The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about 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 your therapist. Please read and indicate that you have reviewed this information.
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.
The session content and all relevant materials to the client’s 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(s). Limitations of such client held privilege of confidentiality exist and are itemized below:
In conducting couples therapy, there are specific positions each therapist holds regarding whether they are willing to “keep secrets” told by one partner from the other partner. Please assume that anything you share with your couples therapist may be shared with your partner, unless you have a specific understanding to the contrary. Exceptions are made in cases regarding the duty to protect/warn or prevent abuse. Exploring your therapist’s policies regarding “secrets” may be something you want to discuss with them specifically.
To uphold myself to the highest professional standards, and to avoid clinical “blind spot,” I consult with the clinicians in our organization without disclosing detailed identifying information. I may also 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.
We employ office staff who have been briefed on the importance of confidentiality, and who have signed a confidentiality agreement to protect your rights. Please rest assured that your private information is respected with all of our staff at Couples Therapy Inc.
ABOUT OUR CLINICIANS
Our clinicians are identified as to license or professional training on this page: https://couplestherapyinc.com/all-star-team/
Clinical Interns are not licensed professionals. However, their cases are supervised by licensed professionals or another practitioner fully empowered by their country to provide independent services to the public.
You agree that our consultations occur in the state or the country where the clinician lives, and that they are governed by the laws of that state or country.
The standard meeting time for psychotherapy is 45 minutes, but evidence-based GOTTMAN METHOD COUPLES THERAPY treatment for couples indicates that 1 hour 20 minutes is needed. It is up to you, however, to determine the length of time of your sessions. Requests to change the 45-minute session for individuals or 1 hour 20 minute sessions for couples needs to be discussed with your therapist in order for time to be scheduled in advance.
Full-Two-day intensives are two full days – 7 hours long, including a 75-90 minute lunch break and two additional brief breaks per day. The assessment is included as part of the intensive work. The “Friday Night Warm-ups” are scheduled for 1.5-2 hours long. The exact start time will be finalized when the clients’ travel times become firmed up.
ASSESSMENT AND THE BIG BIG BOOK
All GOTTMAN METHOD COUPLES THERAPY begins with a detailed assessment of your relationship dynamics. This is an essential requirement to design a treatment plan. This assessment can be conducted over several weeks, or using an intensive format.
As part of this assessment process, you will be completing an online instrument called “The BIG BIG Book” (BBB) and “The BIG BIG Book of SEX.” If at any point, you find it difficult to complete either BBB, this can be done in-person with your therapist at the fee rate established for diagnostic individual sessions.
CANCELLATIONS FOR ONLINE OR IN-PERSON WEEKLY SESSIONS
For clients scheduling in-person or videoconferencing appointments: Once an appointment hour is scheduled, you will be expected to pay for it, unless you provide 48 hours [2 day] advance notice of cancellation, or, at the clinician’s discretion, we are able to reschedule the appointment during the same calendar week. Please remember to cancel or reschedule 48 hours in advance. You will be responsible for the entire fee if cancellation is less than 48 hours.
A $30.00 service charge will be charged for any checks returned for any reason for special handling.
Cancellations for weekly and online psychotherapy will be subject to a full charge if NOT RECEIVED AT LEAST 48 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time.
CANCELLATIONS FOR INTENSIVES
Intensives are in very high demand and are limited in availability. Once the time is set aside for you, it cannot be given to another couple. Therefore, when you schedule an intensive, you will be expected to pay for it in full. If you need to cancel up to 60 days prior to your scheduled intensive, 50% of your fee (minus bank fees) will be refunded.
If weather makes traveling unsafe, your therapist will contact you to reschedule.
If at any point in your therapist’s professional opinion, an Intensive Couples Therapy Retreat is contraindicated, s/he will return the fee prior to the start of the intensive. In extremely rare cases where the intensive has begun, you may be entitled to a refund of up to 50% of your fee, if 3.5 hours or less of clinical work has been conducted. No refunds will be made in the event that it is discovered that vital information critical to accurate professional assessment has been withheld.
If you need to contact your therapist between sessions, you can call: 844 – 926-8753. Clinicians are often not immediately available by telephone, and will not answer the phone when they are with a client. When your clinician is unavailable, the telephone is answered by voicemail. We monitor it frequently. Please respect our week-ends, as we are often in Intensives and unavailable. Your therapist will return calls and emails during the week, unless it is an emergency.
