This page contains the text of my Informed Consent for Services, and you should read it and ask me any questions that you may have about any of the information contained in it. This should be done as early as possible in treatment. You may also ask questions at any time after starting treatment or counseling with me. This information is also referenced in the consent form that is part of the “Application for Services” document on the “Forms” page, accessible from the main menu of the website.
1. Client Rights and Responsibilities – Counseling and Psychotherapy Services: As a client in psychotherapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights of which you should be aware. As your therapist, I have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.
2. Benefits and Risks; No Guarantees: My approach to psychotherapy is tailored to your needs and, at the same time, makes use of interventions such as support, insight, and behavioral suggestions, which research has generally found to be effective. Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, like sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals and families who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress, and resolutions to specific problems. Psychotherapy requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions. Your participation can be expected to improve the results you achieve; however, psychotherapy cannot be guaranteed to result in emotional or functional improvement for everyone.
3. Limits of Practice and Scope of Services: My practice is an outpatient office-based practice, and I do not provide services at a level of intensity sufficient to treat unmanageable mental or emotional states, intense interpersonal conflicts, or other crisis situations. If I become aware that you have problems or issues for which my training does not provide adequate preparation or for which my practice does not offer the intensity of services that would be required, I will refer you to another facility or provider that I believe has the resources, training and experience to provide you with the services you require. You agree to accept my referral based upon my determination that this action may be necessary to protect us both. Professional Counselors and psychologists have an ethical responsibility to respect their clients’ personal values, including religious and cultural values, and my personal beliefs or values will not be a reason for me to refer you elsewhere. However, if you strongly feel that a clinician who shares your values would be a better fit (for example, a counselor who explicitly practices in a Christian counseling model), I will recommend such a person.
4. Confidentiality: My policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled Notice of Privacy Practices. [See the “FORMS” page at www.fitzgeraldcounseling.com]. You have been provided with a copy of that document and we have discussed those issues. See the “Insurance and Privacy” section of this statement also. Protecting your confidentiality is my ethical responsibility, and is also governed by several laws and regulations including the Illinois Mental Health and Developmental Disabilities Confidentiality Act, the Federal Health Insurance Portability and Accountability Act (HIPAA), the federal Health Information Technology for Economic and Clinical Health (HITECH) Act, and federal regulations governing drug and alcohol abuse records. Any authorization to release confidential information must specify the limits of what is released including the type of information, the purpose of the release, the consequences of refusal to release, and the time limit that the authorization will remain in effect. Please remember that you may reopen the conversation about privacy and confidentiality at any time during our work together.
MANDATED REPORTING, DUTY TO WARN: You should also be aware that I am a mandated reporter of child abuse and neglect, and that mental health professionals have responsibilities to protect elderly or otherwise dependent individuals, as well as a complex set of balanced responsibilities to take reasonable steps to warn or protect anyone who may be at risk due to a client’s actions if the professional becomes aware of threats or intent to harm another or themselves, while respecting client confidentiality to the extent that is possible.
PARENTS & MINORS: While privacy in therapy is crucial to successful progress, parental involvement can also be essential. It is my policy not to provide treatment to a child under age 13 unless s/he agrees that I can share whatever information I consider necessary with a parent. For children 14 and older, I request an agreement between the client and the parents allowing me to share general information about treatment progress and attendance, as well as a treatment summary upon completion of therapy. All other communication will require the child’s agreement, unless I feel there is a safety concern (see also above section on Confidentiality for exceptions), in which case I will make every effort to notify the child of my intention to disclose information ahead of time and make every effort to handle any objections that are raised.
5. Treatment Planning: The first 2-4 sessions will involve a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some initial impressions of what our work might include. At that point, we will discuss your treatment goals and create an initial treatment plan. You should evaluate this information and make your own decision about whether you feel comfortable working with me. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion.
6. Appointments, Missed Appointments, and Cancellations: Appointments will ordinarily be 45-55 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours notice. If you miss a session without canceling, or cancel with less than 24-hour notice, my policy is to collect the full amount of your fee [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the portion of the fee as described above. If it is possible, I will try to find another time to reschedule the appointment. In addition, you are responsible for coming to your session on time. If you are late, your appointment will still need to end on time.
7. Professional Fees: The standard fee for the initial intake is $200.00 and each subsequent session is $125.00. You are responsible for paying at the time of your session unless prior arrangements have been made. You may pay by check, cash, or credit card. Any checks returned to my office are subject to an additional fee of up to $25.00 to cover the bank fee that I incur. Checks returned for NSF will result in all future fees and co-payments being payable in cash or cashier’s check only. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment. (Payment options are restricted for DOT Substance Abuse Professional Evaluations.)
OTHER FEES: In addition to weekly appointments, it is my practice to charge my standard fee amount on a prorated basis (I will break down the hourly cost) for other professional services that you may require such as report writing (including disability or employment reports), telephone conversations that last longer than 15 minutes, attendance at meetings or consultations which you have requested, or the time required to perform any other service which you may request of me. If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required (including preparation and travel) even if another party compels me to testify.
8. Insurance: In order for us to set realistic treatment goals and priorities, it is important to evaluate the resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. With your permission, I will assist you in filing claims and obtaining information about your coverage, but you are responsible for knowing your coverage and for letting me know if/when your coverage changes. Health care plans often require advance authorization, without which they may refuse to 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. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, and you are not in a position to pay for services, I will do my best to find another provider who will help you continue your psychotherapy.
