Informed Consent for Couples/Family Counseling

OVERVIEW

Couples therapy is a process of identifying interaction and communication patterns that

are negatively impacting the friendship, intimacy, and fulfillment of needs of one or both

partners in a relationship. Each partner will be expected to honestly examine their own

interaction and communication styles, identify and express their own feelings, and make

an attempt at experimenting with alternative methods of communicating and

interacting. Each partner will be helped to further clarify their own values and their own

level of commitment to the relationship, and the outcome of the therapy may be

increased satisfaction with the partnership or increased clarity about the decision to

part ways.

THE COUPLE IS THE CLIENT

When you attend couples therapy sessions,you as a couple are considered to be “the

client” and your mental health records therefore belong to both of you. This means that

except in the circumstances below, I will need a written consent from both of you in order

to disclose any information from your record to a third party. Both parties will need to be

physically located in the state that the clinician is licensed to practice.

CONFIDENTIALITY

The session content and all relevant materials to the client’s treatment will be held

confidential unless the client requests in writing to have all or portions of such content

released to a specifically named person/persons. Limitations of such client held

privilege of confidentiality exist and are itemized below:

1. If one of you pose an imminent danger to yourself, your partner, or a third person,

a therapist is legally required toreport this information to the authorities

responsible for ensuring safety.

2. If the therapist has a reasonable suspicion that a client or other named victim is

the perpetrator, observer of, or actual victim of physical, emotional, sexual

abuse, or neglect of children under the age of 18 years, an elderly or disabled

person.

3. A court order, issued by a judge, may require the Counseling Services staff to

release information contained in records and/or require a therapist to testify in a

court hearing.

Occasionally your therapist may need to consult with other professionals in their areas

of expertise in order to provide the best treatment for you. Information about you may be

shared in this context without using your name.

NO SECRETS POLICY

As a therapist who is entrusted with information from both partners of a relationship, we

have a policy of “No Secrets”, which means that your therapist cannot promise to protect

secrets of either partner from the other person, especially if the secret is harmful or

destructive to the process of the therapy itself or undermines the agreed upon intention

of the therapy.

On occasion during the counseling process, individual partners may be seen for an

individual counseling session by your therapist.

In this case, the individual session is still considered as part of the couple’s counseling

relationship. Information disclosed during individual sessions may be relevant or even

essential to the proper treatment of the couple. If an individual chooses to share such

information, your therapist will offer the individual every opportunity to disclose the

relevant information and will provide guidance in this process. If the individual refuses

to disclose this information within the couple’s session, your therapist may determine

that it is necessary to discontinue the counseling relationship with the couple. If there is

information that an individual desires to address within a context of individual

confidentiality, your therapist will be happy to provide referrals to therapists who can

provide concurrent individual therapy. This policy is intended to maintain the integrity of

the couples/marital counseling relationship.

Because the relationship is the main focus of couples therapy both partners of a couple

must be present for the couples session to start. It is often not in the best interest of the

couple to distribute time unevenly between partners or to have unplanned meetings with

only one partner present. If one partner is late in arriving or does not show for the

appointment, your therapist reserves the right to delay the start of the session or to

cancel the session if necessary.

LIMITATIONS TO COUPLE’S COUNSELING

Couples therapy will only be effective in cases where both partners put in a good faith

effort to work on their problems and their relationship. Deliberate dishonesty or deceit,

unwillingness to introspect and take responsibility for one’s actions, or lack of interest

and motivation to engage in the couples therapy process by one or both partners will

undermine the therapy.

GOOD FAITH ESTIMATE

You are entitled to receive this “Good Faith Estimate” of what the charges could be for

Mental Health services provided to you. While it is not possible for a provider to know, in

advance, how many visits may be necessary or appropriate for a given person, this form

provides an estimate of the cost of services provided. Your total cost of services will

depend upon the number of visits you attend, your individual circumstances, and the

type and amount of services that are provided to you. This estimate is not a contract and

does not obligate you to obtain any services from the provider(s) listed, nor does it

include any services rendered to you that are not identified here. This Good Faith

Estimate is not intended to serve as a recommendation for treatment nor a prediction

that you may need to attend a specified number of Mental Health visits. The number of

visits that are appropriate in your case, and the estimated cost for those services,

depends on your needs and what you agree to in consultation with your provider. You are

entitled to disagree with any recommendations made to you concerning your treatment

and you may discontinue treatment at any time.

