INFORMED CONSENT FOR PSYCHOTHERAPY
Your mental health is more important than your degree. Better to have a degree of sanity than just a degree.
Welcome to Irvine Family Counseling. I look forward to working together. To begin, read this document which contains important information regarding my therapeutic practices and business policies. You will need to know this information in order to consent to my services. Please read it carefully and make note of any questions you have so we can discuss them together. When you sign this document, it will represent an agreement between us. It will further signify your belief that I am adequately suited to serve you.
CONSENTING TO THE THERAPEUTIC RELATIONSHIP
Unlike other professional relationships, the therapeutic relationship is a highly personal one in addition to a professional one with inbuilt expectations. Given this, it is important for us to reach a clear understanding about how our therapeutic relationship will work. The next few sections cover the ethical values I practice and the professional policies I plan to adhere to as a part of our professional relationship. By the end of this document, you will have the information you need to make an informed decision about whether you want to pursue a therapeutic relationship with me. At any time, you may choose not to sign this form.
CONSENTING TO WORKING WITH A MARRIAGE AND FAMILY THERAPIST
I am by title a Marriage and Family Therapist (MFT). My license number is #118825 and may be verified at https://www.breeze.ca.gov/datamart/mainMenu.do. By definition, my role is to advance the mental and emotional wellbeing of individuals and families. The Behavioral Board of Sciences (BBS)- the California state agency crediting my license- believes healthy individuals and families are society’s most precious resource. Therefore, they issue MFT licenses for trained individuals, such as myself, to support their mental and emotional wellbeing. Please see the FAQs section on my website for additional background information, or see “What is a Licensed Marriage and Family Therapist” at https://www.bbs.ca.gov/consumers/info.html.
For information regarding my unique skills and qualifications, you may ask me directly through a complementary consultation or visit my website at www.hustontherapyinirvine.com.
CONSENTING TO THE PERSONAL RELATIONSHIP
With respect to our personal relationship, I take great care to ensure my actions are ethical and legal at all times, such that the Ethic Committees (AAMFT/ CAMFT), the BBS, and other therapists acting in my shoes would approve. When working with clients, my ethics (or ethos) are my top priority. They include:
Do no harm (Non-maleficence)
Work for your benefit and not my own (Beneficence)
Foster your independence (Autonomy)
Honor my promises/ fulfill my responsibilities (Fidelity)
Treat all individuals fairly (Justice)
Treat all individuals truthfully (Veracity)
These principles, and their corresponding values, are the cornerstone of my therapy practice and will not be compromised for any reason. Therefore, without fail, you can expect that your therapy will be conducted in a manner that fosters your growth and well-being. Any complaints and feedback will be taken with careful consideration. Complaints may be filed with the BBS at https://www.breeze.ca.gov/datamart/mainMenu.do. For additional information on my ethics in practice, please see the attached form titled “My Ethical Promises to You.”
In distinguishing the personal relationship from the professional one, my ethics are based primarily on my personal convictions and are my private condition for providing you the service but are not, in my view, part of the paid service itself. Similarly, the personalized care and attention I give you is genuine and comes from a place of pathos (or heart) and is not, in my view, part of the paid service.
Generally, I do not believe I am compensated for the unique bond I form among my clients which are personal in nature and priceless. However, I do believe I am compensated for my educational experience and level of expertise which provides me the opportunity to apply my skills and services. My empathy is free and should be seen as such to facilitate the genuine exchange of heartfelt compassion and empathy I give. My professional agenda, career aspirations or prideful desires will not come before the individual I serve. For additional information on my pathos in practice, please see the attached visual titled “Inside a Therapist’s Heart.”
CONSENTING TO THE PROFESSIONAL RELATIONSHIP
To support the growth and well-being of my clients and their families, I work with you systematically over a period of time to achieve the changes and improvements you are looking for. A structured process is involved, which is called the therapeutic process, and it serves as the framework of the therapy service. The rest of this document will pertain to the logistics (or logos) of my therapy practice and the legal responsibilities I have as a state-licensed mental health provider.
THE THERAPEUTIC PROCESS
Seated in comfortable sofas on a private office floor, we meet regularly to identify and meet mutually agreed-upon goals for 55 minutes a session. After we meet for an initial consultation or first-time appointment, the next 2-3 sessions will be used to gather information regarding your background, presenting difficulties, and current mental health symptoms. This is necessary to formulate a sound clinical diagnosis and treatment plan out of which future sessions are designed. Subsequent sessions usually follow this treatment plan and involve regular check points to assess progress. Deviations in the treatment plan are expected and will require modifications for staying relevant.
