INFORMED CONSENT

Welcome to Good Therapy San Diego. I appreciate your giving me the opportunity to be of help to you.

This brochure answers questions that clients often ask about therapy. I believe our work will be most helpful to you when you have a clear idea of what we are trying to do. Please read this brochure and mark any parts that are not clear to you. Write down any questions you have, and we will discuss them at our next meeting.

About Psychotherapy

I strongly believe you should feel comfortable with the therapist you choose, and hopeful about the therapy. When you feel this way, therapy is more likely to be very helpful to you. Please see my website or ask me more about my background, theoretical approach, central ideas, goals for treatment, and the type of therapy I provide.

I usually take notes during our meetings. You may find it useful to take your own notes, and also to take notes outside the office. By the end of our first or second session, I will tell you how I see your case at this point and how I think we should proceed. I view therapy as a partnership between us. You define the problem areas to be worked on; I use some special knowledge to help you make the changes you want to make. Psychotherapy is not like visiting a medical doctor. It requires your very active involvement. It requires your best efforts to change thoughts, feelings, and behaviors. For example, I want you to tell me about important experiences, what they mean to you, and what strong feelings are involved. This is one of the ways you are an active partner in therapy.

I expect us to plan our work together. In our treatment plan we will list the areas to work on, our goals, the methods we will use, the time and money commitments we will make, and some other things. I expect us to agree on a plan that we will both work hard to follow. From time to time, we will look together at our progress and goals. If we think we need to, we can then change our treatment plan, its goals, or its methods.

An important part of your therapy will be practicing new skills that you will learn in our sessions. I will ask you to practice outside our meetings, and we will work together to set up homework assignments for you. I might ask you to do exercises, keep records, and read to deepen your learning. You will probably have to work on relationships in your life and make long-term efforts to get the best results. These are important parts of personal change. Change will sometimes be easy and quick, but more often it will be slow and frustrating, and you will need to keep trying. There are no instant, painless cures and no “magic pills.” However, you can learn new ways of looking at your problems that will be very helpful for changing your feelings and reactions.

Most of my clients see me once a week for 3 to 4 months. After that, we meet less often for several more months. Therapy then usually comes to an end. The process of ending therapy, called “termination,” can be a very valuable part of our work. Stopping therapy should not be done casually, although either of us may decide to end it if we believe it is in your best interest. If you wish to stop therapy at any time, I ask that you agree now to meet then for at least one more session to review our work together. We will review our goals, the work we have done, any future work that needs to be done, and our choices. If you would like to take a “time out” from therapy to try it on your own, we should discuss this. We can often make such a “time out” be more helpful.

The Benefits and Risks of Therapy

Although therapy has been shown by scientists in hundreds of well-designed research studies to be helpful for many issues, there are no guarantees about treatment outcomes or what the client will experience. Therapy requires effort of on the client’s part to work on issues in session as well as at home. When exploring issues in treatment, the client may feel discomfort, anger, sadness, and anxiety, as well as joy and relief. It is the goal of the therapist to assist the client in coming to terms with difficult material while acquiring coping to skills to manage difficult feelings. Attempting to relieve issues between family members can also lead to discomfort and may result in changes that were not originally intended. The client is encouraged to discuss any uncomfortable thoughts and feelings with the therapist as they arise during the course of treatment.

Consultations

If you could benefit from a treatment I cannot provide, I will help you to get it. You have a right to ask me about such other treatments, their risks, and their benefits. Based on what I learn about your problems, I may recommend a medical exam or use of medication. If I do this, I will fully discuss my reasons with you, so that you can decide what is best. If another professional treats you, I will coordinate my services with them and with your own medical doctor.

If for some reason treatment is not going well, I might suggest you see another therapist or another professional for an evaluation. As a responsible person and ethical therapist, I cannot continue to treat you if my treatment is not working for you. If you wish for another professional’s opinion at any time, or wish to talk with another therapist, I will help you find a qualified person and will provide him or her with the information needed.