The fee for services are listed below:

Mental Health Assessment- $180, Psychotherapy Follow-up- $130

FEE FOR SERVICE

It is your responsibility to inquire about fee for service with the Behavioral Health

Solutions Administration (BHS), if needed. Regardless of negotiated fee arrangements

and/or insurance coverage, payment for services is your responsibility and due at the

time of your appointment or billing statement date. If filing with insurance, you are

ultimately responsible for any claims not paid by your insurance company for any

reason. Behavioral Health Solutions requires clients to submit a credit card

authorization. Payment is expected at the time of your appointment. Your session fee,

co-pay, co-insurance, deductibles, late cancellations fees, and missed appointments

fees will be charged to the credit card on file. If your account has not been paid for more

than 30 days, or you accrue a balance greater than $150, services will be paused until

your balance is paid in full or a payment plan is setup. It is counterproductive to the

therapeutic process to add financial stressors to it. In cases where arrangements for

payment have not been agreed upon, BHS has the option of using legal means to secure

the payment. This may involve hiring a collection agency. The personal information and

insurance information provided is complete and accurate. I authorize the release of any

information necessary to file an insurance claim on my behalf and I assign insurance

benefits to be paid to Behavioral Health Solutions. I understand that payment for copays

and deductibles are required at the time services are rendered. In the event that my

insurance company denies a claim, I will become financially responsible for all amounts

not covered, payable to Behavioral Health Solutions. I agree to be contacted by

telephone, mail or email according to the contact information that I have provided. I

understand if outstanding balances are due for more than 90 days without payment,

Behavioral Health Solutions may turn over the outstanding balance due to a collections

agency and that I will be financially responsible for additional collections costs.

Insurance Disclaimer: A quote of benefits and/or authorization does not guarantee

payment or verify eligibility. Payment of benefits are subject to all terms, conditions,

limitations, and exclusions of the member’s contract at time of service. Behavioral

Health Solutions will attempt to verify your health insurance benefits and/or necessary

authorizations on your behalf.

PLEASE NOTE: this is only a quote of benefits and/or

authorization. We cannot guarantee payment or verification eligibility as conveyed by

your health insurance provider will be accurate and complete. Payment of benefits are

subject to all terms, conditions, limitations, and exclusions of the member’s contract at

the time of service.

Insurance Liability for Payment: Your health insurance company will only pay for services

that it determines to be “reasonable and necessary.” Every effort will be made by this

office to have all services and procedures pre authorized by your health insurance

company, when applicable. If your health insurance company determines that a

particular service is not reasonable and necessary, or that a particular service is not

covered under the plan, your insurer will deny payment for that service. We suggest to

all patients that they contact their insurance to confirm that these services are covered.

Under this arrangement, you are responsible for paying your co-pay, any noncovered

portions, and any deductible you have yet to cover. In addition, if your insurance

company does not pay for our services, you agree to pay for the services provided.

Insurance Referral/Pre-Certification/Authorization of Services: Many insurance

companies may require preauthorization of services. Please know that it is your

responsibility to obtain authorization of services for an out-of-network provider if

needed. You will be responsible for any charges not covered by insurance due to lack of

precertification/authorization for an out-of-network provider. Please contact BHS

administration if you need assistance with this process. Refunds are only issued when

an overpayment has been identified. If you feel there has been an overpayment, please

contact Behavioral Health Solutions’ office. We do NOT accept personal checks.

Beneficiary Agreement: I understand that my health insurance company may deny

payment for the services identified above, for the reasons stated. If my health insurance

company denies payment, I agree to be personally and fully responsible for payment. I

also understand that if my health insurance company does make payment for services,

I will be responsible for any co-payment, deductible, or coinsurance that applies: You

are entitled to receive this “Good Faith Estimate” of what the charges could be for Mental

Health services provided to you. While it is not possible for a provider to know, in