General information
Welcome to counseling and thank you for entrusting me with your treatment. Please take some time to carefully review the following pages – YOU MAY PRINT AND SIGN THEM NOW (AND BRING THEM TO YOUR SECOND SESSION) OR I will send you an e-mail with instructions to sign like documents electronically. Reading and signing these forms constitutes your informed consent to treatment. The information on the next pages will help you understand the therapeutic process as well as important office policies/procedures. Please keep a copy of this agreement for your records. If you would like a copy made for you, please ask and one will be provided. If you ever have any questions about the nature of your treatment or anything else about your care, please do not hesitate to ask.
IF YOU HAVE AN EMERGENCY Call 9-1-1 or go to your nearest emergency room. If you have a crisis and you need to speak with someone immediately, call the crisis hot line (888)724-7240 and someone will assist you. If you absolutely must speak with Nancy, please leave a message at 619-431-0046 and your call will be returned as quickly as possible. PLEASE NOTE your call may not be returned for up to 24 business hours. When Nancy is on vacation or out of the office for any reason, her outgoing voicemail (619-431-0046) will provide instructions on how to deal with urgent matters. Phone calls and emails will not be returned until Nancy returns to the office in those cases. Routine (non-emergency/non-urgent) messages will be responded to within 24-48 business hours.
ABOUT NANCY FADER, MA, LMFT #95040 has been providing mental health services in San Diego County since 2012. She is a licensed marriage and family therapist (MFT) who established a private practice with the hope of bringing much needed assistance to the diverse families and individuals in San Diego. Nancy earned her MA. in Clinical Psychology with and emphasis in Marriage Family Therapy. Nancy is experienced at working with teens, parents, couples and individuals with a variety of mental health diagnoses. She is a Certified Clinical Trauma Professional (CCTP) through the International Association of Trauma Professionals . If you have any questions about Nancy's background, training or areas of expertise, please ask any time.
WHAT IS PSYCHOTHERAPY AND HOW DOES IT HELP People seek therapy or counseling for many reasons. Some need to respond to unexpected changes in their lives, while others seek self-exploration and personal growth. In addition, when coping skills are overwhelmed by guilt, doubt, anxiety, or despair, therapy can help. Seeking support when all other efforts have failed is a true sign of strength, not weakness. Therapy can provide support, problem-solving skills, and enhanced coping for issues such as depression, anxiety, lack of confidence, relationship troubles, unresolved childhood issues, bereavement, spiritual conflicts, stress management, body image issues, and creative blocks amongst other things. People who benefit from psychotherapy or counseling are willing to take responsibility for their actions without blaming others, ready to work towards self-determined change and looking to create greater awareness in their lives. Psychotherapy is a collaborative process through which therapist and client explore different perspectives on the client’s life and experiences in order to help achieve their goals.
WHAT TO EXPECT IN A THERAPY SESSION During sessions you are expected to talk about the concerns and issues in your life. Therapy works best when you have specific goals you wish to accomplish and you and your therapist work together to develop a treatment plan to achieve your goals. A session lasts 50 minutes. Usually weekly sessions are best for at least the first four to six sessions. Some people who are in crisis or extreme distress need more than one session per week, at least until the crisis passes. During the time between sessions it is beneficial to think about and work on what was discussed. At times, you may be asked to take certain actions outside of the therapy sessions such as reading a relevant book or keeping records. For therapy to "work," you must be an active participant, both in and outside of the therapy sessions.
WHAT BENEFITS CAN I EXPECT FROM WORKING WITH A THERAPIST? A number of benefits are possible when participating in therapy or counseling. Often it is helpful just to know that someone is there to listen and understand. Therapy can provide a fresh perspective on a difficult problem or help point you in the direction of a solution. Many people find therapy to be a tremendous asset in managing personal growth, interpersonal relationships, family concerns, and the challenges of daily life. The benefits you achieve from therapy/counseling can also depend on how actively you participate in the process and put into practice what you discover. Some of the potential benefits of therapy include:
NOTE-TAKING/RECORDING OF SESSIONS To increase the effectiveness of your treatment, I will be taking notes. If you desire, you may also take notes, however, you may not record your sessions. An audio and/or video recording of your session is strictly prohibited without exception .
TO SCHEDULE, CHANGE OR CANCEL AN APPOINTMENT Whenever possible, please use the 24-hour, secure online scheduler at www.NancyFaderMFT.com. This service is available to view, schedule, change or cancel appointments 24 hours a day, 7 days a week. If there are fewer than 24 hours prior to your appointment, you must call or email me to change or cancel. If would prefer to schedule/cancel sessions you may do so over the phone or by text.
CONSISTENCY OF TREATMENT When scheduling an appointment, you will have the option of scheduling multiple appointments in advance. Weekly sessions are generally recommended for the first 4 to 6 visits but may be necessary for longer. If you have any specific scheduling needs, it is strongly recommended that you do this in order to avoid lapses in treatment and to ensure convenient appointment times.
CONSULTATION In order to provide you with the best care possible, Nancy Fader MFT will periodically meet with other licensed mental health providers to discuss cases. If your case is discussed, every effort will be made to keep identifying information confidential.
APPOINTMENT REMINDERS If you have provided a valid email address, you will receive email reminders to help you remember to keep your scheduled appointments. If you entered a valid cell phone number, you will also receive a text message reminder. Reminder messages are a courtesy only – it is your responsibility to keep track of all appointments. Even if you do not receive a reminder you are still responsible for all late cancellation/no show fees.
CHARGE FOR LATE CANCELLED/MISSED APPOINTMENTS If you cancel your appointment less than 24 hours prior to your appointment time, you will be assessed a fee for which you are solely responsible. Appointments can be cancelled by leaving a voicemail at 619-431-0046 24 hours a day, 7 days a week. All messages will be time and date-stamped.
BY INITIALING AT THE END OF THIS LINE, I ACKNOWLEDGE THAT IN THE EVENT OF A “NO SHOW” OR FAILURE TO GIVE 24-HOUR NOTICE PRIOR TO A CANCELLATION, A CHARGE WILL BE ASSESSED TO MY ACCOUNT. THIS CHARGE IS SOLELY MY RESPONSIBILITY ________ PATIENT’S FEES are to be paid at the time of your session.
NO SECRETS POLICY When working with couples it is essential for the effectiveness of treatment that you know I do not keep secrets between partners in couples. Should I happen to speak with either party individually the content of those conversations will not be kept secret from the partner/spouse. The only exception is if there is an immediate or ongoing safety issue. This policy does not pertain to family or parent/child therapy.
E-MAIL COMMUNICATION/APPOINTMENT REMINDERS I consent to receive e-mail communication/appointment reminders from Nancy Fader, MFT at this email address: Your email address: _________________________________________
I also acknowledge that communication via e-mail or text is, by nature, impossible to completely secure and it is possible that my information may be accessed by a third-party without the knowledge of Nancy Fader, MFT. I also understand that email communication or text is intended for practical matters such as appointment cancellations and changes. If I choose to include clinical information (any information I would not wish for a third party to view) in my email communication or text message, Nancy Fader, MFT will not be held liable for breach of confidentiality should these messages be viewed. Should I choose to send an email or text message containing personal/clinical information, I give Nancy Fader, MFT permission to respond by referencing the information I have included. Furthermore, I understand that should I desire to change my e-mail address, cell number or rescind permission to communicate via email or text messaging , I must notify Nancy Fader, MFT in writing.
TEXT MESSAGE APPOINTMENT REMINDERS I consent to receive text message appointment reminders from Nancy Fader, MFT at this phone number:
Your cell phone number: _________________________________________
SOCIAL NETWORKS/DUAL RELATIONSHIPS
I understand that as a matter of policy, Nancy Fader, MFT will not accept friend requests or any other request to be added to any social network (including, but not limited to, Facebook, Twitter, LinkedIn and Google+). In addition, Nancy Fader, MFT is does not engage in friendships and/or business relationships with clients outside of their treatment, even after treatment has terminated.
