INFORMED CONSENT AND CLIENT AGREEMENT

Welcome to the Center for the Psychology of Women.  We look forward to helping you reach your goals. This form requests basic information and informs you of the Center’s services and policies. Please take a few moments to review it; if you have any questions, we are happy to answer them. When you sign this document, it will represent an agreement between you and the Center for the Psychology of Women.

Client Name *
Client Name
Date of Birth *
Date of Birth
Address *
Address
Phone
Phone
Emergency Contact Name *
Emergency Contact Name
Phone
Phone
INSURANCE INFORMATION
For those with insurance, your insurance company may pay a portion of the cost of your office visits. In this case, your patient responsibility becomes your fee, which may include a deductible; co-pay (a fixed amount specified by insurance companies for certain services); or coinsurance (a percentage of costs specified by insurance companies for certain services), while I collect the remainder of your fees from the insurance company. Please remember, however, that you are ultimately responsible for payment of your costs, not your insurance company. You are responsible for obtaining any authorization your insurance requires prior to treatment.
Name of Insured
Name of Insured
Date of Birth of Insured
Date of Birth of Insured
Changes in Insurance Coverage:
As a reminder, it is the client’s responsibility to inform service providers of any changes in insurance coverage. Your insurance company will only inform service providers about any changes in insurance coverage after a bill for services has been submitted to the insurance company.
Canceled or Missed Appointments:
A scheduled appointment means that time is reserved only for you. If an appointment is missed or cancelled with less than 24 hours’ notice, you, not your insurance company, are responsible for full payment of that appointment.
Non-Sufficient Funds (NSF) Check Returns:
Checks that are returned as NSF will incur a reprocessing fee of $10.00 per occurrence.
Date
Date
TREATMENT PHILOSOPHY
At the Center for the Psychology of Women, we work towards empowering each client to explore ways of living a happier and more fulfilled life. We encourage our clients to explore their strengths and weaknesses and foster an environment of personal growth and self-awareness. Together we work in a spirit of collaboration toward meaningful change and an improved quality of life. Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness and helplessness. On the other hand, psychotherapy has also been shown to benefit those who seek it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. However, there are no guarantees of what you will experience. If you ever have any questions about the nature of the treatment or anything else about your care, please don’t hesitate to ask.
CONFIDENTIALITY
The overriding principal is that the Center respects the confidences of its clients. Information that clients share with us will be held confidential unless: i) the client authorizes release of information with his/her signature; ii) the client presents a physical danger to self; iii) the client presents a danger to others; iv) child/dependent or adult/elder abuse and/or neglect are suspected; v) when the psychotherapist is a defendant in a civil, criminal, or disciplinary action arising from the therapy (in which case client confidences may only be disclosed in the course of that action); or vi) as otherwise may be permitted or mandated by law. The Center has rarely encountered most of these situations, but if a similar situation occurs, the Center will make best efforts to discuss it with the client prior to taking action.
EMERGENCY PROCEDURES
An emergency is defined as wanting to seriously harm yourself or someone else. If an emergency situation arises, dial 911 or go to your local emergency room. The Center for the Psychology of Women is not on call after hours. If you place a call to the Center for the Psychology of Women in the evening or on the weekend, you may not receive a return call until the following business day.
CONSENT FOR TREATMENT
I consent that I am creating a treatment relationship with the Center for the Psychology of Women. I further authorize and request that the Center for the Psychology of Women carry out mental health examinations, treatments, or diagnostic procedures, which now or during the course of my care are advisable. I understand that the purpose of these procedures will be explained to me upon my request and are subject to my agreement. I also understand that, while the course of therapy is designed to be helpful, it may at times be difficult and uncomfortable. Therapy is not an exact science, and the Center for the Psychology of Women cannot guarantee results.
I understand and agree to all of the above information, and my signature below indicates I have read this document and agree to abide by its terms during our professional relationship.
Date *
Date