Statement of Understanding and Consent to Treatment
Welcome. I want you to be fully informed about the legal and ethical boundaries of the therapeutic process. Please read this document thoroughly and discuss any questions with me.
The information disclosed in therapy is generally confidential and will not be released to any third party without written authorization from you, except where required or permitted by law. Exceptions to confidentiality, include, but are not limited to, reporting child, elder and dependent adult abuse and neglect, when a client makes a serious threat of violence towards a reasonably identifiable victim, or when a client is dangerous to him/herself or the person or property of another.
The information disclosed by you, the client, as well as any records created, is subject to the psychotherapist-client privilege. The psychotherapist-client privilege results from the special relationship between a therapist and a client in the eyes of the law. It is akin to the attorney-client privilege or the doctor-client privilege. Typically, the client is the holder of the psychotherapist-client privilege. If a therapist receives a subpoena for records, deposition testimony, or testimony in a court of law, a therapist will assert the psychotherapist-client privilege on a client’s behalf until instructed, in writing, to do otherwise by a client or client’s representative. You should be aware that you might be waiving the psychotherapist-client privilege if you make your mental or emotional state an issue in a legal proceeding. You should address any concerns you might have regarding the psychotherapist-client privilege with an attorney.
Risks and Benefits of Therapy
Psychotherapy is a process in which we may discuss a variety of issues, events, and experiences for the purpose of creating positive change. Psychotherapy is a collaborative effort between a client and a therapist. Progress and success may vary depending upon the particular problems or issues being addressed, as well as many other factors. Participating in therapy may result in a number of benefits to a client, including, but not limited to, reduced stress and anxiety, improved interpersonal relationships, increased comfort in social, work, and family settings, increased capacity for intimacy, and increased self-confidence. There is no guarantee that therapy will yield any or all of the benefits listed above. Participating in therapy may also involve some discomfort, including remembering and discussing unpleasant events, feelings and experiences.
You agree that therapy services will be rendered for $150 per session and that each session is approximately 50 minutes in length. All fees for service are due at the end of each session unless otherwise negotiated. In the event of non-payment, you authorize release of outstanding account balance information for collection purposes.
You will be emailed an electronic invoice that can be paid using your credit card, Health Savings Account Card, Debit, PayPal or Venmo. Save your credit card information to file and your card will be charged automatically after each session.
I will not voluntarily participate in any litigation or custody dispute in which you and another individual, or entity, are parties. It is my policy to decline communication with your attorney and will generally not write or sign letters, reports, declarations, or affidavits to be used in a legal matter. I will generally not provide records or testimony unless compelled by a court order to do so. Should I be subpoenaed, or ordered by a court of law, to appear as a witness in an action involving you, you agree to reimburse me for any time spent for preparation, travel, or other time in which I have made myself available for such an appearance at my usual and customary hourly rate of $150.00.
Therapist Background and Qualifications
My theoretical orientation can be described as social constructionist including the use of Narrative Therapy, Solution Focused Therapy and Expressive Arts. I obtained a PhD in Psychology with a research focus on resilience after trauma and have been practicing since 2009 as a Marriage and Family Therapist – first as an Intern and then I was licensed in CA in 2015. My background includes: working with individuals, couples and families who have struggled with communication, conflict, violence, sexual assault, trauma, anxiety, depression, chronic health issues, work- related challenges, gender, racial/ethnic and cultural oppression, LGBTQI+ and immigration/refugee struggles. I am a certified domestic violence and sexual assault treatment provider and trainer.
Clinical consultation is an important component of a collaborative and sustainable psychotherapy practice. As such, I regularly participate in clinical, ethical, and legal consultation with clinical professionals. During such consultations, I will not reveal any personally identifying information regarding you, the client.
Records and Record Keeping
I may take notes during session. These notes constitute the therapist’s clinical and business records, which by law, a therapist is required to maintain. You may ask for a copy of these notes at any time.
Any appointment scheduled is time set exclusively for you. Should you need to cancel any scheduled appointment, you must do so at least 24 hours in advance in order to avoid the cancellation
fee of: $150 (full cost of session). You may text, call or email: email@example.com
to cancel, however, you will be charged the full fee of $150 if you do not provide notification of cancellation within 24 hours.
Consent to Treatment
I am requesting services from Margaret Slaska, PhD, LMFT and I understand that this is a business of psychological and relational treatment. If for any reason you do not believe I can meet your needs, I will offer referral resources.
Good Faith Estimate Notice
You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost. Under the new law which took effect Jan 1, 2022, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services. You can ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises