CONSENT TO TREATMENT
I________________________________, have requested Daphne Stevens, Ph.D., LCSW provide psychotherapeutic services for me. I understand that the benefits of therapy are highly dependent on my cooperation, and I agree to work in therapy to the best of my ability.
I understand that fees are due at the time of service unless I make prior arrangements with Dr. Stevens.
I agree to pay full fee for any appointment missed without a notice of cancellation at least 24 hours in advance. I understand that I can call Dr. Stevens’s voice mail any time during the day or night to cancel an appointment, but that missed appointment fees are due in full at the time of the next session.
I understand that Dr. Stevens does not file insurance, but that my policy may include coverage for mental health services. If I choose to submit my own claims, Dr. Stevens will provide me with the information necessary for me to submit a claim to my insurance company.
Confidentiality
I understand that all information disclosed within therapy is confidential and may not be revealed it to anyone without written permission except where disclosure is required by law. Disclosures may be legally required in the following circumstances:
1. Where there is a reasonable suspicion of child or elder abuse.
2. Where there is reasonable suspicion that the client presents a danger to others, or where the client is likely to harm him or herself unless protective measures are taken.
3. Where disclosure is required pursuant to a legal proceeding.
4. To report on professional misconduct by other health-care professionals; in the event of disciplinary proceedings regarding unprofessional conduct, information may be released to substantiate disciplinary issues.
5. To disclose information by a minor child to the parents or legal guardians of the child.
6. To third-party payers such as health insurance companies to include diagnosis, treatment plan, dates of service, and prognosis.
7. Consultation: provider may disclose information in seeking consultation with other professionals to provide the most effective treatment, in which case the patient’s identity will not be disclosed. The client may also agree to consultation between the provider and another professional (e.g. a physician, attorney, or other designated professional) by signing a written release authorizing disclosure.
8. I understand that Dr. Stevens does not do litigation work. If a legal situation requires an evaluation or testimony by a mental health professional, I agree to be referred to another provider.
My initials indicate that I have been informed of the limitations on confidentiality described above. I understand that information may be disclosed based on these ethical and legal requirements. Initials _____
Emergencies:
In case of emergency, please call Dr. Stevens’s office at 478- 731-7663. If you need more immediate attention, be please call H C A Coliseum Psychiatric Hospital’s Lifeline at 478-741-1355.
I have read and understand each of the policies outlined above.
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client signature date
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witness date
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Authorization for Release of Information
This is to authorize Daphne Stevens, Ph.D., LCSW, to release or exchange information regarding my treatment or consultation to:
_________________________________________________________________
for the purpose of____________________________________________________.
Specific information to be released includes but is not limited to:
_________________________________________________________________
I acknowledge that I may rescind this authorization at any time, and that if not renewed it will expire in one (1) year following my signing this form.
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(patient)
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(date)
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Coaching Agreement
Client Name_________________________________________
This agreement between Daphne Stevens, Ph.D., and the above named client will begin on _____________________________. The monthly fee is $_______, payable in advance each month.
Coaching, which is not advice, therapy, or counseling, may address specific personal projects, business success, living with specific life challenges (e.g. adult children, caregiving, office bullying, etc) or general conditions in the client’s life or profession. Other coaching services include values clarification, examining basic core beliefs, strategizing, and creating “homework,” or tasks for growth.
The coach promises the client that all information provided to the coach will be kept strictly confidential.
The client understands that the power of the coaching relationship is granted by the client. If you believe coaching is not working as desired, please communicate that so we can put YOU in the driver’s seat.
Our signatures on this agreement indicate full understanding of and agreement with the information outlined above.
_____________________ _____________ _________________ ______
Client Date Coach Date