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Terms and Policy

Office Terms & Policy Client Services / Consent Agreement
CONFIDENTIALITY: All information disclosed within sessions and the written records per-taining to those sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law.

WHEN DISCLOSURE IS REQUIRED OR MAY BE REQUIRED BY LAW: Some of the circumstances where disclosure is required or may be required by law include the following:
• If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychotherapist-client privilege law. I cannot disclose any information without a court order or your written consent. If you file a complaint or lawsuit against me, however, I may disclose relevant information regarding our work in my defense.
• If a government agency is requesting information about our work for health oversight activities, or if you file a worker’s compensation claim, I may have to provide a copy of your file to a State representative, your employer, or an appropriate designee.
• There are some situations in which I am legally obligated to take some action that will likely involve revealing information about our sessions to an outside party, possibly without your con-sent. These situations are unusual and are limited to situations in which harm is likely, including: cases in which I have reason to believe a child under 18 may be an abused or neglected; cases in which I have reason to believe an adult over the age of 60 has been abused or neglected in the preceding 12 months; cases in which you have made a specific threat of violence against another, or if I believe that you present a clear, imminent risk of serious physical harm to another or your-self. If such a situation arises, I will make every effort to fully discuss it with you before taking any action or releasing any information about you, and I will limit disclosure of information to what is necessary. Confidentiality issues can be complicated, so if you have any questions about them, please feel free to ask them now or in the future as needed.

EMERGENCY: If there is an emergency during therapy, or in the future after termination, where Courtney Lansdowne becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, she will do whatever she can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, she may also contact the person whose name you have provided on the biographical sheet.

HEALTH INSURANCE & CONFIDENTIALITY OF RECORDS: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. If you so instruct, only the minimum necessary information will be commu-nicated to the carrier. Courtney Lansdowne has no control over, or knowledge of, what insurance companies do with the information she submits or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy or to future capacity to obtain health or life insurance or even a job. The risk stems from the fact that mental health information is likely to be entered into big insurance companies' computers and is likely to be reported to the National Medical Data Bank. Accessibility to companies' computers or to the National Medical Data Bank database is always in question as computers are inherently vulnerable to hacking and unauthorized access. Medical data has also been reported to have been legally accessed by law enforcement and other agencies, which also puts you in a vulnerable position.

LITIGATION LIMITATION: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confiden-tial nature, it is agreed that, should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you nor your attorney(s), nor anyone else acting on your behalf will call on Courtney Lansdowne to testify in court or at any other pro-ceeding, nor will a disclosure of the psychotherapy records be requested unless otherwise agreed upon.

CONSULTATION: Courtney Lansdowne consults regularly with other professionals regarding her clients; however, each client's identity remains completely anonymous and confidentiality is fully maintained.

E–MAILS, CELL PHONES, COMPUTERS, AND FAXES: It is very important to be aware that computers and e-mail communication can be relatively easily accessed by unauthorized peo-ple and hence can compromise the privacy and confidentiality of such communication. Faxes can easily be sent erroneously to the wrong address. E-mails, in particular, are vulnerable to unauthor-ized access due to the fact that internet servers have unlimited and direct access to all e-mails that go through them. It is important that you be aware that e-mails, faxes, and important texts are part of the medical records. Additionally, Courtney Lansdowne’s e-mail account Therapist-Courtney@gmail.com is not encrypted. Please notify Courtney Lansdowne if you decide to avoid or limit in any way the use of any or all communication devices, such as e-mail, cell phone, or faxes. If you communicate confidential or private information via e-mail (TherapistCourtney@gmail.com), Courtney Lansdowne will assume that you have made an in-formed decision, will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via e-mail. Please do not use e-mail or faxes for emergencies.

RECORDS AND YOUR RIGHT TO REVIEW THEM: Both the law and the standards of Courtney Lansdowne’s profession require that she keep treatment records for at least 7 years. Unless otherwise agreed to be necessary, Courtney Lansdowne retains clinical records only as long as is mandated by Arizona law. If you have concerns regarding the treatment records, please discuss them with Courtney Lansdowne. As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when Courtney Lansdowne assesses that releasing such information might be harmful in any way. In such a case, Courtney Lansdowne will provide the records to an appropriate and legitimate men-tal health professional of your choice. Considering all of the above exclusions, if it is still appro-priate, and upon your request, Courtney Lansdowne will release information to any agen-cy/person you specify unless Courtney Lansdowne assesses that releasing such information might be harmful in any way. When more than one client is involved in treatment, such as in cases of couple and family therapy, Courtney Lansdowne will release records only with signed authoriza-tions from all the adults (or all those who legally can authorize such a release) involved in the treatment.

TELEPHONE & EMERGENCY PROCEDURES: If you need to contact Courtney Lans-downe between sessions, you may telephone me at 480-648-4116. Due to my schedule, I may not be immediately available to receive calls or return calls. However, my phone will be answered by confidential voice mail 24 hours a day. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please leave some specific times when you are available to speak. If an emergency situation arises and if you need to talk to someone right away, call 911 or go to the nearest emergency room, or call the Maricopa County Crisis Response Network at 602-222-9444. In the event that I am una-vailable for an extended period of time, I will provide you with the name of colleagues to contact if necessary.

