Informed Consent Form Bloom into Being Informed Consent LLC This Informed Consent contains important information concerning engaging in psychotherapy Please read this consent carefully. General Information The therapeutic relationship is unique in that it is highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding of how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document. The Therapeutic Process You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself. Confidentiality The session content and all relevant materials to the clientʼs treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below: If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm. If a client threatens grave bodily harm or death to another person. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses. . Suspected neglect of the parties named in items #3 and # 4. If a court of law issues a legitimate subpoena for information stated on the subpoena. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expertʼs report to an attorney. Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name. If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office. BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD, AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT BLOOM INTO BEING LLC INFORMED CONSENT I AGREE Bloom into Being LLC Informed Consent Form First Name Last Name Date MM DD YYYY Thank you! Scroll down the page for the next form. Teletherapy Informed Consent Bloom into Being Informed Consent LLC This Informed Consent for Teletherapy contains important information concerning engaging in electronic psychotherapy or teletherapy. Please read this consent carefully. Benefits and Risks of Teletherapy Teletherapy refers to the remote provision of psychotherapy services using telecommunications technologies such as video conferencing or telephone therapy. One of the benefits of teletherapy is that the client and therapist can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the client or therapist are in a situation where they are unable to continue to meet in person due to extenuating circumstances. It can also increase the convenience and time efficiency of both parties. There are benefits of teletherapy, as well as some inherent risks of teletherapy. There are some differences between in-person psychotherapy and teletherapy. Risks to confidentiality: Because teletherapy sessions take place outside of the typical office setting, there is potential for third parties to overhear sessions if they are not conducted in a secure environment. We will take reasonable steps to ensure the privacy and security of your information, and it is important for you to review your own security measures and ensure that they are adequate to protect information on your end. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation. Issues related to technology: There are risks inherent in the use of technology for therapy that are important to understand, such as: potential for technology to fail during a session, potential that transmission of confidential information could be interrupted by unauthorized parties, or potential for electronically stored information to be accessed by unauthorized parties. Crisis management and intervention: As a general rule we will not engage in teletherapy with patients who are in a crisis situation. Before engaging in teletherapy, we will develop an emergency response plan or safety plan to address potential crisis situations that may arise during the course of our teletherapy work. It is urgent that you share with your therapist any thoughts that you may have of harming yourself; and any history that you may have of suicide attempts or hospital treatment which you received for suicidal thoughts. Efficacy: While most research has failed to demonstrate that teletherapy is less effective than in-person psychotherapy, some experienced mental health professionals believe that something is lost by not being in the same room. For example, there is debate about ones ability when doing remote work to fully process non-verbal information. If you ever have concerns about misunderstandings between you and your therapist related to the use of technology, please bring up such concerns immediately and your therapist will address the potential misunderstanding together. Electronic Communications We will discuss which is the most appropriate platform to use for teletherapy services. You may be required to have certain system requirements to access electronic psychotherapy via the method chosen. You are solely responsible for any cost to you to obtain any additional/necessary system requirements, accessories, or software to use electronic psychotherapy. For communication between sessions, email exchanges and text messages with the office should be limited to matters such as setting and changing appointments, and other related issues. You should be aware that no therapist can guarantee the confidentiality of any information communicated by email or text. Therefore, we will not include any clinical material by email and request that you do not as well. Treatment is most effective when clinical discussions occur at your regularly scheduled sessions, however, if an urgent issue arises, you should feel free to attempt to reach us by phone. We will make every effort to return your call on the same day you make it. If you are unable to reach us and feel that you cannot wait for us to return your call, please contact 911 in the case of an emergency. Bloom into Being Therapy LLC is licensed only within the state of Colorado. Should you travel to another state it is up to you to communicate this to your therapist ahead of your scheduled session. Your therapist will let you know if they can have a session in the state you travel to. Some states within the US allow out of-state therapy and some do not. Confidentiality Counselors have a legal and ethical responsibility to make our best efforts to protect all communications, electric and otherwise, that are a part of our teletherapy. However, the nature of electronic communications technologies is such that we cannot guarantee that our communications will be kept confidential and/or that a third party may not gain access to our communications. Even though we may utilize state-of-the-art encryption methods, firewalls, and backup systems to help secure our communication, there is a risk that our electronic communications may be compromised, unsecured, and/or accessed by a third party. The extent of confidentiality and the exceptions to confidentiality that are outlined in our Disclosure Statement still apply in teletherapy. Please let us know if you have any questions about exceptions to confidentiality. Emergencies and Technology Assessing and evaluating threats and other emergencies can be more difficult when conducting teletherapy than in traditional in-person therapy. In order to address some of these difficulties, we will ask you where you are located at the beginning of each session and we will ask that you identify emergency resources that are near your location that we may contact in the event of a crisis or emergency to assist in addressing the situation. We may also ask that you sign a separate authorization form allowing us to contact your emergency contact person as needed during such a crisis or emergency. If the session cuts out, meaning the technological