CONFIDENTIALITY AND MANDATED REPORTING All information exchanged between patient and therapist is strictly confidential. I will not release any information about your therapy unless such release is permitted or required by law. Examples include: 1. It is agreed upon in writing and complies with State Laws 2. The patient presents an imminent danger to himself or herself or to others 3. There is any reason to suspect the abuse or neglect of a child or a dependent elderly person 4. As necessary for continuity of care 5. If a judge determines that our discussions are not confidential, the judge may order that specific information be released 6. As requested by a court appointed attorney for a child involved in court proceedings. 7. If you are bringing in your child for treatment, it is up to the therapist to determine the level of confidentiality he or she will require. As a general rule, children ages 12 and up will retain confidentiality from their parents, prohibiting the therapist from discussing the content of sessions with parents. (Except in the cases of numbers 2 and 3).
In the cases of numbers 2 and 3, Nancy Fader, MFT is mandated by law to inform potential victims and legal authorities so that protective measures can be taken. If you participate in couples counseling as part of your treatment, please be advised that no information will be released without the written consent of both parties . As a standard, I will follow the “minimum necessary” rule for information being released.
GENERAL CONSENT TO TREATMENT By signing below, I authorize and request that Nancy Fader, MFT carry out psychological examinations, treatment and/or diagnostic procedures that now or during the course of my care as patient are advisable. I also understand that the purpose of these procedures will be explained to me upon my request and subject to my agreement. I also understand that while the course of therapy is designed to be helpful, it may be difficult and uncomfortable and may ultimately result in an increase in negative feelings and/or deterioration in functioning. Nancy Fader, MFT can make no guarantees regarding treatment progress or outcomes.
I also understand that while therapy can be helpful, it is not the only available method for addressing my treatment goals. Other methods include (but are not limited to) psychiatric treatment, spiritual/religious consultation and/or other psychotherapy modalities that differ from those employed by Nancy Fader, MFT. If I wish to explore other treatment options, I may, at any time, ask/inform Nancy Fader, MFT of my desire to do so and he will assist me as her expertise allows. I also understand that participation is psychotherapy is 100% voluntary and may be terminated at any time by the client.
For couples, we acknowledge that although therapy is intended to improve marital functioning and help keep marriages/relationships intact, couples counseling may still result in marital/relationship functioning worsening and can even result in a couple deciding to divorce or otherwise end their relationship.
Further, if I am consenting on behalf of a minor child, dependent or beneficiary, I hereby authorize Nancy Fader, MFT to deliver mental health services to the patient. I understand that all policies stated in this packet apply to the patient(s). I further accept that although my participation may be required as part of the patient’s treatment, the patient’s records are confidential, and by law I cannot access these records if Nancy Fader, MFT believes such access would be detrimental to the patient.
FINANCIAL TERMS: I agree to pay session fees at each session. Nancy Fader, MFT does not bill insurance companies but will supply an insurance super bill when requested so that I may submit to my insurance company to be reimbursement. I will be responsible for any applicable deductibles and co-payments at the time of service. I understand that if I am not eligible at the time that services are rendered, I am solely responsible for payment, even if this determination is made after services are rendered.
EMERGENCY PROCEDURES If you need to contact me at any time, please leave a detailed message according to the instructions given on my voicemail and your call will be returned. If a medical emergency/immediate safety concern arises, call 9 - 1 - 1 or go immediately to the nearest emergency room. In the case of a crisis, leave a detailed message, and Nancy Fader, MFT will return your call as soon as possible (within 24 business hours) or call the crisis hot line at (888)724-7240 for immediate help.
HEALTH INSURANCE BILLING/PAYMENT AUTHORIZATION I authorize Nancy Fader, MFT to release any medical or other information necessary to process insurance claims for services rendered as part of my treatment. I understand that in order to establish and maintain the medical necessity of my treatment, this information will include a multi-axial diagnosis in accordance with DSM-V criteria and that I have a right to know what my diagnosis is at any time (unless Nancy Fader, MFT believes that it would be detrimental to me to know this information, in which case she may choose to withhold it).
