Introduction
To assure
that you are fully informed about the nature of your therapist's practice,
to protect your confidentiality, and to access information that may be useful
in making our time together most efficient, we are putting in this section
downloadable copies of the forms most frequently used in our practice. Not
all the forms will be relevant to your particular situation, but this will
make them more available to you if/when you and your therapist together
decide, for example, to request records from prior treatment or to communicate
with a physician who might be prescribing medications. Of all the forms
listed in this section, the only one we strongly encourage you to read before
your first session is the Patient Therapist Agreement, so you have time
to consider the information before you decide to proceed.You will need Adobe
Acrobat Reader to download a printable copy of the form. If you do not have
Adobe, just click on the link below to download and install.
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Patient
Therapist Agreement
This
is the most important of the forms for you to read before your first session.
We admit it is a long document, but we do want you to be fully informed
of your rights as a patient, of steps we have taken to protect your personal
information, and of policies concerning scheduling and fees. Federal law
requires that we have made this information available to you, but our
own view of the work we will be doing together depends on you being fully
informed as well. Please read this document before your first session,
and we will take time to discuss any questions or concerns you may have,
and to know that you can raise questions at any time during the course
of treatment.
Consent to
Treat
After
you have read the Patient Therapist Agreement, and discussed any questions
you have with your therapist, she/he will ask you to sign the Consent
to Treat, in which you and your therapist agree to abide by the terms
of the Agreement.
Insurance
Form
This
is a single copy of the common insurance form that is used by most insurance
companies. Completing this form assures that all the information that
is required to process a claim on your behalf would be available. Your
therapist will go over this form with you before you sign it, so you understand
why we are requesting information.
Personal History
Form
This form allows your
therapist to save some time in gathering information that is very useful
in assessing issues currently facing you. We have found that asking you
to complete this form, which includes a symptom checklist, will allow
us to cover some areas more quickly, and to be sure that the issues that
have brought you to therapy, or which affect your current issues will
receive appropriate attention. Again, you and your therapist will discuss
this form in the first session.
Primary Care
Contact Authorization Form
If you permit it, we
will work closely with your primary care provider, especially in situations
in which you are taking medications as part of the treatment for which
you have sought therapy. There may be other health related matters in
which close collaboration with your physician will be helpful. Finally,
some managed care plans, particularly HMO's, require that you have
specifically permitted or specifically denied access to this information.
Your access to treatment can not be made contingent on granting release
of information, under ordinary circumstances.
Information
Release Authorization Form
At times, you and your
therapist may find it useful to seek records of past treatment, to discuss
your situation with another party at your request, or to release our records
to a professional you may be seeing after our treatment is concluded.
In order to obtain or release your protected health information, you must
fully understand what you are releasing, and the terms under which it
can be released. Again, your therapist will go over this form with you
if the occasion arises.
Children's Rights
and Stipulation Form
We
often see children in treatment whose parents are in process of separation,
divorce, or litigation regarding the parenting plan subsequent to divorce.
Children often are brought to treatment because of the effects of the parental
conflict on them. Assessment and evaluation of custodial or access suitability
is a highly specialized field, and we are not qualified to provide objective
assessment in this area. Furthermore, children seeking treatment during
this process must have a therapist whose only responsibility is providing
treatment, not assessment of the adequacy of either parent or effects of
contact with one parent or the other. Consequently, your child's therapist
may ask each parent to sign this stipulation that the sole purpose of these
sessions is for the treatment of the child, and that neither parent will
request records or testimony from the therapist in any level of litigation
between the parents. |
