INFORMED CONSENT FOR PSYCHOTHERAPY

This document has been modified on December 9, 2022

Congratulations on taking the first step towards your therapeutic journey. The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important to reach a clear understanding about how the therapeutic relationship will work, and what to expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with your therapist.

All of our mental health professionals at Pediatric and Adult Behavioral Counseling (PABC) meet the State of Michigan Requirements for licensure. This consent discusses the variable aspects of psychotherapy. Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. Therapy can be done both in the office and via telehealth for individual, groups, families, and marriage counseling.

Risks of Therapy: Therapy is the Greek word for change. Therapy can be difficult, uncomfortable, emotional, and seem defeating at times. Clients often learn things about themselves that they don’t like. Often growth cannot occur until past issues are experienced and confronted, often causing distressing feelings such as sadness and anxiety. The success of therapy depends upon the quality of the efforts of both the therapist and client, along with the reality that clients are responsible for the lifestyle choices/changes that may result from therapy. Specifically, one risk of marital therapy is the possibility of exercising the divorce option.

Relationship: Your relationship with the therapist is a professional and therapeutic relationship. In order to preserve this relationship, it is imperative that the therapist not have any other type of relationship with you. Personal, business, and social media relationships undermine the effectiveness of the therapeutic relationship. Your therapist cares about helping you but is not in a position to be your friend or to have a social and personal relationship with you as duel relationships are unethical and will not provide value that you are seeking therapeutically. Gifts, bartering, and trading services are not appropriate and should not be shared between you and the therapist.

Social Media: Due to the importance of your confidentiality and the importance of minimizing dual relationships, your clinician does not accept friend or contact requests, direct messages or any form of communication from current or former clients on any social networking site (Facebook, LinkedIn, TikTok, SnapChat, etc). Adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when you meet with your therapist to discuss more.

Number and Length of Sessions: The number of sessions needed depends on many factors and will be discussed during your intake assessment (your first appointment). The length of therapy sessions range depending on several factors, and the therapist will discuss this with you. We usually recommend weekly to start as it helps build a therapeutic relationship, while providing you with tools and confidence to manage your symptoms independently.

Therapist Leaves Practice or Unable to Provide Services Due to Death, Maternity, Illness, Vacation, or Personal Reasons: In the event that your therapist is unable to provide services due reasons above; it may be necessary for another therapist to take possession of client records. By signing the Informed Consent and Privacy Practices Receipt, you give your consent to another licensed mental health professional at PABC to take possession of your files and records and provide you with copies upon request, or to deliver them to a therapist of your choice. You also provide our clinicians to case consult with each other if needed.

Therapist Transfer Request: In the event that you would like to try a new therapist for services, by signing the Informed Consent and Privacy Practices Receipt, you give your consent to another licensed mental health professional at Pediatric and Adult Behavioral Counseling to take possession of your files and records for continuum of care. If you choose to transfer to a therapist outside of PABC, we will provide you with a Release of Information to complete and upon return we will deliver them via fax or email to the individual or company of your choice.

Inclement Weather and Closures: If there is inclement weather and/or if local schools are closed due to weather conditions, most likely, our physical office will be closed too. Your therapist may contact if there is need to reschedule or switch your appointment to telehealth.

Accessibility: Your therapist’s direct contact information including contact number, email and Simple Practice Secure Messaging System: this will be provided upon assignment of clinician

You may contact our office in the following ways:

• Main office: 248-973-7958 via phone or text
• Email: hello@pabcounseling.com
• Fax: 972-323-7684

Your therapist may not be immediately available; however, will attempt to return your call within 24-48 business hours. In case of an emergency in which you or someone you know is in a life threatening situation, please call 911. If you are experiencing a mental health crisis and need someone to talk to immediately, please call, text or chat 988.

Crisis and After Hour Emergencies: In situation that you are experiencing a mental health crisis, you are allowed to contact your therapist to see if they have a same day appointment available to provide crisis intervention services. Your therapist is not required to provide these services, but will do their best to accommodate. If your counselor is unavailable you, please call 988 for mental health crisis, 911 for life threatening emergencies or go to your nearest hospital.

Scheduling: Scheduling is conducted through PABC for your initial appointment and is based on provider’s normal hours. You may schedule or reschedule appointments by calling the main office at 248-973-7958 or contacting your counselor via text, phone, email, or SimplePractice private messaging system.