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I acknowledge that Nancy Fader, MFT have either provided me with a copy of the Notice of Privacy Practices or that I will review/obtain my own copy at www.NancyFaderMFT.com as required by the Health Insurance Portability and Accountability Act (HIPAA).
IF YOU HAVE QUESTIONS If you ever have any questions of any kind regarding your treatment or any issues related to your treatment, please feel free to ask me at any time. You may contact me via telephone or email at your convenience. All messages will be returned as soon as possible. Always remember that I am here to support you in every way I can.
____________________________________________
#1: Patient/Legal Representative Signature
Date_______________________________________
Provider Signature ________________________________________
Please Print Name Relationship to Client _______________________________________
#2: Second Adult Patient Signature ______________________________________
Date ________________________________________
Please Print Name Relationship to Client ________________________________________
BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND AGREED TO ALL OF THE AFOREMENTIONED TREATMENT GUIDELINES, POLICIES AND PROCEDURES.
A Message to My Clients About Arbitration Please Read Before Continuing to the Next Page
The attached contract is an arbitration agreement. By signing this agreement, we are both agreeing that any dispute arising out of the services you receive is to be resolved in binding arbitration rather than a suit in court. Lawsuits are something that no one anticipates and everyone hopes to avoid. I believe that the method of resolving disputes by arbitration is one of the fairest systems for both clients and providers. Arbitration agreements between health care providers and their patients have long been recognized and approved by the California courts.
By signing this agreement, you are changing the place where your claim will be presented. You are not forfeiting your right to file a claim should you feel the need arises. You may still call witnesses and present evidence. Each party selects and arbitrator (party arbitrators) who then select a third, neutral arbitrator. These three arbitrators hear the case. This agreement generally helps to limit the legal costs for both patients and providers. Further, both parties are spared some of the rigors of a trial and the publicity that may accompany judicial proceedings.
My goal is always to provide mental health services in such a way as to avoid any such disputes. Still, I know that most problems begin with miscommunication. If you have any questions at any time about your care, please ask me immediately.
Please sign/initial the requested lines on the next page. A copy of this agreement will be provided to you upon your request.
THERAPIST-PATIENT ARBITRATION AGREEMENT
Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical/mental health services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review or arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided on in a court of law before a jury, and instead are accepting the use of arbitration.
Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or related to treatment or service provided by the therapist including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean the mother and the mother’s expected child or children. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the therapist, and the therapist’s partners, associates, association, corporation or partnership, and the employees, agents and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any court by the therapist to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim.
Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party’s own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law.
Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator.
The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.
The parties agree that provisions of California law applicable to health care providers shall apply to disputes within this arbitration agreement, including, but not limited to, Code of Civil Procedure Section 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any party may bring before the arbitrations a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure section 1283.05, however, depositions may be taken without prior approval of the neutral arbitrator.
Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions relating to arbitration.
Article 5: Revocation: This agreement may be revoked by written notice delivered to the therapist within 30 days, or signature. It is the intent of this agreement to apply to all medical/mental health services rendered any time for any condition.
Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is Effective as of the date of first medical/mental health services.
__________________________________________________ Patient’s or Patient Representative’s Initials If any provision if this arbitration agreement is held invalid of unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.
I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy.
NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. IF YOU WISH TO HAVE A COPY OF THIS CONTRACT, YOU MUST REQUEST ONE. PLEASE NOTIFY YOUR PROVIDER AND A SIGNED COPY WILL BE PROVIDED.