connection fails, and you are having an emergency do not call us back, but call 911, the Colorado Crisis Hotline at 844-493-TALK (8255), or go to your nearest emergency room. Call us after you have called or obtained emergency services. If the session cuts out and you are not having an emergency, disconnect from the session and we will wait five (5) minutes and then re-contact you via the teletherapy platform on which we agreed to conduct therapy. If you do not receive a call back within five (5) minutes, then call us on the phone number we provided you. If there is a technological failure and we are unable to resume the connection, you will only be charged the prorated amount of actual session time. Fees The same fee rates shall apply for teletherapy as apply for in-person psychotherapy. Consent: This agreement is intended as a supplement to the general informed consent that we may have agreed to at the outset of treatment. Your signature below indicates agreement with its terms and conditions. This agreement is supplemental to the consent for treatment that is given when you sign a Client Disclosure Statement and does not amend any of the terms of that agreement. By clicking the box below you agree you have been fully informed of the risks and benefits of teletherapy; the security measures in place, which include procedures for emergency situations; the fees associated with teletherapy; the technological requirements needed to engage in teletherapy; and all other information provided in this informed consent, agree to and understand the procedures and policies set forth in this consent. BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD, AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT. I AGREE Name First Name Last Name Date MM DD YYYY Thank you! Thank you! Scroll down the page for the next form. Practice Policies Bloom into Being LLC Practice Policies TELEPHONE ACCESSIBILITY Availability by Phone Between Sessions: Please be aware that as a policy, I am generally not available by phone between sessions. Regularly scheduled sessions are the appropriate platform for discussing concerns, queries, or updates regarding your progress. Communication for Non-Emergencies: For non-urgent matters, you can contact me via email, and I will make every effort to respond within 48 hours. However, please note that email should not be used to communicate urgent or sensitive information as it is not a secure form of communication. Emergencies: If you are in a crisis or emergency situation, I am unable to provide immediate support. It is crucial to contact appropriate emergency services. Dial 911, or go to the nearest hospital emergency room for immediate help. Crisis Hotlines: In non-life threatening situations, but where immediate emotional support is needed, consider calling a crisis hotline, such as the National Suicide Prevention Lifeline (1-800-273-TALK) or the Crisis Text Line (text HOME to 741741). Scheduled Contact Outside of Sessions: In the event that we have agreed upon communication between sessions, this will occur at pre-arranged times and will usually be done via a secure messaging platform or through a phone call. SOCIAL MEDIA AND TELECOMMUNICATION Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it. ELECTRONIC COMMUNICATION Electronic Communication: The confidentiality of electronic communication, including text messages and emails, cannot be entirely assured. You may use these methods for administrative matters such as scheduling or cancellations. Despite endeavors to respond promptly, immediate responses are not guaranteed. Please avoid using these methods for discussing therapeutic content or in emergency situations. Telemedicine Regulations: Telemedicine services in Colorado are governed by various regulations and statutes, including Colorado Revised Statutes (C.R.S.) 10-16-123 and the Colorado Medical Practice Act (C.R.S 12-36-106). These regulations set forth definitions, reimbursement standards, and guidelines for telemedicine practice. Consent for Telemedicine: If you opt to use telemedicine for your treatment, it is important to understand: a) You may withhold or withdraw your consent at any time without negatively impacting your future care or treatment, or risking the loss of benefits you would otherwise be entitled to. b) All existing confidentiality protections are applicable. c) You are entitled to access all medical information transmitted during telemedicine consultations, and copies can be provided for a reasonable fee. Potential Risks, Consequences, and Benefits: There are several potential benefits, risks, and consequences related to telemedicine: a) Benefits: These may include improved quality and continuity of care, reduced costs and travel time, better communication, and convenient access to current information and support. b) Risks: There are inherent risks in using telemedicine, including the therapist's inability to make direct visual and olfactory observations that could be clinically relevant. c) Consequences: There is a risk that your therapist may not become aware of significant information that you may not recognize as important to verbally share during a telemedicine session. TERMINATION Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after an appropriate discussion with you or if I determine that the psychotherapy is not being effectively used or if you are in default on payment and/or attendance. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source. ATTENDANCE Should you fail to schedule an appointment for two consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued. Should you no-show, late cancel, reschedule or in any other way jeopardize the integrity of the original appointment more than two times then you and I will need to explore if therapy is appropriate at this time. This is to protect the professional relationship you and I have as well as to respect the time that has been reserved for you. Should you continue to no-show, late cancel, reschedule or continue jeopardizing the integrity of the original appointment after discussion then you will be notified of your termination and provided referrals. UNDER THE INFLUENCE Bloom into Being LLC does not provide mental health services to clients who are under the influence or actively using drugs. We understand this population needs and deserves mental health care and we believe it is outside our scope of expertise to work with this population. We do believe it is within our scope to work with clients who are actively quitting substances. Should you come to a session under the influence of drugs or alcohol, this includes but is not limited to being hung over or coming off of a substance, your therapist will terminate the session and you will be charged for your entire session. If you come to the session under the influence a second time you will be immediately discharged from care under Bloom into Being LLC, charged for your entire session, and given three referrals. This policy is in place to protect the professional relationship between you and your counselor. BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD, AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT BLOOM INTO BEING LLC PRACTICE POLICIES AGREEMENT I AGREE Bloom into Being LLC Practice Policies Agreement First Name Last Name Date MM DD YYYY Thank you! Scroll down the page for the next form.