Cancellation Policy: Pease see our Cancellation and File Closure Policy.

Payment, Fees and Insurance: Please review our Fee Agreement

INFORMED CONSENT FOR TELEHEALTH PSYCHOTHERAPY

Sessions conducted by electronic means: video, phone, email, fax, or text is considered telemedicine by the State of Michigan. Under the Michigan Telemedicine Act of 1996, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist chose to use information technology for some or all of your treatment, you need to understand that:

1. You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
2. All existing confidentiality protections are equally applicable.
3. Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee.
4. Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent.

Telehealth best serves the following:

• Individuals, couples and families that have busy schedules, but want to prioritize their mental wellness from anywhere at anytime as they can do visits during lunch, school, and work anywhere in the state that their clinician is licensed in, and on the go
• Individuals that may be more comfortable speaking to a professional in the comfort of their home rather than from the provider’s office
• Individuals and families that have difficulty with attendance
• Those challenged with the barrier of needing transportation resulting in “no-shows.” This results in greater continuity of treatment – nami.og
• Families that are fractured, living separately, or have different schedules as it allows them to all “get into one room”
• Underserved individuals whom may need culturally competent and clinically specific clinicians
• Individuals that may struggle with anxiety or panic disorders at work, school or social situations as clinical interventions are the most useful when experiencing heightened emotions
• People with disabilities, areas with mental health provider shortages, and rural communities
• Individuals unable to travel to the clinician of preference due to distance, transportation, schedule, etc.

When using telehealth services, potential risks include, but are not limited to the therapist’s inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally the therapist.

CONSENT TO USE THE TELEHEALTH BY SIMPLEPRACTICE SERVICE

Telehealth by SimplePractice is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:

1. Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
2. Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
3. The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.
4. I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service.
5. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.
6. I have the right to withdraw my consent at any time.
7. I understand that there are risks and consequences associated with telehealth including, but not limited to the possibility, despite reasonable efforts on the part of my counselor/therapist/clinical intern, that the transmission of my medical information could be disrupted or distorted by technical failures. In addition, I understand that telehealth-based services and care may not be as complete as face-to-face services. I also understand that if my counselor believes I would be better served by another form of psychotherapeutic services (e.g. face-to-face services) I will be referred to a counselor/therapist who can provide such services in my geographic area.
8. I understand that I may benefit from telehealth but that results cannot be guaranteed or assured.
9. I understand that PABCounseling may not provide telehealth services to me if I am outside of the State of Michigan, and I understand that I may access telehealth services from PABCounseling from within the State of Michigan only.

Technology: I understand that I may need to download an application and/or software to use this platform. I also need to have a broadband Internet connection or a smart phone device with a good cellular connection deemed appropriate for services. I also understand that in case of technology failure, I may contact my counselor via phone to coordinate alternative methods of treatment. I understand that using the telehealth platform allows access to mental health services that might not otherwise be available to me due to my mental health, and/or my physical, resource, or geographic limitations.

Video/Audio Recording: As a general practice Pediatric and Adult Behavioral Counseling DOES NOT record telehealth sessions without prior permission.

Confidentiality During Telehealth: The laws that protect the confidentiality of my medical information also apply to telehealth. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality including, but not limited to: reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. PABCounseling telehealth platform is HIPAA compliant to protect my privacy and confidentiality. This is further explained in the Privacy Policies and Confidentiality Agreement.

Court: It is out of the scope of practice for our Licensed Professional Counselors to testify in court on any situation including custody hearings unless certified as a Forensic Evaluator. Please review our confidentiality notice and fee agreement regarding court related costs.

Consent to Treatment:

• By signing this Informed Consent, you voluntarily agree to receive mental health assessment, care, treatment, or services and authorize the therapist to provide such care, treatment, or services as are considered necessary and advisable. Signing indicates that you understand and agree that you will participate in the planning of your care, treatment, or services, and that you may stop such care, treatment, or services at any time.
• By signing this Informed Consent for, you acknowledge that you have both read and understood all the terms and information contained herein. Ample opportunity has been offered for you to ask questions and seek clarification of anything that remains unclear.
• You may view and download a copy of this consent at www.pabcounseling.com