Psychotherapy Treatment contract
Welcome to my psychotherapy practice. This document contains important information about my professional services and business policies. Please read it carefully and note questions you have so we can discuss them at our next session. When you sign this document, it will represent an agreement between us and it will become part of your Clinical Record.
Psychotherapy varies depending on the problems you bring as a client and the approach of the therapist. It is therefore important you take care in selecting a therapist that fits your style and goals. Our first 1 to 3 sessions will involve an evaluation of your current concerns, needs, history, and hopes for treatment. By the end of the evaluation, I will be able to offer you my clinical impressions and a recommended approach to treatment. During this time, we can decide if I am the best person to provide the services you need to meet your therapy goals. As therapy involves a commitment of time, money, and energy, it is important you feel comfortable working with me.
If we agree to initiate psychotherapy together, I will usually recommend one 50-minute session per week at a mutually agreed upon time. My approach to treatment involves collaborative goal setting at both the onset and throughout therapy as well as actively discussing techniques that are found to be most helpful. In order for therapy to be most successful, it is recommended you work on things we talk about both during and outside of our sessions. If at any time during your treatment you have questions or concerns about our work together, please bring them to my attention.
Psychotherapy can have benefits and risks. Because therapy involves discussing difficult aspects of your life, you may experience uncomfortable feelings like sadness, guilt, frustration, anxiety, or anger. It can be painful to approach unpleasant thoughts and feelings as well as difficult to make changes to beliefs and behaviors. On the other hand, psychotherapy has also been shown to have many benefits. Therapy often leads to improved relationships, solutions to specific problems, and significant reductions in distress. However, the results of therapy cannot be guaranteed.
PROBABLE LENGTH OF TREATMENT
The length of psychotherapy treatment varies considerably depending on the person and the nature of the person’s problem. It is difficult, if not impossible, to accurately pinpoint the amount of time it will take to experience relief. Several factors contribute to the timeline, including
The nature of the problem itself (simple vs. complicated)
How long the problem has been a problem (recently developed vs. chronic or longstanding)
How much support you have from significant others (substantial versus negligible)
How much work you put into solving the problem outside of therapy
For those seeking relief from troublesome but straightforward problems, therapy can be effective in as little as 8 to 12 sessions. For more complex issues, therapy may last several months to several years.
You may end therapy at any time. Generally, you will be the one who decides when therapy will end. When possible, I encourage you to make this decision in collaboration with me. However, there are two situations in which I may decide the therapy will end.
First, if I assess in my clinical judgment that I am not able to help you, I will inform you of this fact and refer you to another therapist who may meet your needs. Some reasons I may reach such a decision include (but are not limited to):
I may recognize you are coping with a problem outside my scope of competence or expertise.
I may become aware of an existing relationship with you, your family, a client, or a shared mutual friend that may interfere with my objectivity or role as your therapist. Due to confidentiality, I may not be able to disclose the nature of this relationship to you.
I may become aware of another factor that would interfere with my role as your therapist, with my ability to maintain objectivity, or my potential to foster a sense of rapport with you.
Second, if at any time, you engage in behaviors that threaten my safety (directly or indirectly), that harass me (verbally, physically, or electronically), or if you harass or threaten the safety of my office, colleagues, clients, or family, then I reserve the right to terminate our therapeutic relationship immediately. If I terminate you from therapy, I will offer referrals to other sources of care, but cannot guarantee that they will accept you for therapy.
OTHER MENTAL HEALTH PROFESSIONALS
On occasion I may consult with other highly-trained licensed clinical psychologists. Consultation is for the purpose of continuously working to improve the quality and effectiveness of my services. In the event that I consult with other psychologist(s) regarding general details of our work together, I will not use your name and will make every effort to avoid revealing your identity. My colleagues are also legally bound to keep the information confidential. I will not tell you about these consultations unless I feel it is important for our work together or you request otherwise. I will note consultations in your Clinical Record.
You will be expected to pay for each session at the time it is held. You may pay by cash, check or credit card. The fee for a 50-minute session of individual therapy is $200. Bills that are 60 days past due may be placed in collection; I will inform you before I take this measure so that you will have the opportunity to pay promptly. If such legal action is necessary, the costs associated with that action, including attorneys’ fees, will be included in the claim and you agree to pay them. In most collection situations, the only information I release regarding a client’s treatment is his/her name, the nature of services provided, and the amount due.