By: _____________________________________ ___________ Therapist’s Signature (Date)
By: _____________________________________ ___________ Primary Patient’s or Representative’s Signature (Date)
By: ________________________________________________ Printed Name of Provider
By:_________________________________________________Print Patient’s Name
By: _____________________________________ ___________ Second Adult Patient’s Signature (Date)
By:_________________________________________________If Representative, Print Your Name and Relationship to Patient
IF YOU HAVE AN EMERGENCY Call 9-1-1 or go to your nearest emergency room. If you have a crisis and you need to speak with someone immediately, call the crisis hot line (888)724-7240 and someone will assist you. If you absolutely must speak with Nancy, please leave a message at 619-431-0046 and your call will be returned as quickly as possible. PLEASE NOTE your call may not be returned for up to 24 business hours. When Nancy is on vacation or out of the office for any reason, her outgoing voicemail (619-431-0046) will provide instructions on how to deal with urgent matters. Phone calls and emails will not be returned until Nancy returns to the office in those cases. Routine (non-emergency/non-urgent) messages will be responded to within 24-48 business hours.
ABOUT NANCY FADER, MA, LMFT #95040 has been providing mental health services in San Diego County since 2012. She is a licensed marriage and family therapist (MFT) who established a private practice with the hope of bringing much needed assistance to the diverse families and individuals in San Diego. Nancy earned her MA. in Clinical Psychology with and emphasis in Marriage Family Therapy. Nancy is experienced at working with teens, parents, couples and individuals with a variety of mental health diagnoses. She is a Certified Clinical Trauma Professional (CCTP) through the International Association of Trauma Professionals . If you have any questions about Nancy's background, training or areas of expertise, please ask any time.
WHAT IS PSYCHOTHERAPY AND HOW DOES IT HELP People seek therapy or counseling for many reasons. Some need to respond to unexpected changes in their lives, while others seek self-exploration and personal growth. In addition, when coping skills are overwhelmed by guilt, doubt, anxiety, or despair, therapy can help. Seeking support when all other efforts have failed is a true sign of strength, not weakness. Therapy can provide support, problem-solving skills, and enhanced coping for issues such as depression, anxiety, lack of confidence, relationship troubles, unresolved childhood issues, bereavement, spiritual conflicts, stress management, body image issues, and creative blocks amongst other things. People who benefit from psychotherapy or counseling are willing to take responsibility for their actions without blaming others, ready to work towards self-determined change and looking to create greater awareness in their lives. Psychotherapy is a collaborative process through which therapist and client explore different perspectives on the client’s life and experiences in order to help achieve their goals.
WHAT TO EXPECT IN A THERAPY SESSION During sessions you are expected to talk about the concerns and issues in your life. Therapy works best when you have specific goals you wish to accomplish and you and your therapist work together to develop a treatment plan to achieve your goals. A session lasts 50 minutes. Usually weekly sessions are best for at least the first four to six sessions. Some people who are in crisis or extreme distress need more than one session per week, at least until the crisis passes. During the time between sessions it is beneficial to think about and work on what was discussed. At times, you may be asked to take certain actions outside of the therapy sessions such as reading a relevant book or keeping records. For therapy to "work," you must be an active participant, both in and outside of the therapy sessions.
WHAT BENEFITS CAN I EXPECT FROM WORKING WITH A THERAPIST? A number of benefits are possible when participating in therapy or counseling. Often it is helpful just to know that someone is there to listen and understand. Therapy can provide a fresh perspective on a difficult problem or help point you in the direction of a solution. Many people find therapy to be a tremendous asset in managing personal growth, interpersonal relationships, family concerns, and the challenges of daily life. The benefits you achieve from therapy/counseling can also depend on how actively you participate in the process and put into practice what you discover. Some of the potential benefits of therapy include:
- Attaining a better understanding of yourself and your personal goals and values
- Developing skills for improving your relationships
- Finding resolution to the issues or concerns that led you to seek therapy
- Finding new ways to cope with stress and anxiety
- Managing anger, depression, and other emotional pressures
- Improving communications skills - learn how to listen to others, and have others listen to you
- Getting "unstuck" from unhealthy behavior patterns - breaking old behaviors and develop new ones
- Discovering new ways to solve problems
- Improving your self-esteem and boosting self-confidence
NOTE-TAKING/RECORDING OF SESSIONS To increase the effectiveness of your treatment, I will be taking notes. If you desire, you may also take notes, however, you may not record your sessions. An audio and/or video recording of your session is strictly prohibited without exception .