We will make every effort to return your call on the same day you make it, with the exception of weekends, vacations, and holidays. If you do not hear from us within 24 hours, please email your therapist and cc Jessica at: Jessi[email protected] If you are difficult to reach, please inform us of some times when you will be available. Please also include your telephone number during each call, even if you think we have it.
If a true emergency situation arises, please call 911 or any local emergency room, and ask for the psychologist or psychiatrist on call.
If we will be unavailable for an extended time, we will provide you with the name(s) of a colleague to contact, if necessary.
SOCIAL MEDIA AND TELECOMMUNICATION
Due to the importance of your confidentiality and the importance of minimizing dual relationships, we ask that you consider the matter carefully before making a friend or contact requests on any social networking site (Facebook, LinkedIn, etc). We 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. As always, however, it is your decision to make. If you have questions about this, please bring them up when we meet and we can talk more about it.
We are also available by email. You can feel free to email us. Some couples find it helpful to clarify their thinking in an email. Be aware, however, that we will not discuss ongoing couples issues with you in an email. We will, however, read anything you would like to write, within reason. We will also urge you to “cc” your partner, so that both of you are aware of what you are sharing with your therapist.
We cannot ensure the confidentiality of any form of online communication, but especially through text messages, and therefore please don’t text your therapist. If you prefer to communicate via email for issues regarding scheduling or cancellations, we will do so. While we try to return messages in a timely manner, we cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.
Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine. Telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another.
If you and I chose to use information technology for some or all of your treatment, you need to understand that:
(1) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
(2) All existing confidentiality protections are equally applicable.
(3) Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent.
(4) There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to, improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs. Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited “To the therapist” inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally to the therapist.
(5) We also may experience difficulties that are beyond our control including:
While we use a service that requires minimal bandwidth, and is used by medical practitioners all over the world, problems are possible. If this happens, we will make every effort to contact you to reestablish communications. For this reason, we ask you to email us a telephone number where we can contact you in the event of continuing interruption to our online communication, even if our contact is restricted to psychotherapy via videoconferencing.
(6) You verify through this document that you speak a language offered by one of our clinicians adequately to be able to converse about your intimate and marital/relationship life. If, at any time, you are uncertain about what is being said, you agree to stop the interaction and ask for clarification. You understand that your ability to understand the English language or the language you and your clinician have agreed to speak in session, and emotional nuance expressed in this language are essential for effective psychotherapy.
(7) IF YOU ARE CURRENTLY CONSIDERING OR THREATENING SUICIDE OR ANY FORM OF HARM TO YOURSELF OR OTHERS, YOU TAKE FULL RESPONSIBILITY FOR SEEKING APPROPRIATE HELP IMMEDIATELY AND FOR ANY ACTION YOU MAY TAKE.
Online videoconferencing mental health or intensive forms of couples therapy is NOT an appropriate form of treatment under these circumstances.
You understand that information on nationwide crisis intervention and help resources exists in the United States and includes the following:
You can do an internet search for crisis intervention help in the country you currently live in.
INTENSIVE COUPLES THERAPY RETREATS AREN’T DESIGNED FOR THOSE IN:
This particularly includes suicidal or homicidal thoughts, or a history of serious harm you’ve done to yourself or another person.
If you have a mental health condition which is currently stable and/or in remission, you are welcome to participate in this form of treatment.
We do not work with minors. You verify that you are of legal age and fully competent to receive psychotherapy without permission of a parent, legal guardian, or other authorized parties.
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. We may terminate treatment after appropriate discussion with you and a termination process if we determine that the psychotherapy is not being effectively used or if you are in default on payment. We will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating.
Treatment in the GOTTMAN METHOD COUPLES THERAPY and EMOTIONALLY FOCUSED COUPLES THERAPY is often timed at greater intervals as our work progresses: from weekly to semi-weekly frequency, and then at monthly and bimonthly intervals. Research by The Gottman Institute suggests 4 sessions as part of relapse prevention. These final four sessions are scheduled at 6 month intervals, after the last treatment session is held.
If therapy is terminated for any reason or you request another therapist, we will provide you with a list of qualified psychotherapists to treat you within or outside our Team. You may also choose someone on your own or from another referral source.
Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, we must consider the professional relationship discontinued.
Notice of Privacy Practices – Release for Videotaping
As a primary tool in Gottman Method Couples Therapy, and in order to augment your therapy work, we use videotape feedback as part of therapy sessions. This means that we may ask to videotape you during specific dialogues or exercises, or during entire sessions. We will play back these tapes in sessions to help you see patterns of behavior between the two of you and to help you process conflicts. By viewing the videotapes in sessions, it allows us to “stop action” and process how you might approach a conflict in a more productive way. It also allows you to witness your progress as your relationship becomes more satisfying to both of you.
