forward transfers.” (Georgia Code 135-11-.01)
TeleMental Health is a relatively new concept despite the fact that many therapists have been using technology-assisted media for years. Breaches of confidentiality over the past decade have made it evident that Personal Health Information (PHI) as it relates to technology needs an extra level of protection. Additionally, there are several other factors that need to be considered regarding the delivery of TeleMental Health services in order to provide you with the highest level of care. Therefore, our therapists have completed specialized training in TeleMental Health. We have also developed several policies and protective measures to assure your PHI remains confidential. These are discussed below.
The Different Forms of Technology-Assisted Media Explained
Telephone via Landline:
It is important for you to know that even landline telephones may not be completely secure and confidential. There is a possibility that someone could overhear or even intercept your conversations with special technology. Individuals who have access to your telephone or your telephone bill may be able to determine who you have talked to, who initiated that call, and how long the conversation lasted. If you have a landline and you provided us with that phone number, we may contact you on this line from our own landline in our office or from a cell phone, typically only for purposes of setting up an appointment if needed. If this is not an acceptable way to contact you, please let your therapist know. Telephone conversations (other than just setting up appointments) are billed at your therapist's hourly rate.
Cell phones:
In addition to landlines, cell phones may not be completely secure or confidential. There is also a possibility that someone could overhear or intercept your conversations. Be aware that individuals who have access to your cell phone or your cell phone bill may be able to see who you have talked to, who initiated that call, how long the conversation was, and where each party was located when that call occurred. However, we realize that most people have and utilize a cell phone. We may also use a cell phone to contact you, typically only for purposes of setting up an appointment if needed. Additionally, your therapist may keep your phone number in his/her cell phone, but it will be listed by your initials only and his/her phone is password protected. If this is a problem, please let your therapist know, and you he/she will be glad to discuss other options. Telephone conversations (other than just setting up appointments) are billed at your therapist's hourly rate.
Text Messaging:
Text messaging is not a secure means of communication and may compromise your confidentiality. However, we realize that many people prefer to text because it is a quick way to convey information. Nonetheless, please know that it is our policy to utilize this means of communication strictly for appointment confirmations. Please do not bring up any therapeutic content via text to prevent compromising your confidentiality. You also need to know that we are required to keep a copy or summary of all texts as part of your clinical record that address anything related to therapy.
Email:
Email is not a secure means of communication and may compromise your confidentiality. However, we realize that many people prefer to email because it is a quick way to convey information. Nonetheless, please know that it is our policy to utilize this means of communication strictly for appointment confirmations. Please do not bring up any therapeutic content via email to prevent compromising your confidentiality. You also need to know that we are required to keep a copy or summary of all emails as part of your clinical record that address anything related to therapy. We also strongly suggest that you only communicate through a device that you know is safe and technologically secure (e.g., has a firewall, anti-virus software installed, is password protected, not accessing the internet through a public wireless network, etc.). If you are in a crisis, please do not communicate this to us via email because we may not see it in a timely matter. Instead, please see below under "Emergency Procedures."
Social Media - Facebook, Twitter, LinkedIn, Instagram, Pinterest, Etc:
It is our policy not to accept "friend" or "connection" requests from any current or former client on any of our therapist's personal social networking sites such as Facebook, Twitter, Instagram, Pinterest, etc. because it may compromise your confidentiality and blur the boundaries of your relationship. However, CENTER FOR PSYCHOLOGICAL PERFORMANCE, INC. has a professional Facebook page and professional Instagram account for the sport psychology component of their practice, THE ATHLETE’S ACADEMY. You are welcome to "follow" us on any of these professional pages where we post motivational quotes and tips about sport psychology. However, please do so only if you are comfortable with the general public being aware of the fact that your name is attached to CENTER FOR PSYCHOLOGICAL PERFORMANCE, INC. and THE ATHLETE’S ACADEMY. Please refrain from making contact with us using social media messaging systems. These methods have insufficient security, and we do not watch them closely. We would not want to miss an important message from you.
Blogs:
We may post information about various psychological topics, including sport psychology and learning disorders, on our professional blog. If you have an interest in following our blog, please feel free to do so. However, please be mindful that the general public may see that you're following CENTER FOR PSYCHOLOGICAL PERFORMANCE, INC.’s blog. Once again, maintaining your confidentiality is a priority.