TO SCHEDULE, CHANGE OR CANCEL AN APPOINTMENT Whenever possible, please use the 24-hour, secure online scheduler at www.NancyFaderMFT.com. This service is available to view, schedule, change or cancel appointments 24 hours a day, 7 days a week. If there are fewer than 24 hours prior to your appointment, you must call or email me to change or cancel. If would prefer to schedule/cancel sessions you may do so over the phone or by text.
CONSISTENCY OF TREATMENT When scheduling an appointment, you will have the option of scheduling multiple appointments in advance. Weekly sessions are generally recommended for the first 4 to 6 visits but may be necessary for longer. If you have any specific scheduling needs, it is strongly recommended that you do this in order to avoid lapses in treatment and to ensure convenient appointment times.
CONSULTATION In order to provide you with the best care possible, Nancy Fader MFT will periodically meet with other licensed mental health providers to discuss cases. If your case is discussed, every effort will be made to keep identifying information confidential.
APPOINTMENT REMINDERS If you have provided a valid email address, you will receive email reminders to help you remember to keep your scheduled appointments. If you entered a valid cell phone number, you will also receive a text message reminder. Reminder messages are a courtesy only – it is your responsibility to keep track of all appointments. Even if you do not receive a reminder you are still responsible for all late cancellation/no show fees.
CHARGE FOR LATE CANCELLED/MISSED APPOINTMENTS If you cancel your appointment less than 24 hours prior to your appointment time, you will be assessed a fee for which you are solely responsible. Appointments can be cancelled by leaving a voicemail at 619-431-0046 24 hours a day, 7 days a week. All messages will be time and date-stamped.
BY INITIALING AT THE END OF THIS LINE, I ACKNOWLEDGE THAT IN THE EVENT OF A “NO SHOW” OR FAILURE TO GIVE 24-HOUR NOTICE PRIOR TO A CANCELLATION, A CHARGE WILL BE ASSESSED TO MY ACCOUNT. THIS CHARGE IS SOLELY MY RESPONSIBILITY ________ PATIENT’S FEES are to be paid at the time of your session.
NO SECRETS POLICY When working with couples it is essential for the effectiveness of treatment that you know I do not keep secrets between partners in couples. Should I happen to speak with either party individually the content of those conversations will not be kept secret from the partner/spouse. The only exception is if there is an immediate or ongoing safety issue. This policy does not pertain to family or parent/child therapy.
E-MAIL COMMUNICATION/APPOINTMENT REMINDERS I consent to receive e-mail communication/appointment reminders from Nancy Fader, MFT at this email address: Your email address: _________________________________________
I also acknowledge that communication via e-mail or text is, by nature, impossible to completely secure and it is possible that my information may be accessed by a third-party without the knowledge of Nancy Fader, MFT. I also understand that email communication or text is intended for practical matters such as appointment cancellations and changes. If I choose to include clinical information (any information I would not wish for a third party to view) in my email communication or text message, Nancy Fader, MFT will not be held liable for breach of confidentiality should these messages be viewed. Should I choose to send an email or text message containing personal/clinical information, I give Nancy Fader, MFT permission to respond by referencing the information I have included. Furthermore, I understand that should I desire to change my e-mail address, cell number or rescind permission to communicate via email or text messaging , I must notify Nancy Fader, MFT in writing.
TEXT MESSAGE APPOINTMENT REMINDERS I consent to receive text message appointment reminders from Nancy Fader, MFT at this phone number:
Your cell phone number: _________________________________________
SOCIAL NETWORKS/DUAL RELATIONSHIPS
I understand that as a matter of policy, Nancy Fader, MFT will not accept friend requests or any other request to be added to any social network (including, but not limited to, Facebook, Twitter, LinkedIn and Google+). In addition, Nancy Fader, MFT is does not engage in friendships and/or business relationships with clients outside of their treatment, even after treatment has terminated.
