Agreement for Psychological Consultation — First Step Session


This Agreement contains important information about receiving a 45-minute initial psychological consultation at Create Outcomes where a licensed therapist will gather information to determine whether one of our therapists can meet your treatment needs. If we do not have a therapist that is a match for your current treatment needs, we may refer you to another therapist or treatment program outside of our organization. This agreement also informs you about our business policies as well as provides a clear framework for our work together. Please read the information carefully. You are free to revoke this agreement or discontinue your work with our organization at any time.

I.

The Nature of Consultation — First Step Session



Create Outcomes offers an initial psychological consultation to aid you and/or family in finding the treatment that is right for you. This session will be done over video when possible, using the online secure and HIPAA-compliant platform Zoom. Consultation can cover a variety of questions regarding your needs, presenting problem(s), current life circumstances, and your history. However, the depth in which these topics can be explored is limited by the very nature of consultation. The initial consultation is a one time-limited meeting and does not include in-depth assessment, treatment interventions, on-going therapy or any diagnostic procedures. Consultation with our organization will be provided by a Licensed Therapist and sessions are typically 45-minutes long.

We cannot promise that your particular situation will improve as a result of this initial consultation and sometimes the outcome of consultation may include specific recommendations regarding seeking services with a provider outside of our organization who can better meet your treatment needs. It is your choice and responsibility to follow through on those recommendations once consultation is over.

II.

Confidentiality and Limitations



The law protects the privacy of all communications between a client and a licensed therapist. All information disclosed within sessions is confidential and may not be revealed to anyone without written permission except where disclosure is required by law. Disclosure is required by law in the following circumstances:

1. 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.

2. If a client threatens grave bodily harm or death to another person. If a client communicates an immediate threat of serious harm to an identifiable victim, we may be required to notify the potential victim, contact the police, and/or seek hospitalization for the client. 

3. If the therapist has a reasonable suspicion that an adult client is the perpetrator, or, if the adult client or child client is the actual victim of physical, emotional or sexual abuse.
Suspected neglect of the parties named in items #3.

4. If a court of law issues a legitimate subpoena for information stated on the subpoena.
If information is obtained for the purpose of rendering an expert’s report to an attorney.

At Create Outcomes we are committed to professional growth and as such consult with each other on cases as well as provide supervision to interns and students. During these consultations, we will avoid revealing any information that may identify you personally. If any such situation arises, we will make every effort to discuss it with you fully before taking any action, and will try to limit disclosure to what is necessary.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex and in situations where specific advice is required, formal legal advice may be needed.

III.

Business Policies and Procedures



Payment and Fees: Our initial consultation fee is $100. If on-going therapy with our practice is appropriate for your treatment need, fees range from $190 in Colorado to $250 in New York for each 45-minute therapy session. Payment will be collected after your appointment from the debit or credit card you have provided to us. Please be aware there will be a 4% administration fee for each transaction. This fee is to securely hold your credit card information on file.

Health Insurance: We will provide you with an invoice for services rendered and any paperwork necessary should you wish to try and seek reimbursement from your insurance company through out-of-network benefits. You are ultimately responsible for determining what services are covered and to what degree.

Cancellation Policy: All appointments require advance notice of cancellation, which allows us to serve all of our clients in an effective and timely manner. In the event that you need to cancel your appointment you must do so by 3:00pm on the previous business day. If you do not cancel by this time or do not show for your scheduled appointment, you will be responsible for the full session fee. If you need to cancel or reschedule a session, please do so by telephone at ︎︎︎(866) 232-7328. Cancellations via email will not be accepted.

IV.

Consent for Electronic Communications



During the course of treatment, it may be useful for us to communicate with you electronically, for example, via email or text messages (unless you would prefer an alternate means of communication). The benefits of electronic communication can include:

—Resolving scheduling and billing issues quickly and efficiently

—Allowing your therapist to send reminders and appointment confirmations

—Transmission of helpful resource material, worksheets, educational information, etc.

—Access to your therapist remotely in between scheduled sessions, if you and your therapist have determined that this is clinically appropriate

—We strive to provide you with convenient, timely means of communicating with us, and also make every effort to protect your privacy; however, electronic communication is never completely secure. Some potential risks of electronic communication include:

—Others accessing your device in case of loss/theft, or incidental contact at home/work

—Email accounts can be hacked

—Text messages are stored on servers
e-mails or text messages may be delivered to an incorrect address

V.

Contact Information



You may reach us by telephone at ︎︎︎(866) 232-7328. You may also be provided with additional contact information as necessary. Due to the nature of our work, we may not always be available by telephone. When we are unavailable, the telephone is answered by a confidential voicemail that is monitored frequently. Every effort will be made to return your call within 2 business days (excluding weekends and holidays).

Consultation does not provide any provisions for emergency situations. If you find yourself in an urgent situation, it is up to you to make a judgment about the prudence of waiting for a return call versus calling your primary care physician or 911. If you anticipate a need for emergency consultations or will be requiring more frequent contact then please be advised that consultation may not be a suitable service.




By electronically accepting this Agreement, it indicates that you have read this agreement, agree to its terms and acknowledge that no therapeutic relationship has been established between you and the assigned consultant. Your acceptance also serves as an acknowledgment that you have received the HIPAA notice titled “Notice of Privacy Practices.”

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