Given the diversity of circumstances giving rise to individual needs and concerns, the duration of time required for meeting goals is difficult to predict. If your curiosity persists, you may ask me directly for an estimation of your therapy duration. Certainly, therapy beyond what is necessary for your mental health will not be entertained out of respect for your time, finances and independence.
During the course of therapy, I draw on various psychological approaches according to the need that is being treated and my assessment of what will best benefit you. These approaches include, but are not limited to, cognitive behavioral therapies, humanistic-existential therapies, post-modern therapies, systemic therapies, and psychodynamic therapies.
I do not conduct psychological assessments, provide custody evaluation reports, recommend medications or prescriptions, or offer legal advice as these activities do not fall within my scope of practice. Further, I do not testify in legal proceedings unless subpoenaed.
Your confidence that I will respect your privacy fosters your willingness to be open and is the best indication that I can help you. In order to earn this trust with you, I practice the following policy on confidentiality.
All information disclosed to me within therapy sessions and the written records pertaining to those sessions are kept confidential and may not be revealed to anyone without your written permission except where disclosure is required by law. The circumstances requiring disclosure by law are listed below:
ABUSE. When there is a reasonable suspicion of child abuse, elder abuse, or abuse of a dependent adult that is physical, sexual, or emotional, I will file a report with the appropriate state agency.
HARM TO SELF. When the client threatens serious bodily harm to self, I will seek hospitalization for the client and contact family members or others who can help provide safety.
HARM TO OTHER. When a client threatens serious bodily harm to another, I will notify the potential victim, contact the police, or seek hospitalization for the client.
COURT ORDER. When disclosure is required for a legal proceeding, I will comply.
PERMISSION: When a client wishes their therapist to speak with a third party, I will comply.
If the above circumstances do not apply, all information discussed or written pertaining to our therapy is kept confidential. When the above circumstances apply, I make every effort to inform you of the steps I take when breaching your confidentiality and share the minimum information required to secure your safety and the safety of others.
Throughout our clinical work, I keep written records to meet required standards of care. You are entitled to receive a paper copy or summary of your records at any time. Once you submit a request in writing, I have 5 days until you may inspect the records, 10 days until you receive a summary, and 15 days until you may receive a copy of your entire record.
Sometimes, these professional records can be misinterpreted by untrained readers. Therefore, if you wish to view your records, I recommend you review them in my presence so we can discuss the contents.
RISKS AND BENEFITS
The benefits of therapy are endless. They include, but are not limited to, better relationships, improved work performance, enhanced self-awareness, solutions to specific problems, reduced feelings of distress, stronger communication skills, resolved childhood trauma, personal liberation, self-regulation strategies, intellectual insight, increased happiness, and an enhanced sense of purpose, etc.
The risks of therapy may involve periods of discomfort. Among other discomforts not listed here, they include confronting denial, acknowledging vulnerabilities, revisiting old wounds, detaching from familiar comforts, unlearning bad habits, developing new skills, and changing behavioral patterns, etc.
Moreover, there is no guarantee that therapy will yield the positive or intended results hoped for. The surest way to reduce this risk is to engage in the process consistently, thoughtfully and dutifully. If progress is not occurring within a reasonable amount of time, we may have a conversation to discuss the potential causes and alternative options for your mental health improvement.
If you are the parent or legal guardian bringing a minor to therapy, please see the additional form titled “Consent for Minors”. When you sign this form, unless conditions for breaching confidentiality have been met, you will agree to having access to general information regarding your minor’s therapy in place of full access. This will enable your minor to have a confidential relationship with me while I serve as their advocate.
For minors under the age of 12, you may sign the “Consent for Minors” form on their behalf. For minors between the ages of 12-18, they will receive a copy of this form to sign separately. If you share custody of the minor, please provide a copy of the custody agreement prior to beginning therapy.
FEES AND SERVICES
My fee is $150 for an appointment hour of 55 minutes in duration. Payment is due for each session at the time it is held unless we agree otherwise. I accept Visa, MasterCard, American Express, Discover, Cash, Check, and Venmo. There is a 3% fee for using credit cards. Once the first credit card authorization is given and signed, future credit card authorizations (with additional and/or replacement cards) may be given verbally. You may request a receipt for your services at any time.
If we decide to meet longer or shorter than one hour, your prorated rated will be based on this fee. Emergency phone calls less than 15 minutes are complimentary. Any conversation over 15 minutes may be charged. Other therapeutic services priced at my prorated rate include report writing, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing others service you request of me.