CONFIDENTIALITY AND MANDATED REPORTING All information exchanged between patient and therapist is strictly confidential. I will not release any information about your therapy unless such release is permitted or required by law. Examples include: 1. It is agreed upon in writing and complies with State Laws 2. The patient presents an imminent danger to himself or herself or to others 3. There is any reason to suspect the abuse or neglect of a child or a dependent elderly person 4. As necessary for continuity of care 5. If a judge determines that our discussions are not confidential, the judge may order that specific information be released 6. As requested by a court appointed attorney for a child involved in court proceedings. 7. If you are bringing in your child for treatment, it is up to the therapist to determine the level of confidentiality he or she will require. As a general rule, children ages 12 and up will retain confidentiality from their parents, prohibiting the therapist from discussing the content of sessions with parents. (Except in the cases of numbers 2 and 3).
In the cases of numbers 2 and 3, Nancy Fader, MFT is mandated by law to inform potential victims and legal authorities so that protective measures can be taken. If you participate in couples counseling as part of your treatment, please be advised that no information will be released without the written consent of both parties . As a standard, I will follow the “minimum necessary” rule for information being released.
GENERAL CONSENT TO TREATMENT By signing below, I authorize and request that Nancy Fader, MFT carry out psychological examinations, treatment and/or diagnostic procedures that now or during the course of my care as patient are advisable. I also understand that the purpose of these procedures will be explained to me upon my request and subject to my agreement. I also understand that while the course of therapy is designed to be helpful, it may be difficult and uncomfortable and may ultimately result in an increase in negative feelings and/or deterioration in functioning. Nancy Fader, MFT can make no guarantees regarding treatment progress or outcomes.
I also understand that while therapy can be helpful, it is not the only available method for addressing my treatment goals. Other methods include (but are not limited to) psychiatric treatment, spiritual/religious consultation and/or other psychotherapy modalities that differ from those employed by Nancy Fader, MFT. If I wish to explore other treatment options, I may, at any time, ask/inform Nancy Fader, MFT of my desire to do so and he will assist me as her expertise allows. I also understand that participation is psychotherapy is 100% voluntary and may be terminated at any time by the client.
For couples, we acknowledge that although therapy is intended to improve marital functioning and help keep marriages/relationships intact, couples counseling may still result in marital/relationship functioning worsening and can even result in a couple deciding to divorce or otherwise end their relationship.
Further, if I am consenting on behalf of a minor child, dependent or beneficiary, I hereby authorize Nancy Fader, MFT to deliver mental health services to the patient. I understand that all policies stated in this packet apply to the patient(s). I further accept that although my participation may be required as part of the patient’s treatment, the patient’s records are confidential, and by law I cannot access these records if Nancy Fader, MFT believes such access would be detrimental to the patient.
FINANCIAL TERMS: I agree to pay session fees at each session. Nancy Fader, MFT does not bill insurance companies but will supply an insurance super bill when requested so that I may submit to my insurance company to be reimbursement. I will be responsible for any applicable deductibles and co-payments at the time of service. I understand that if I am not eligible at the time that services are rendered, I am solely responsible for payment, even if this determination is made after services are rendered.
EMERGENCY PROCEDURES If you need to contact me at any time, please leave a detailed message according to the instructions given on my voicemail and your call will be returned. If a medical emergency/immediate safety concern arises, call 9 - 1 - 1 or go immediately to the nearest emergency room. In the case of a crisis, leave a detailed message, and Nancy Fader, MFT will return your call as soon as possible (within 24 business hours) or call the crisis hot line at (888)724-7240 for immediate help.
HEALTH INSURANCE BILLING/PAYMENT AUTHORIZATION I authorize Nancy Fader, MFT to release any medical or other information necessary to process insurance claims for services rendered as part of my treatment. I understand that in order to establish and maintain the medical necessity of my treatment, this information will include a multi-axial diagnosis in accordance with DSM-V criteria and that I have a right to know what my diagnosis is at any time (unless Nancy Fader, MFT believes that it would be detrimental to me to know this information, in which case she may choose to withhold it).