In addition to weekly appointments, I may charge the same rate (prorated according to length) for other professional services you need. Other services may include report writing, telephone conversations lasting longer than 15 minutes, attendance at meetings with other professionals you have authorized, and preparation of records or treatment summaries. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party.
CANCELLATION AND TARDINESS POLICY
Once an appointment is scheduled you will be expected to pay for it unless you provide 24 hours advance notice of cancellation, regardless of the reason for cancellation. I will make every effort to start our sessions on time. Sessions will end 50 minutes after the scheduled appointment time, even if you are late. If (on rare occasion) I have to begin our session late, I will make up the missed time in some mutually agreeable fashion (e.g., by extending the session, if convenient for you). If it becomes necessary for me to cancel an appointment with you with less than 24 hours notice, you will not be charged for the session.
If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will be considered an “out of network” provider. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. Your insurance company may reimburse you directly for fees you have paid.
Managed Health Care plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. Some managed care plans will not allow me to provide services to you once your short-term benefits end. If this is the case, I will discuss your options with you and do my best to help you find a provider with whom you can continue your psychotherapy.
You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank.
You may contact me or reach my voicemail at 425-577-3939. I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voicemail that I monitor frequently during business hours. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are unable to reach me and feel that it is an emergency and you cannot wait for me to return your call, contact your psychiatrist or family physician, or go to the nearest emergency room (e.g., Stanford Hospital ER: 650.723.5111).
SOCIAL NETWORKING AND WEBSITES
I do not engage in relationships via social media networks (Facebook, Twitter, LinkedIn, etc.) with current or former clients. Ethical guidelines, as well as legal statutes of our licensing board have strict regulations with regards to dual relationships, confidentiality, and professional boundaries, which prohibit such contact.
In general, the privacy of all communications between a client and a psychologist is protected by law, and I can only release information about our work to others with your written permission. In most situations, I cannot even confirm to a third party that you are being seen in my practice unless you agree to this. However, there are a few exceptions. These situations rarely occur, and if this type of situation occurs, I will make every effort to fully discuss it with you before taking any action. Limits to confidentiality include:
To Protect You. My primary concern is the safety of clients who are working with me. If I have reason to believe that you are at risk for injuring or killing yourself, I am legally and ethically required to work with you to prevent this from occurring. This may range from contacting family members or others who can help provide protection, arranging for hospitalization with your consent, or even, in the event of an emergency, facilitating involuntary hospitalization.
To Protect the Public. In certain situations, I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a client’s treatment. For example, if I believe that a child, older adult (age 65 and older), or a dependent adult is being neglected or abused, I must file a report with the appropriate state agency. If I believe that a client is threatening serious bodily harm to another, I am also legally and ethically required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client.
In Legal Proceedings. Although I will make every effort to safeguard your privacy, your records may be subpoenaed by a court of law. In most legal proceedings, you may have the right to restrict access to information about your treatment. In some proceedings, such as those involving child custody and those in which your emotional condition is an important issue, it is possible that a judge may order my records and/or testimony. Confidentiality may also be limited by other situations in which the law requires or directs that confidentiality does not exist.
If you are unhappy with what is happening in therapy, or have a concern or complaint about your treatment, please talk about it with me so that I can respond to your concerns. I will take your criticism seriously, and with care and respect. If you continue to feel dissatisfied, you may file a complaint by contacting the Board of Psychology at: 1625 North Market Boulevard, Suite N-215, Sacramento, CA 95834 or 1-866-503-3221.
Your signature below indicates you have read the information in this document and agree to its terms.
CONSENT FOR EMAIL COMMUNICATION (optional)
If you wish to contact me for basic communication purposes or to schedule appointments, you may call me at 425.577.3939 or email me at email@example.com.
The decision of whether to have email contact with me is your decision. While email can be useful for scheduling or for exchanging information and resources, I do not recommend using email as a means to convey personal information. I do not offer advice, therapy, or emergency care via email as it is not a secure form of communication and the privacy of email exchanges cannot be guaranteed.
I understand that email is not a secure means of communicating, and the confidentiality of communication through e-mail exchanges is not guaranteed. I consent to mutual communication with Dr. Levoy via e-mail.