Video Conferencing (VC):
Video Conferencing is an option for your therapist to conduct remote sessions with you over the internet where you may speak to one another as well as see one another on a screen. We utilize Google Meet. This VC platform is encrypted to the federal standard, HIPAA compatible, and has signed a HIPAA Business Associate Agreement (BAA). The BAA means that Google Meet is willing to attest to HIPAA compliance and assumes responsibility for keeping your VC interaction secure and confidential. We strongly suggest that you only communicate through a computer or device that you know is safe (e.g., has a firewall, anti-virus software installed, is password protected, not accessing the internet through a public wireless network, etc.).
Recommendations to Websites or Applications (Apps):
During the course of our treatment, your therapist may recommend that you visit certain websites for pertinent information or self-help. She or he may also recommend certain apps that could be of assistance to you and enhance your treatment. Please be aware that websites and apps may have tracking devices that allow automated software or other entities to know that you've visited these sites or applications. They may even utilize your information to attempt to sell you other products. Additionally, anyone who has access to the device you used to visit these sites and/or apps, may be able to see that you have been to these sites by viewing the history on your device. Therefore, it is your responsibility to decide if you would like this information as adjunct to your treatment or if you prefer that your therapist does not make these recommendations.
Electronic Record Storage:
Your communications with us will become part of a clinical record of treatment, and it is referred to as Protected Health Information (PHI). Your PHI will be kept on our password protected computer in an encrypted file format.
Electronic Transfer of PHI for Certain Credit Card Transactions:
We utilize both Square and QuickBooks, as appropriate, as the companies that process your credit card information. These companies may send the credit card-holder a text or an email receipt indicating that you used that credit card at our facility, the date you used it, and the amount that was charged. This notification is usually set up two different ways - either upon your request at the time the card is run or automatically. Please know that it is your responsibility to know if you or the credit card holder has the automatic receipt notification set up in order to maintain your confidentiality if you do not want a receipt sent via text or email. Additionally, please be aware that the transaction will also appear on your credit-card bill. The name on the charge will appear as CENTER FOR PSYCHOLOGICAL PERFORMANCE, INC.
Your Responsibilities for Confidentiality & TeleMental Health
Please communicate only through devices that you know are secure as described above. It is also your responsibility to choose a secure location to interact with technology-assisted media and to be aware that family, friends, employers, co-workers, strangers, and hackers could either overhear your communications or have access to the technology that you are interacting with. Additionally, you agree not to record any TeleMental Health sessions.
In Case of Technology Failure
During a TeleMental Health session, you and your therapist could encounter a technological failure. The most reliable backup plan is to contact one another via telephone. Please make sure you have a phone with you, and your therapist has that phone number. If you and your therapist get disconnected from a video conferencing or chat session, end and restart the session. If you are unable to reconnect within ten minutes, please call your therapist. If you and your therapist are on a phone session and you get disconnected, please call your therapist back or contact her or him to schedule another session. If the issue is due to your therapist's phone service, and the two of you are not able to reconnect, you will not be charged for that session.
Limitations of TeleMental Health Therapy Services
TeleMental Health services are an alternative form of therapy or adjunct therapy, and it involves limitations. Primarily, there is a risk of misunderstanding one another when communication lacks visual or auditory cues. For example, if video quality is lacking for some reason, your therapist might not see a tear in your eye. Or, if audio quality is lacking, he or she might not hear the crack in your voice that he or she could have easily picked up if you were in our office. There may also be a disruption to the service (e.g., phone gets cut off or video drops). This can be frustrating and interrupt the normal flow of personal interaction. Please know that we have the utmost respect and positive regard for you and your wellbeing. We would never do or say anything intentionally to hurt you in any way, and we strongly encourage you to let your therapist know if something she or he has done or said upset you. We invite you to keep the communication with your therapist open at all times to reduce any possible harm.
Consent to TeleMental Health Services
At CENTER FOR PSYCHOLOGICAL PERFORMANCE, INC. we currently utilize much of the technology listed within this document, as it is built into our practice. This includes texting, email, video conferencing, and recommendations to websites or apps, when appropriate. However, you may withdraw your authorization to use any of these services at any time during the course of your treatment just by notifying us in writing.
In summary, technology is constantly changing, and there are implications to all of the above that we may not realize at this time. Feel free to ask questions, and please know that we are open to any feelings or thoughts you have about these and other modalities of communication and treatment.
Communication Response Time
Our practice is considered to be an outpatient facility, and we are set up to accommodate individuals who are reasonably safe and resourceful. We do not carry beepers nor are we available at all times. If at any time this does not feel like sufficient support, please inform your therapist, and he or she can discuss additional resources or transfer your case to a therapist or clinic with 24-hour availability. We will return phone calls, texts, and emails within 24 hours. However, we do not return calls, texts, or emails on weekends or holidays. If you are having a mental health emergency and need immediate assistance, please follow the instructions below.