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I acknowledge that Nancy Fader, MFT have either provided me with a copy of the Notice of Privacy Practices or that I will review/obtain my own copy at www.NancyFaderMFT.com as required by the Health Insurance Portability and Accountability Act (HIPAA).
IF YOU HAVE QUESTIONS If you ever have any questions of any kind regarding your treatment or any issues related to your treatment, please feel free to ask me at any time. You may contact me via telephone or email at your convenience. All messages will be returned as soon as possible. Always remember that I am here to support you in every way I can.
____________________________________________
#1: Patient/Legal Representative Signature
Date_______________________________________
Provider Signature ________________________________________
Please Print Name Relationship to Client _______________________________________
#2: Second Adult Patient Signature ______________________________________
Date ________________________________________
Please Print Name Relationship to Client ________________________________________
BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND AGREED TO ALL OF THE AFOREMENTIONED TREATMENT GUIDELINES, POLICIES AND PROCEDURES.
A Message to My Clients About Arbitration Please Read Before Continuing to the Next Page
The attached contract is an arbitration agreement. By signing this agreement, we are both agreeing that any dispute arising out of the services you receive is to be resolved in binding arbitration rather than a suit in court. Lawsuits are something that no one anticipates and everyone hopes to avoid. I believe that the method of resolving disputes by arbitration is one of the fairest systems for both clients and providers. Arbitration agreements between health care providers and their patients have long been recognized and approved by the California courts.
By signing this agreement, you are changing the place where your claim will be presented. You are not forfeiting your right to file a claim should you feel the need arises. You may still call witnesses and present evidence. Each party selects and arbitrator (party arbitrators) who then select a third, neutral arbitrator. These three arbitrators hear the case. This agreement generally helps to limit the legal costs for both patients and providers. Further, both parties are spared some of the rigors of a trial and the publicity that may accompany judicial proceedings.
My goal is always to provide mental health services in such a way as to avoid any such disputes. Still, I know that most problems begin with miscommunication. If you have any questions at any time about your care, please ask me immediately.
Please sign/initial the requested lines on the next page. A copy of this agreement will be provided to you upon your request.
THERAPIST-PATIENT ARBITRATION AGREEMENT
Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical/mental health services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review or arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided on in a court of law before a jury, and instead are accepting the use of arbitration.
Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or related to treatment or service provided by the therapist including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean the mother and the mother’s expected child or children. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the therapist, and the therapist’s partners, associates, association, corporation or partnership, and the employees, agents and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any court by the therapist to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim.
Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party’s own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law.
Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator.
The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.
The parties agree that provisions of California law applicable to health care providers shall apply to disputes within this arbitration agreement, including, but not limited to, Code of Civil Procedure Section 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any party may bring before the arbitrations a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure section 1283.05, however, depositions may be taken without prior approval of the neutral arbitrator.
Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions relating to arbitration.
Article 5: Revocation: This agreement may be revoked by written notice delivered to the therapist within 30 days, or signature. It is the intent of this agreement to apply to all medical/mental health services rendered any time for any condition.
Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is Effective as of the date of first medical/mental health services.
__________________________________________________ Patient’s or Patient Representative’s Initials If any provision if this arbitration agreement is held invalid of unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.
I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy.
NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. IF YOU WISH TO HAVE A COPY OF THIS CONTRACT, YOU MUST REQUEST ONE. PLEASE NOTIFY YOUR PROVIDER AND A SIGNED COPY WILL BE PROVIDED.
By: _____________________________________ ___________ Therapist’s Signature (Date)
By: _____________________________________ ___________ Primary Patient’s or Representative’s Signature (Date)
By: ________________________________________________ Printed Name of Provider
By:_________________________________________________Print Patient’s Name
By: _____________________________________ ___________ Second Adult Patient’s Signature (Date)
By:_________________________________________________If Representative, Print Your Name and Relationship to Patient