Phone calls are offered as a professional courtesy and this service does not constitute an emergency psychological service. I am not responsible for your behaviors or decisions occurring outside the therapy room at any given time, whether before or after a phone call or therapy session. If you are unable to reach me and feel that you can’t wait for me to return your call, contact 911, your personal physician or the nearest emergency room to ask for the psychologist (or psychiatrist) on call. If I am unavailable for an extended period of time, a qualified professional will be available for you to contact during my absence.
APPOINTMENTS AND CANCELATIONS
Since scheduling an appointment involves the reservation of time specifically for you, in place of other appointments that could take place, a minimum of 24 hours (1 day) notice is required for re-scheduling or cancelling an appointment. Unless we reach a different agreement in advance, the full fee will be charged for sessions missed without such notification. If you were unable to attend due to circumstances beyond your control, the fee will be waived and if possible, we will find another time to reschedule the appointment.
You are responsible for ensuring that your account balance is paid in full. If your account has not been paid for more than 30 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure unpaid payments. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, such costs will be included in the claim. In most collection situations, the only information I will release regarding a client's treatment is the client’s name, the nature of services provided, and the amount due.
I am considered an “out of network” provider meaning I accept PPO insurances. After compensating me directly for my service, I will provide a super-bill or a receipt of two or more services which you can submit to your insurance company for reimbursement (often around 50-80% depending on whether you have met your deductible). You can call your insurance company in advance to determine your out-of-pocket payment. For a list of helpful questions to ask your insurance company, please email me.
For those who do not have PPO insurance and/or require financial accommodations, I provide, based on financial need, a sliding scale fee which is not fixed and may be subject to change. Periodically, we will have conversations to reassess your level of need and your fixed rate may be adjusted. These conversations should occur before consenting to therapy and may happen in-person or over the phone.
The subject matter of all electronic communication (text or email) will be limited to logistical information. For the sake of your privacy, please do not text or email information which should be discussed in therapy. I may opt to not return any electronic communication that violates this policy in order to reduce the amount of opportunities for your private information to be hacked.
Phone calls are the best way to contact me outside of therapy. If you do not reach me directly, you may leave a confidential voicemail in my inbox, which I monitor periodically throughout the day. I will make every effort to return your call within one business day, with the exception of weekends and holidays. If you are difficult to reach, please inform me of times when you will be available.
Phone calls are considered a professional courtesy and do not constitute an emergency psychological service. I am not responsible for your behaviors or decisions occurring outside the therapy room at any given time, whether before or after a phone call or therapy session.
Your participation in psychotherapy and other psychological services is voluntary and you have the right to withdraw from treatment at any time. When termination is considered, whether on my end or yours, I recommend we create a plan for termination to minimize any possible negative effects. When termination is considered prematurely for any reason, my services may remain available for future considerations. Referrals may be provided for your continuation of care.
If you fail to appear for 3 consecutive scheduled appointments, your treatment will be considered terminated and you will be financially responsible for the fees of the missed sessions. A letter will be sent to you acknowledging the termination along with a closing bill for any unpaid balance.
Welcome to the near-end of this document. In the information provided above I have briefly described my ethical practices and empathic approach. I spoke at length regarding my logistical policies and provided avenues for you to obtain additional information not included in this document. In summary, you should have a clear understanding of my practice’s ethos, pathos and logos. You now have enough information to make an informed decision about whether you want to pursue a therapeutic relationship with me.
If the above meets your expectations and you’re ready to proceed with therapy, please read the final statements below and check the box. If any doubt persists and our conversations do not allay them, I will be happy to refer you to another therapist for a second opinion.
CONSENT FOR TREATMENT
___I request and authorize Monica Huston (LMFT #118825) to provide psychological assessments, examinations, treatment, and/or diagnostic procedures which are advisable during the course of my care as her client.
___I understand that there is an expectation that I will benefit from psychotherapy but there is no guarantee that this will occur.
___I understand that maximum benefit will occur with consistent attendance and that, at times, I may feel conflicted about my therapy as the process can sometimes be uncomfortable.
___I understand that my participation in psychotherapy is completely voluntary and that I may terminate psychotherapy at any time.
___I understand that the purpose of these guidelines is to clarify the nature of our professional relationship.
___I understand that I can obtain a copy of this informed consent by downloading it from my client portal under SimplePractice or by emailing Monica Huston directly at email@example.com