What to Expect from Our Relationship

As a professional, I will use my best knowledge and skills to help you. This includes following the standards of the National Association of Social Workers (NASW) and, when you are being treated by Dr. Rita Romero, The American Psychological Association . In your best interests, the NASW and the APA put limits on the relationship between a therapist and a client.

First, I am licensed and trained to practice psychotherapy—not law, medicine, finance, or any other profession. I am not able to give you good advice from these other professional viewpoints.

Second, state laws require me to keep what you tell me confidential (that is, just between us). You can trust me not to tell anyone else what you tell me, except in certain limited situations. I explain what those are in the “About Confidentiality” section of this brochure. Here I want to explain that I try not to reveal who my clients are. This is part of my effort to maintain your privacy. If we meet on the street or socially, I may not say hello or talk to you very much. My behavior will not be a personal reaction to you, but a way to maintain the confidentiality of our relationship.

Third, in your best interest, and following the NASW and APA standards, I can only be your therapist. I cannot have any other role in your life. I cannot, now or ever, be a close friend to or socialize with any of my clients. I cannot be a therapist to someone who is already a friend. I can never have a sexual or romantic relationship with any client during, or after, the course of therapy. I cannot have a business relationship with any of my clients, other than the therapy relationship.

If you ever become involved in a divorce or custody dispute, I want you to understand and agree that I will not provide evaluations or expert testimony in court. You should hire a different mental health professional for any evaluations or testimony you require. This position is based on two reasons: (1) My statements will be seen as biased in your favor because we have a therapy relationship; and (2) the testimony might affect our therapy relationship, and I must put this relationship first.

About Confidentiality

I will treat with great care all the information you share with me. It is your legal right that our sessions and my records about you be kept private. That is why I ask you to sign a “release-of-records” form before I can talk about you or send my records about you to anyone else. In general, I will tell no one what you tell me. I will not even reveal that you are receiving treatment from me. In all but a few rare situations, your confidentiality (that is, our privacy) is protected by federal and state laws and by the rules of my profession. Here are the most common cases in which confidentiality is not protected:

1. When there is reasonable suspicion of child abuse or neglect, elder abuse, or dependent adult abuse

2. If the client threatens to harm another person

3. If the client threatens to harm himself/ herself

4. Records are subpoenaed by court

5. The client has authorized a release of information by his/ her signature

There are three situations in which I might talk about part of your case with another therapist or entity. I ask now for your understanding and agreement to let me do so in these two situations.

First, when I am away from the office for a few days, I have a trusted fellow therapist “cover” for me. This therapist will be available to you in emergencies. Therefore, he or she needs to know about you. Of course, the same laws and rules bind this therapist, as I am to protect your confidentiality.

Second, I sometimes consult other therapists or other professionals about my clients. This helps me in giving high-quality treatment. These persons are also required to keep your information private. Your name will never be given to them, some information will be changed or omitted, and they will be told only as much as they need to know to understand your situation.

Third, as part of cost control efforts, an insurance company will sometimes ask for more information on symptoms, diagnoses, and my treatment methods. It will become part of your permanent medical record. I will let you know if this should occur and what the company has asked for. Please understand that I have no control over how these records are handled at the insurance company. My policy is to provide only as much information as the insurance company will need to pay your benefits.

About Our Appointments

The very first time I meet with you, we will need to give each other much basic information. For this reason, I usually schedule 1–2 hours for this first meeting. Following this, we will usually meet for a 50-minute session once or twice a week, then less often. We can schedule meetings for both your and my convenience. I will tell you at least a month in advance of my vacations or any other times we cannot meet. Please ask about my schedule in making your own plans.

You will be charged the full fee for sessions cancelled with less than 24 hours’ notice, for other than the most serious reasons.

Except for unpredictable emergencies (or because of a situation that would be seen by both of us as an unpredictable emergency), if the appointment is not kept or is cancelled with less than 24 hours’ advance notice, you can expect me to charge you for it.

Fees and Payments

Payment for services is an important part of any professional relationship. This is even truer in therapy; one treatment goal is to make relationships and the duties and obligations they involve clear. You are responsible for seeing that my services are paid for. Meeting this responsibility shows your commitment and maturity.

