Informed Consent to Participate in Psychological Therapy
Informed Consent to Participate in Psychological Therapy
Thanks for contacting us and for your interest in our professional services in Clinical Psychology. We welcome you to our practice, and will gladly assist you. This document contains important information about our professional services and business policies. Please read it carefully and ask any questions you might have at any time. When you sign this document, it will represent an agreement between us.
I(We) understand and agree that information discussed in psychological therapy is for therapeutic purposes and is not intended for use in any legal proceedings involving myself(us) and/or my(our) significant others, current or past. I(we) agree, now and in the future, not to subpoena Dr. Pacheco, his Assistants, and/or Associates to testify for or against any of us or to provide records in a court action.
I(We) understand the limits and benefits of using insurance or third-party payers to pay for psychological therapy. If I(we) use insurance or a third-party payer, I(we) give you my(our) consent to provide to the insurance or third-party payer all information needed to comply with their regulations and/or requirements. I(we) understand that if I(we) use insurance or a third-party payer, Dr. Pacheco, his Assistants, and/or Associates will not retain control over information provided to the insurance company or to the third-party payer.
I(We) understand that psychological therapy begins with an evaluation of the past and present, and of what I(we) would like to accomplish in psychotherapy. While Dr. Pacheco is deciding whether he is the appropriate therapist for me(us), I(we) will decide whether I(we) wish to begin psychological therapy with him, his Assistants and/or Associates. I(we) understand that because of the commitment of time and money, plus the potential impact on me(us) and others, especially if children and significant others are involved, it is important to make an informed choice for a psychological therapist.
I(We) have been given the opportunity to ask questions and discuss confidentiality and disclosure policies with Dr. Pacheco, his Assistants, and/or Associates. I(We) understand that while working in psychological therapy with significant others, anything any of us might say individually to Dr. Pacheco, his Assistants, and/or Associates, whether by phone, fax, in writing, electronically, in an individual session or by any other means, may not be held as confidential, and that at the discretion of Dr. Pacheco, his Assistants, and/or Associates, may be shared with my(our) significant other(s) at a subsequent occasion.
I(We) agree to share responsibility with Dr. Pacheco, his Assistants, and/or Associates for the therapy process, including goal setting and termination. By entering into psychological therapy, I(we) accept that I(we) understand that working toward change may involve experiencing difficult and intense feelings, some of which may be painful, in order to reach therapy goals.
I(We) understand that reaching the goals of therapy is not guaranteed, and understand that no promises have been made to me(us) as to the results of treatment or of any procedures provided by Dr. Pacheco, his Assistants, and/or Associates.
I(We) understand that the changes I(we) make will have an impact on my partner, if I have one, and/or on others around me(us). I(We) accept that such changes can have both positive and/or negative effects and agree to clarify and evaluate potential effects of changes before undertaking them. This is especially true if I(we) have dependent children.
If participating in individual, couples, or family therapy, Dr. Pacheco, his Assistants, and/or Associates has(have) explained that the therapeutic focus in psychological therapy is on preserving and enhancing any relationship I(we) may have rather than a focus on individual happiness. Also, that if remaining together is harmful to one or both partners or to any of the family members, the focus will be on facilitating an amicable and growth-fostering separation.
I(We) hereby authorize Dr. Pacheco, his Assistants, and/or Associates to provide the professional services he(they) may deem necessary while consulting, interviewing, assessing, and/or treating me(us), and/or the persons under my(our) responsibility participating in this process.
I(We) also give permission to Dr. Pacheco, his Assistants, and/or Associates to contact me(us) and/or the person(s) I(we) have designated In The Event of an Emergency, via phone, fax, postal mail, e-mail, telephone text messaging, computer teleconference, and/or by any other means, as he(they) deem(s) convenient or necessary, during and/or after the conclusion of the psychological services.
I(We) agree to pay the fees related to all services provided by Dr. Pacheco, his Assistants, and/or Associates, as per the Cost Sheet, including any charges not fully reimbursed by the insurance company or a third-party payer. I(We) hereby also give Dr. Pacheco, his Assistants, and/or Associates permission in full to use legal services and/or collection agencies, at my(our) expense, and charge interest on amounts owed, if I(we) fail to pay for services as agreed, and/or in the event my(our) account becomes overdue.
I(We) understand that no insurance company or third-party payer will pay for missed sessions, and I(we) agree to Dr. Pacheco’s policy of charging the fee established in the Cost Sheet, which I(we) will pay as required, if I(we) fail to cancel any appointment at least twenty-four (24) hours in advance, excluding weekends and statutory holidays. Additionally, if using insurance, I(we) hereby authorize Dr. Pacheco, his Assistants, and/or Associates, upon request, to confirm to the insurance company my(our) attendance and fees paid.
ACCEPTED IN ACCORDANCE:
Printed Name Signature Date
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