Below is a suggestion of an office policy (Treatment
Consent) form. Review the various points to get a sense of how a psychological
practice is conducted, and what a new client might expect of a psychological
Be advised, though,
that not every practice employs exactly the same policies, and that the policies
described here conform to California law.
If any mental
health provider does not give you a written office policy statement (if the
treatment will be conducted in person) or a website statement (if the treatment
will be conducted remotely), you have a right to ask that all policies be made
clear to you before starting treatment.
of Confidentiality: All information that
you disclose within your sessions is
and will not be revealed to anyone without your written permission (or
your parents permission if you are under 18 years old). Disclosure,
however, may be
or required by law
where there is
a reasonable suspicion of
abuse or elder adult physical abuse;
where there is
a reasonable suspicion that you may present a danger of violence to
where there is
a reasonable suspicion that you are likely to harm yourself unless protective
measures are taken.
may also be required pursuant to a legal
clinical file may consist of a record of sessions and
payments, clinician notes, testing reports, written communications, and any other
documents related to treatment.
Training and Experience: The clinician should
disclose his or her education, license, professional training, and any specialized
and Success of Services: The success of
psychological treatment depends on the motivation and aptitude of the person
being treated, and so guarantees about treatment success cannot be made. You
have the right to decide when to terminate the
of Services: You should be aware that despite
treatment you may not improve at all, you may not improve as quickly as you might
like, or you may start to improve only after treatment has ended. You should also
be aware that treatment is intended to induce change in your life, and that when
this change occurs it may disrupt your accustomed manner of living and your
relationships with others. Treatment can also provoke feelings of affection for
the clinician or anger at the clinician, and these experiences should be considered
normal aspects of the treatment to be discussed openly within the
Rights: You may ask about information
that the clinician has about you from outside sources, such as other service
providers. You have the right to terminate treatment
at any time.
In all cases,
professional treatment never includes sexual contact with the treatment
for Service: The clinicians fees should
be specified before starting treatment. You may be expected to pay for services
at the time they are rendered, unless other arrangements have
If you pay by
a check that is ever returned for insufficient funds, you may have to pay for
any service charges levied by the clinicians bank.
In general, large
balances should not accrue, and this should be prevented from happening.
As a last resort, the clinician has a right to use a collection agency if you
do not pay a large balance.
Reimbursement: If you use insurance to pay for
your treatment, your use of insurance will breach the
confidentiality of your treatment because any employee
of the insurance company can demand the details of your treatment. Furthermore,
insurance companies require a psychiatric diagnosis
(which becomes an indelible part of your world-wide medical record).
The scheduling of an appointment involves
the reservation of time specifically for you, and if you are late, you will meet
for whatever amount of your time remains, and you will be required to pay for
the full session. A minimum of 24 hours notice is required for rescheduling
or cancellation of an appointment. A feeequal to your regular session
feewill be charged for missed sessions and late
companies cannot be billed for missed sessions, please understand that if
you are using insurance coverage you will always be personally responsible
for paying the charges for late cancellations and missed
You may leave
messages on the clinicians voice-mail at any time. If, in an
extraordinary circumstance, you leave a message requesting that you be called
back, it might take several hours before your call can be returned. If you call
in the evening, on a weekend, or over a holiday, the clinician may be unable
to call you back until the next business day. In case of an emergency, leave
a message for and then immediately contact your local crisis services.
that, in general, spontaneous telephone calls are not meant to be a form of
free counseling. If you make repeated requests for telephone support, or if
you require extended time on the phone, you may be billed at the same
hourly rate as your regular sessions.
messages: Because of the danger of privacy
breaches, the use of text messages should be short, information specific, and not
refer to any psychological details.
If you choose to contact your clinician through e-mail,
keep in mind that e-mail is not secure and that someone, somewhere,
could be reading anything you write by e-mail. Realize also that, if you are using
a computer at your work site, your network administrator has the capability to read
every piece of e-mail you send and receive through your companys