HEALTH INSURANCE AND PRIVACY: You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Diagnoses are terms that describe the nature of your problems and help providers suggest generally accepted treatments. Mental health diagnoses come from the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) and/or the International Classification of Diseases (ICD). Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or (in rare cases) copies of the entire record. This information will become part of the insurance company files and may be stored electronically. Although HIPAA and other laws and regulations apply to health records, I have no control over what insurers do with personal health information once it is in their hands. Although employers generally do not have access to this information, it may affect your ability to enroll in life or health insurance plans in the future. Insurers may also share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. Your signature on the release authorization above ensures that I can provide requested information to your carrier if you plan to pay with insurance.
PREAUTHORIZATION: If you plan to use your insurance or EAP benefit, authorization from the insurance company or EAP Company may be required before they will cover therapy fees. If you did not obtain authorization and it is required, you may be responsible for full payment of the fee. Many policies leave a percentage of the fee (which is called co-insurance) or a flat dollar amount (referred to as a co-payment) to be covered by the patient. Either amount is to be paid at the time of the visit by check, credit card, or cash. In addition, some insurance companies also have a deductible, which is an out-of-pocket amount that must be paid by the patient before the insurance companies begin paying any amount for services. This will typically mean that you will be responsible to pay for initial sessions with me until your deductible has been met; the deductible amount may also need to be met at the start of each calendar or benefit year. Once we have all of the information about your insurance coverage, we will discuss what we can reasonably expect to accomplish with the benefits that are available and what will happen if coverage ends before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above, unless prohibited by my provider contract.
OUT-OF-NETWORK BENEFITS: If I am not a participating provider for your insurance plan, I will supply you with a receipt of payment for services, which you can submit to your insurance company for reimbursement. Please note that not all insurance companies reimburse for out-of-network providers, and coverage is often reduced. If you prefer to use a participating provider, I will refer you to a colleague.
9. Employee Assistance Program (EAP) Services, If Applicable: There are several EAP organizations with which I am contracted to provide assessment, referral, short-term counseling, and follow-up services to covered employees and their family members. EAP benefits may be managed by your health insurer or by a separate organization. In general, employees and their family members may receive EAP services with no co-payment or fee charged. I am required by some of my contracts to refrain from charging for missed appointments or services that are denied payment by the EAP or health plan; however, missing an appointment will usually reduce the number of EAP sessions available to you. Sometimes there is initial confusion about whether EAP benefits, health insurance, or both, apply to your services. For this reason, I reserve the right to charge for services for which your failure to secure authorization results in a denial of payment for services I provide. In that situation, you agree to be responsible for fees for services I provide. You should contact your human resources department concerning any questions you may have about your responsibilities for accessing EAP benefits, prior to starting to receive services.
10. Liability for Others’ Use of My Clinical Findings: I do not provide formal evaluations for child custody or fitness for employment, DUI services under Illinois law, nor any other forensic evaluations. However, some Employee Assistance Programs use clinicians like me to assess whether an employee has met the conditions for return to duty and/or make recommendations about a return to work date. If I am asked to do this, I will require your written consent to release such information. Responsibility for the final decision to place an employee back on duty, or for any decisions to terminate employees, rests with the employer; and I make no warranty whether any such decision will be favorable to the employee. Likewise, my reports and records about you may be used (with or without the permission of either party) in court cases and other situations in which I am compelled to provide records or testimony. My sole responsibilities are to perform a thorough assessment and to exercise careful and sound judgment in reporting clinical findings within the standard of care for a licensed behavioral health clinician. You agree that I will not be held liable for decisions by other parties, using my reports or records, which may be unfavorable to you. (Please note that my role as a Substance Abuse Professional under US Department of Transportation regulations involves additional responsibilities on my part, and you should read the section of this website on “SAP Evaluations” to be sure that you understand the limits of confidentiality, and my duty to protect the public imposed by the regulations governing the return-to-duty process).
11. Professional Records: I am required to keep appropriate records of the services that I provide. Your records are maintained in a secure location in one of my offices. I keep brief records noting that you were here, your reasons for seeking therapy, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records I receive from other providers, copies of records I send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be unclear for untrained readers to understand or interpret. For this reason, I recommend that you initially review them with me, or have them forwarded to another mental health professional to discuss the contents. If I refuse your request for access to your records, you have a right to have my decision reviewed by another mental health professional, which I will discuss with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request.
12. Contact Information and Emergency Procedures: Telephone or fax are considered secure communications, while e-mail is not, and you use it at your own risk. I am often not immediately available by telephone. I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a message on my confidential voice mail and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters. Phone service, voice mail, and e-mail are all subject to outages and interruptions. If, for these reasons or any number of other unforeseen reasons, you do not hear from me or I am unable to reach you, I encourage you to try contacting me again. If you are unable to reach me and you feel you cannot wait for a return call, or if you feel unable to keep yourself safe, 1) contact your local crisis line or mental health agency (I can provide these numbers for you and they are listed in the phone book), 2) go to your local hospital Emergency Room, or 3) call 911 and ask to speak to an emergency worker. If you feel that you are in danger from a family member or domestic partner, you should contact law enforcement or the local domestic violence agency.
VACATIONS AND OTHER ABSENCES: I will make every attempt to inform you in advance of planned absences, and provide you with the name and phone number of the mental health professional covering my practice.
13. Other Rights: If you are unhappy with what is happening in therapy, I encourage you to talk with me so that I can respond to your concerns. Your concerns will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist and are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect that I will not have social or sexual relationships with clients or with former clients. If I become aware of a multiple relationship (such as a business or family connection) or role conflict that may compromise the effectiveness of my services to you, I will refer you to another competent provider instead.
Your signature on the Application for Services form indicates that you have read this Agreement and the Notice of Privacy Practices and agree to their terms. You may keep this agreement for future reference. If you have any questions or concerns at any time, you may contact Dr. Fitzgerald by phone, mail, or e-mail.