Informed Consent

 

Patient Full Name:
Date:

Treatment Process:

Psychotherapy is a voluntary process which involves examining and changing thoughts, feelings, and behaviors. Successful therapy involves a commitment to this process, often including regular sessions (typically weekly or biweekly). Successful therapy also requires you and possibly your support persons or other providers, to be actively involved in session and homework between sessions.

Treatment at Roamers Therapy begins with an assessment. This assessments determines if Roamers Therapy is able to provide treatment appropriate to your needs. Based on this assessment, your therapist may recommend further assessment/services to other providers, including psychiatric evaluation, a psychological evaluation, substance abuse evaluation, couples assessment, or medical evaluation. Completing these recommendations is voluntary, but may help your treatment to be effective by providing additional insight.

Roamers Therapy is able to provide multiple styles of therapy which include individual psychotherapy, couples therapy, and online therapy. At the end of the assessment your therapist will discuss which type is recommended based on your assessment and response to treatment. It is up to you if you decide to engage in the recommended treatment, but Roamers Therapy may decline to offer further services if you decline recommended services.

Potential benefits of therapy include obtaining a professional guidance and change troubling thoughts, feelings, or behaviors. Risk of therapy include confronting difficult emotions, memories, or conversations. Any negative response to treatment should be shared with your therapist.

I have read the "Treatment Process" section carefully.

 

 

Client Rights and Responsibilities

Confidentiality

Sessions with your therapist are confidential with some exceptions. The following are some exceptions:

  1. If you are in therapy by an order of the court, the results of treatment ordered must be revealed to the court.
  2. In the event of a mental health emergency, defined by threat to harm yourself or another individual, your therapist will complete an assessment of risk, and may recommend further assessment (known as an emergency psychiatric evaluation) at a local emergency room or other location. Your cooperation with the recommendations is requested. If you decline a recommendation, your therapist may act to ensure your safety, including, but not limited to: contacting local authorities to conduct a safety check, contacting your emergency contact, warning the person threatened, invoking your parents/guardian, requesting a court-mandated psychiatric evaluation, contacting DCFS, or contacting 911.
  3. If physical abuse, sexual abuse, or neglect to any minor child or vulnerable adult is suspected, the therapist must report their knowledge or suspicions to the appropriate authorities.
  4. If you are under 18 or have a guardian, the therapist reserves the right to advise parents or legal guardians about developments that could significantly affect your health or wellbeing.
  5. If you choose to sign a a release of information, the information defined on the release of information may be shared.
  6. If you elect family or group therapy, Roamers Therapy can not guarantee that information will not be shared by individuals participating.
  7. If you elect to communicate with the Roamers Therapy via text or e-mail, we cannot guarantee the information will remain confidential, although, we utilize a HIPPA complaint platform.
  8. If Roamers Therapy receives a court-order to provide information on your record or to testify, the agency may be mandated to comply.
  9. If you bring a suit against Roamers Therapy staff member or former staff, Roamers Therapy may utilize information in your record to defend its actions.
  10. Roamers Therapy may need to reveal protected heal information to your health insurance for reimbursement purposes.
  11. Roamers Therapy staff may consult and seek supervision with another professional about your assessment or treatment.
  12. If you are coming in for legally mandated treatment, Roamers Therapy staff will ask you to sign a release of information and staff member reserves the right to report the status of your attendance.
  13. If you are have been a a client, the staff member may consult with your prior files for more information.
  14. Roamers Therapy may utilize interns and unlicensed therapist to provide treatment services. All unlicensed interns and therapist are supervised by fully licensed therapist.
  15. Roamers Therapy utilizes a cloud-based electronic health record to maintain client files. Clients seeking services at Roamers Therapy agree to maintaining of their files in this system.

I have read the "Confidentiality" section carefully.

 

 

Treatment Planning

You will be asked to complete a set of assessments before, during, and the end of the treatment. These assessment will help structure your treatment plan and monitor progress and effectiveness.

Roamers Therapy is not capable of meeting the needs of all clients for treatment issues. Following your assessment, your therapist will discuss the treatment options available, as well as your appropriateness for treatment at Roamers Therapy. If Roamers Therapy determines it cannot meet your needs, you will be provided referrals.

You have the right to ask questions and actively participate in the setting of goals at the beginning and throughout treatment.

Please arrive promptly to your appointments, if you are more than 15 minutes late, your session may be cancelled, and you will be charged a fee.

I have read the "Treatment Planning" section carefully.

 

 

Fee Schedule

Roamers Therapy ensures that when time and effort has been put into scheduling and securing mental health services, that individuals are guaranteed quality services. Roamers Therapy holds a non-refundable and missed-appointment policy. Once you have booked a session fees are 100% non-refundable If you need to cancel, a missed-appointment fee will be automatically charged of up to $150 an hour. If you are unable to make it please contact Roamers Therapy via e-mail.

Please review Roamers Therapy fee schedule, for more information on missed appointment policy. [ATTACHED FEE SCHEDULE & POLICY].

I have read the "Fee Schedule" section carefully.

 

 

Financial/Insurance issues

As a courtesy, Roamers Therapy will bill your insurance company, responsible party or third-party payer for you if you wish. Roamers Therapy ask that at each session you pay your co-pay and co-insurance. In the event you have not met your deductible, the full fee is due at each session until the deductible is satisfied. If your insurance company denies payment or does not cover counseling, Roamers Therapy request that you pay the balance due at that time. If your balance exceeds $300.00 Roamers Therapy will need to ask that you pay for services when rendered.

Roamers Therapy will ask that every client authorize payment of medical benefits directly to Roamers Therapy LLC.

I have read the "Financial/Insurance issues" section carefully.

 

 

Termination of Therapy

Treatment is voluntary. You may elect to end treatment at any time for any reason. Treatment may end for the following reasons among others:

  • Therapy may end based on mutual consent.
  • Therapy may end if you have completed number of contracted sessions.
  • Therapy may end if you have met your treatment goals.
  • Therapy may end if you fail to comply with treatment recommendations.
  • Therapy may end if Roamers Therapy determines your needs cannot be met with the services the agency provides.
  • Therapy may end if you harass, threaten, or harm any property, staff, or another client at Roamers Therapy.
  • Therapy may end if you are not seen face-to-face for 30 days or more.
  • Therapy may end if you fail to pay outstanding balance of rendered services.

I have read the "Termination of Therapy" section carefully.

 

 

 

Client Signature (12 or older)


My signature below indicates that I have been informed and understand my rights and give consent for treatment at Roamers Therapy LLC.

 

Signature: You can draw your signature on the gray area below.



 

 

Next step: Initial Assessments →