In addition to in-session use, we may wish to use the videotapes to receive consultation as part of supervision internally or by a senior Gottman supervisor. Supervision is crucial to our ability to continue to hone our skills, and to enable you to receive the highest quality care.
During this process, your name will be kept confidential. In addition, all matters discussed in consultations will remain completely confidential with the consulting supervising clinician. The videotapes are not part of your clinical record and will be used for no other purpose without your written permission and they will be erased when they are no longer needed for these purposes.
These tapes are the property of your clinician, and will remain solely in our possession during the course of your therapy. Should you wish to review these tapes for any reason, we will arrange a session to do so. These materials will remain in locked facilities at all times, or deleted after reviewing.
You always have the right to refuse to be videotaped, and can do so at the time when it is requested by your therapist. You will never be taped without your full awareness and consent.
I understand and accept the conditions of this statement and give my permission to have my therapy sessions videotaped or digitally recorded. I understand I may revoke this permission in writing at any time, but until I do so it shall remain in full force and effect until the purposes stated above are completed.
In addition to clinical appointments, we charge for other professional services you may need, though we will break down the hourly cost if we work for periods of less than one hour, in 7.5 minute increments. Other services may include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of your therapist.
If you become involved in legal proceedings that require your clinician’s participation, you will be expected to pay for my professional time even if the therapist is called to testify by another party. Because of the difficulty of legal involvement, we charge $400 per hour for preparation and attendance at any legal proceeding, and $350 per hour for travel. Travel expenses and per diem rates are charged separately, and the per diem fee will be set depending upon the travel time or country we will be working in.
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information.
I am required by law to:
HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.
For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow healthcare providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any healthcare provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.
Disclosures for treatment purposes are not limited to the minimum necessary standard because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one healthcare provider to another.
Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on April 25, 2014
Acknowledgement of Receipt of Privacy Notice
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By reading this document, you are acknowledging that you have received a copy of HIPPA Notice of Privacy Practices.
The document below is relevant to those who have chosen to be seen by a supervised Marriage and Family Therapy Intern. If this doesn’t apply to you, just confirm and move on to the next document.
Marriage and Family Therapy Interns-in-training are dependent upon the ability to see clients, couples, and families, in order to complete their training, and become licensed. If you have chosen to see a Couples Therapy Inc (CTI) Intern, this document explains the student’s training, offers information about the counseling relationship, and provides information about client rights and responsibilities.
Interns at CTI are enrolled or have completed coursework in a Master’s degree in Marriage and Family Therapy program accredited by Commission on Accreditation for Marriage and Family Therapy Education (COAMFTE). Students have completed core courses in Marriage and Family Therapy prior to beginning their clinical experience at this independent clinical placement, and have been approved by their program to practice clinically. A few examples include courses in ethics, psychopathology, theories of marriage and family therapy, and other courses relevant to the student’s specialization in marriage and family therapy. The courses are offered in a developmental sequence in which students apply their knowledge under intensive supervision.
Your counseling services will be based on a relationship characterized by trust and respect. The MFT-in-training and client will work together to both identify goals for therapy and to move toward meeting those goals. The therapy sessions may include an exploration of thoughts, feelings, personal and family history, communication styles, attitudes and beliefs about self and others, and personal developmental needs. The MFT-in-training will receive supervision from a qualified, experienced supervisor who is licensed at an independent level to practice in their discipline.
CLIENT RIGHTS AND RESPONSIBILITIES
Clients have the right to receive counseling in which the individual’s dignity, worth, and uniqueness are respected. Your MFT-in-training will provide you with quality informed services that are offered under close supervision. Additionally, however, the success of the counseling relationship depends on your willingness to be open and involved in the process. Individuals who participate in counseling can experience changes in personal views, attitudes, and coping skills. Sometimes those close to you may need time to adjust to new perspectives and positive behavioral changes that may evolve during your therapy.
Your MFT-in-training may ask to record some or all of your counseling sessions. The recording of sessions is something that occurs only with your verbal consent at the start of your therapy. You have the right to allow or to refuse this process to take place. However, the recordings are taking place to ensure that supervisors can observe the trainee objectively and to ensure the highest quality of service to you, the client. All recordings, if made, will be destroyed at the end of your treatment. Recordings will both serve the intern’s training needs and enrich your personal counseling experience via the added perspective of supervisory review.
If you have any concerns at any time about the services provided by your intern, you may contact their supervisor.