Informed Consent for Psychotherapy General Information

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. It is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with your therapist. Please read and indicate that you have reviewed this information and agree to it by signing your name at the end of this document.

The Therapeutic Process

You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings such as anger, depression, and anxiety among others. There are no miracle cures. Your therapist cannot promise that your behavior or circumstance will change. Your therapist can promise to support you and strive to understand you and your repeating patterns, as well as to help you clarify what it is that you want for yourself.

Confidentiality

The session content and all relevant materials to the your treatment will be held confidential unless you request in writing to have all or portions of such content released to a specifically named person/persons. Limitations of your held privilege of confidentiality do exist:

1. If a client threatens or attempts to commit suicide or otherwise conducts him/herself in a manner in which there is a substantial risk of incurring serious bodily harm.

2. If a client threatens grave bodily harm or death to another person. 

3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of eighteen (18) years.

4. Suspicions as stated above in the case of an elderly person who may be subjected

5. Suspected neglect of the parties named in items #3 and # 4.

6. If a court of law issues a legitimate subpoena for information stated on the subpoena.

7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert's report to an attorney.

Occasionally your therapist may need to consult with other professionals in their areas of expertise in order to provide you the best treatment. Information about you may be shared in this context without using your name.

If you and your therapist see each other accidentally outside of the therapy office, your therapist will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance, and we do not wish to jeopardize your privacy. However, if you acknowledge your therapist first, your therapist will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

 Social Media/Email Contact

Your therapist is unable to engage with you through social media. Your therapist cannot accept a friend/follow request.

Your therapist is unable to provide clinical information via email. You are more than welcome to share information via email regarding your child and their care. Your therapist will notify you of receipt of this information and follow up at your next session. In the event it is urgent, your therapist may recommend connecting via phone or an emergency session prior to the next scheduled session. In the event of a life threatening emergency please do not email; call 911 or visit your local emergency room.

Any person who receives services for mental health, alcoholism, drug abuse or developmental disability is guaranteed certain rights by the State of Wisconsin. Among these rights are the following:

1. You must be treated with dignity and respect, free of any verbal or physical abuse.

2. You have the right to have staff make fair and reasonable decisions about your treatment.

3. You cannot be treated unfairly because of your race, national origin, sex, religion, age, disability or sexual orientation.

4. You must be provided prompt and adequate treatment and other services which are appropriate to your individual needs.

5. You must be allowed to participate in the planning of your treatment.

6. You have the right to discuss positive and negative effects of your treatment and to discuss alternative treatments with your therapist.

7. No treatment may be given without your consent except in an emergency.

8. You have a right to know the cost of your treatment and to discuss these costs with your therapist.

9. You will not be filmed or taped without your consent.

10. Information regarding your treatment must be kept confidential unless you have released them.

11. Your records cannot be released without your consent unless a valid court order or a valid HIPAA form is in effect and is produced, except to report child abuse or to prevent violence or suicide.

12. You have the right to see your records and to discuss them with your therapist.

13. You may challenge the accuracy of your records and have corrections placed into the record.

14. If any of your rights are violated you may make an informal complaint or file a formal grievance or seek legal redress in court.

15. To make an informal complaint, discuss the issue with your therapist and ask for resolution.

16. To file a formal grievance contact: Ashley Hall Practice Manager at 414-774-9200.

 

You have other rights which have been promulgated by the State of Wisconsin. If you would like to learn more about these rights, ask your therapist for a copy of the brochure published by the State

I have read and understood these rights. I may request a copy of these rights. Please sign this copy and return it to your therapist; if desired, please request an extra copy for future reference.

FOR PARENTS/GUARDIANS OF CHILDREN: BY SIGNING BELOW I AM ATTESTING THAT I HAVE THE LEGAL RIGHT TO CONSENT TO TREATMENT FOR THIS CHILD.

BY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.