PAYMENTS & INSURANCE REIMBURSEMENT: Clients are expected to pay the standard fee of $130.00 per 50 minute session at the end of each session unless other arrangements have been made. Telephone conversations, site visits, writing and reading of reports, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed upon otherwise. Please notify Courtney Lansdowne if any problems arise during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that professional services are ren-dered and charged to the clients and not to the insurance companies. Unless agreed upon differ-ently, Courtney Lansdowne will provide you with a copy of your receipt on a weekly or monthly basis, which you can then submit to your insurance company for reimbursement, if you so choose. As was indicated in the section, Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems, which are dealt with in psychotherapy, are reimbursed by in-surance companies. It is your responsibility to verify the specifics of your coverage. If your ac-count is overdue (unpaid) and there is no written agreement on a payment plan, Courtney Lans-downe can use legal or other means (courts, collection agencies, etc.) to obtain payment. Also, from time to time, Courtney Lansdowne’s fee may increase.

MEDIATION & ARBITRATION: All disputes arising out of, or in relation to, this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of Courtney Lansdowne and the client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed upon. In the event that mediation is unsuccessful, any unre-solved controversy related to this agreement should be submitted to and settled by binding arbi-tration in Arizona in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, Court-ney Lansdowne can use legal means (court, collection agency, etc.) to obtain payment. The pre-vailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum as and for attorney's fees. In the case of arbitration, the arbitrator will determine that sum.

THE PROCESS OF THERAPY/EVALUATION AND SCOPE OF PRACTICE: Participation in therapy can result in a number of benefits to you, including improving interpersonal relation-ships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involve-ment, honesty, and openness in order to change your thoughts, feelings, and/or behavior. Court-ney Lansdowne will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, re-membering or talking about unpleasant events, feelings, or thoughts can result in you experienc-ing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. Courtney Lansdowne may challenge some of your assump-tions or perceptions or propose different ways of looking at, thinking about, or handling situa-tions, which can cause you to feel very upset, angry, depressed, challenged, or disappointed. At-tempting to resolve issues that brought you to therapy in the first place, such as personal or inter-personal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, hous-ing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, Courtney Lansdowne is likely to draw on vari-ous psychological approaches according, in part, to the problem that is being treated and her as-sessment of what will best benefit you. These approaches include, but are not limited to, behav-ioral, cognitive-behavioral, Somatic Experiencing, EMDR, cognitive, psychodynamic, existential, system/family, developmental (adult, child, family), humanistic or psycho-educational. Courtney Lansdowne provides neither custody evaluation recommendation nor medication or prescription recommendation nor legal advice, as these activities do not fall within his/her scope of practice.

TREATMENT PLANS: Within a reasonable period of time after the initiation of treatment, Courtney Lansdowne will discuss with you her working understanding of the problem, treatment plan, therapeutic objectives, and her view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, there pos-sible risks, Courtney Lansdowne’s expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and the risks and benefits.

TERMINATION: As set forth above, after the first couple of meetings, Courtney Lansdowne will assess if she can be of benefit to you. Courtney Lansdowne does not accept clients who, in her opinion, she cannot help. In such a case, she will give you a number of referrals that you can contact. If at any point during psychotherapy, Courtney Lansdowne assesses that she is not ef-fective in helping you reach the therapeutic goals or that you are non-compliant, she is obligated to discuss it with you and, if appropriate, to terminate treatment. In such a case, she would give you a number of referrals that may be of help to you. If you request it and authorize it in writing, Courtney Lansdowne will talk to the psychotherapist of your choice in order to help with the transition. If, at any time, you want another professional's opinion or wish to consult with another therapist, Courtney Lansdowne will assist you with referrals, and, if she has your written con-sent, she will provide her or him with the essential information needed. You have the right to terminate therapy at any time. As a client, you may also refuse any recommended treatment. If you choose to do so, and if appropriate, Courtney Lansdowne will offer to provide you with names of other qualified professionals.

SOCIAL NETWORKING AND INTERNET SEARCHES: Courtney Lansdowne does not ac-cept friend requests from current or former clients on social networking sites, such as Facebook. She believes that adding clients as friends on these sites and/or communicating via such sites is likely to compromise their privacy and confidentiality. For this same reason, Courtney Lans-downe request that clients not communicate with her via any interactive or social networking web sites.

CANCELLATION: Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours (1 day) notice is required for re-scheduling or cancel-ing an appointment. Unless we reach a different agreement, the full fee will be charged for ses-sions missed without such notification. Most insurance companies do not reimburse for missed sessions.

I have read the above Office Policies and General Information, Agreement for Psychotherapy Services or Informed Consent for Psychotherapy carefully (a total of 5 pages); I understand them and agree to comply with them.
( Type Full Name )
Informed Consent
I agree to pay for psychotherapy services and other clinical services according to the fee agreement between the therapist and the client.

I understand the following terms apply to this agreement:

• Payment will be made at the time of service.

• The fee for psychotherapy, consultation, letter or report writing or other clinical services is $130 per 50 minute session unless otherwise specified. For more details, see previous informed con-sent.

• Please inform the therapist as soon as you know if there are changes in your ability or willing-ness to pay.

• Services will be terminated if timely payment is not made as agreed to by this consent.

• Consent to assume financial responsibility for these services does not entitle the third-party payer access to confidential information unless otherwise agreed in writing by the above named client.

• Upon your request and upon obtaining the client’s written permission, if appropriate, you will be provided with a bill, which is suitable for presenting to your insurance carrier for possible re-imbursement. Not all conditions are reimbursable.

• This agreement supplements previous informed consents.
( Type Full Name )