Consent for Treatment
FOR TREATMENT IN CALIFORNIA AND ARIZONA ONLY
PAYMENTS AND REFUND POLICY: The standard psychotherapy fee is $185 per 50-minute session and is expected to be paid in full at the end of each session. Credit cards are the only acceptable payment for services.
LIMITS ON CONFIDENTIALITY: The law protects the privacy of all communications between clients and therapists. Also, there are some situations where licensed marriage and family therapists are permitted or required to disclose information without either your consent or authorization:
1. If a client threatens self-harm, we may be obligated to seek hospitalization or contact family members or others who can provide protection.
2. If you are involved in a court proceeding and a request is made for information about the professional services provided you and the records thereof, such information is protected by therapist-patient privilege law, and no information will be provided without your (or your legally appointed representative) authorization, a court order, or compulsory process (subpoena) or discovery request from another party to the court proceeding where that party has given you proper notice ( when required) has stated valid legal grounds for obtaining personal health information (PHI), and we do not have grounds for objecting under state law (or you have instructed him or her not to object). If you are involved in litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information.
3. If a government agency is requesting the information for health oversight activities pursuant to its legal authority, we may be required to provide it to the agency.
4. If a client files a complaint or lawsuit against Everett Andrew Stenhouse, relevant information may be disclosed regarding that client for proper defense of the therapist.
Therapists are legally obligated as mandated reporters for the state to take actions that they believe are necessary to protect others from harm and are required to report to the appropriate governmental agency. Following are instances that will be reported:
1. If there is knowledge of a child under 18 or reasonable suspicion of a child under 18 is the victim of physical abuse, sexual abuse, or neglect, we are required to contact child protective serves and file a report.
2. If there is knowledge of an elder age 65 or older that reasonably appears to be physical abuse, sexual abuse, abandonment, abduction, isolation, financial abuse, or neglect of an elder, dependent adult. A report is mandatory to Adult Protective Services.
3. If a client communicates a serious threat of physical violence against an identifiable victim a report must be made to local authorities.
4. If there is reasonable suspicion to believe that the client is in such a mental or emotional condition as to be dangerous to himself or herself.
If such a case arises, we will make every effort to fully discuss it with you before taking any action and will limit disclosures to what is necessary.
Understanding the nature of the therapeutic relationship: In order to maintain the integrity of the therapeutic relationship, your therapist is restricted from socializing with any client outside of sessions for purposes of business or pleasure. Part of what makes the therapeutic relationship safe is that your therapist is outside of your circle of contacts. A secondary relationship can compromise the therapeutic relationship. In addition, all clients should be informed that professional therapy never includes sex. If a therapist has ever made sexual comments or flirtatious advances, initiated a sexual relationship of any kind, or responded to a sexual relationship that you initiated, this constitutes unethical, illegal behavior and your rights as a client have been violated.
CONTACTING THE THERAPIST: Due to the nature of therapy, you may feel triggered or overwhelmed by what you are processing. If the topic of concern needs more individual attention, and cannot wait until the next scheduled appointment, an additional individual session with your therapist may be arranged by contacting him directly via his confidential email (andrewstenhouse@proton.me). Allow 24 hours for your therapist to respond.
PROFESSIONAL RECORDS: The law and standards of licensed professional clinical counselors require keeping Protected Health Information (PHI) about you in your clinical record. You may request to examine this record.
CONFIDENTIALITY AND CONTRIBUTION OF KNOWLEDGE: We are committed to the advancement of psychology and marriage and family therapy as a science and profession. We contribute professional time to teaching, writing, training, and improving the standards of psychotherapy. Some of this teaching and writing requires the use of case illustrations. These illustrations are general and do not expose the identity of any person. Unless you notify us to the contrary, it will be assumed that you have no objection to this work in lectures or publications.
Your signature on this form is your acknowledgement of the above facts. Please feel free to discuss any concerns you may have, on these or other administrative matters as they arise.
I Consent To Treatment
By providing your full name, date of birth, address, and selecting "I Agree," you affirm that you have read and understand the contents of the above material, giving your consent for treatment.