Please fill in the amount you agreed to with Good Therapy San Diego:

Fee:

Initial Evaluation, 50 minutes _______

Individual Session, 50 minutes _______

Couples Session, 50 minutes _______

Group Session, 50 minutes ________

The client will provide a credit card number in order to hold his/ her appointment and will be charged after each session on this same card. Other arrangements can be made to pay with cash or check, but must be made with the therapist prior to the session. If requested, a billing statement will be provided to the client so that they may be reimbursed directly by their insurance company. All checks will be made out to Good Therapy San Diego.

Telephone consultations:

I believe that telephone consultations may be suitable or even needed at times in our therapy. Phone calls that are less than 10 minutes will not be charged. Longer calls will be charged the regular fee, prorated over the time needed. If I need to have long telephone conferences with other professionals as part of your treatment, you will be billed for these at the same rate as for regular therapy services. If you are concerned about all this, please be sure to discuss it with me in advance so we can set a policy that is comfortable for both of us. Of course, there is no charge for calls about appointments or similar business.

Extended sessions: Occasionally it may be better to go on with a session, rather than stop or postpone work on a particular issue. When this extension is more than 10 minutes, I will tell you, because sessions that are extended beyond 10 minutes will be charged on a prorated basis.

Initials _____________

If You Need to Contact Me

I cannot promise that I will be available at all times. Although I am in the office Monday through Friday, I usually do not take phone calls when I am with a client. You can always leave a message on my answering machine, and I will return your call as soon as I can. Generally, I will return messages daily except on Weekends and holidays. If I am out of town, or otherwise unavailable, I will let clients know in advance unless an emergency arises such as a sudden illness, or family emergency. In this case, a qualified professional will notify you and will discuss treatment options.

If you have an emergency or crisis, leave an urgent voicemail and I will try my best to return it as soon as I can. If you have a behavioral or emotional crisis and cannot reach me immediately by telephone, you or your family members should call 911 or visit the closest Hospital Emergency Room.

Our Agreement

I, _________________________ the client (or his or her parent or guardian), understand I have the right not to sign this form. My signature below indicates that I have read and discussed this agreement; it does not indicate that I am waiving any of my rights. I understand that any of the points mentioned above can be discussed and may be open to change. If at any time during the treatment I have questions about any of the subjects discussed in this brochure, I can talk with you about them, and you will do your best to answer them. I understand that after therapy begins I have the right to withdraw my consent to therapy at any time, for any reason. However, I will make every effort to discuss my concerns about my progress with you before ending therapy with you.

I understand that no specific promises have been made to me by this therapist about the results of treatment, the effectiveness of the procedures used by this therapist, or the number of sessions necessary for therapy to be effective.

I have read, or have had read to me, the issues and points in this brochure. I have discussed those points I did not understand, and have had my questions, if any, fully answered. I agree to act according to the points covered in this brochure. I hereby agree to enter into therapy with this therapist (or to have the client enter therapy), and to cooperate fully and to the best of my ability, as shown by my signature here.

____________________________________________	____________________________________________

Signature of client (or person acting for client)	Date

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Printed name

____________________________________________	____________________________________________

Signature of client (or person acting for client)	Date

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Printed name

Relationship to client:	❑ Self	❑ Parent	❑ Legal guardian

❑ Health care custodial parent of a minor (less than 14 years of age)

❑ Other person authorized to act on behalf of the client - specify

I, the therapist, have met with this client (and/or his or her parent or guardian) for a suitable period of time, and have informed him or her of the issues and points raised in this brochure. I have responded to all of his or her questions. I believe this person fully understands the issues, and I find no reason to believe this person is not fully competent to give informed consent to treatment. I agree to enter into therapy with the client, as shown by my signature here.

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Signature of therapist	Date

I truly appreciate the chance you have given me to be of professional service to you, and look forward to a successful relationship with you. If you are satisfied with my services as we proceed, I (like any professional) would appreciate your referring other people to me who might also be able to make use of my services.