Information from this form will be used to register you on our Electronic Medical Record (EHR) at Carepaths. If you would like your login information to your EHR record or if you have any questions, please do not hesitate to call us 631-257-5900.

This form documents that we, SEE ABOVE: NAME OF PERSON BEING SEEN and SPOUSE NAME, give our consent to (the “psychotherapist of Transformations Counseling Group LCSW PLLC”) to provide psychotherapy treatment to us.

While we expect benefits from this treatment, we fully understand that no particular outcome can be guaranteed. We understand that we are free to discontinue treatment at any time but that it would be best to discuss with the psychotherapist any plans to end therapy before doing so.

We have read the Welcome Letter of what is involved in psychotherapy and we understand and agree to the policies about schedule, fees and missed appointments. The parents have fully discussed with the psychotherapist what is involved in psychotherapy and understanding agree to the policies about schedule fee and missed appointments. We have been informed of and understand the psychotherapist's fees for treatment services. We understand that we are fully financially responsible for treatment, which includes any portion of the psychotherapist's fees that are not reimbursed by insurance. If our insurer has a network of providers, then we have been whether the psychotherapist participates in that network. We understand that the frequency of my sessions will be weekly sessions, unless otherwised discussed and that I am fully responsible for payment of all deductibles and co-payments. The frequency of billing will be, see the Copay / Deductible / Session fee policy, we understand we are fully responsible for payments of all deductibles and copays, at the frequency of billing, see the Copay / Deductible / Session fee policy. That payment will be due as explained in the Copay / Deductible / Session fee policy, and that we will be personally responsible for payment in full for any canceled sessions if we do not give at least see, Cancellation Policy, advance notice of the cancellations. (Please note that jurors do not pay for canceled sessions.)

Our discussion about therapy will included the psychotherapist evaluation and diagnostic formulation of our problems, the method of treatment, goals and length of treatment We have read the information about record-keeping in the Welcome Letter. Warned about understand the extent of treatment, it's foreseeable benefits and risks, and the possible alternative methods of treatment. We understand that therapy can sometimes cause upsetting feelings to emerge, that we may feel worse temporarily before feeling better, and that we may experience distress caused by changes we may decide to make in our lives.

We understand that the psychotherapist cannot provide emergency service. The psychotherapist has told us who to call if an emergency arises and the psychotherapist is unavailable. We understand that information about psychotherapy is almost always kept confidential by the psychotherapist and not revealed to others unless we give our consent. There are a few exceptions as follows:

1. The psychotherapist is required by law to report suspected child abuse or neglect to the proper authorities. Psychotherapist is also mandated to report to the authority’s patients who are at imminent risk of harming themselves or others for the purpose of those authorities checking to see whether such patience our own is a firearm, and if they are, or applied to be, then limiting and possibly removing their ability to possess them.

2. If one of us tells the psychotherapist of an intention to harm another person, the psychotherapist must try to protect that person, including by telling the police or the person or other health care providers. Similarly, if one of us threatens to harm ourselves, or our life or health is in any immediate danger, the psychotherapist will try to protect us, and including by telling others such as relatives or the police rather health care providers, you can assist in protecting us.

3. If we are involved in certain court proceedings the psychotherapist may be required by law to reveal information about our treatment. These situations include child custody disputes, cases where a patience psychological condition is an issue, lawsuits or formal complaints against the psychotherapist, civil commitment hearings, and court ordered treatments.

4. If our health insurance or managed care plan will be reimbursing us or paying the psychotherapist directly, they will require that we waive confidentiality and that the psychotherapist give them information about our treatment.

5. Psychotherapist may consult with other psychotherapist about our treatment, but in doing so will not reveal our names or other information that might identify us unless specific consent to do so is obtained. Further, when the psychotherapist is away or unavailable, another psychotherapist might answer calls and so will have to have some information about our treatment.

6. If our account with the psychotherapist becomes overdue and we do not work out a payment plan, the psychotherapist will have to reveal a limited amount of information about our treatment and taking legal measures to be paid. This would include our names, Social Security number, address, dates the type of treatment and the amount do.

7. Clinical records will be held separately for each individual. Information in those records will not be released to the other without written consent.

In all of the situations described above we understand that the psychotherapist would try to discuss the situation with us before any confidential information is revealed, it will reveal only the least amount of information that is necessary.

We agreed that each of us has and shall continue to have the right of information about our individual and conjoint treatment sessions, into the treatment records of the psychotherapist regarding out individual and conjoint treatment sessions. We each agree that the psychotherapist may release such information or records to either or all of us without any additional authorization(s) of the other(s).

We agree that if marriage or parenting problems lead to legal disputes over child custody or Visitation, neither of us will ask no require that the psychotherapist testify regarding custody or visitation. If a custody or Visitation preceding does occur, we agreed that the psychotherapist role will be limited to providing you have mental health professional appointed to perform a forensic evaluation, and/or to the attorneys, law guardian, if any, and the judge involved in the legal proceeding, written information regarding, and/or the record of, our treat; psychotherapist will provide these either as required by law or upon our authorization.

If we are participating in a managed care plan, we have discussed with the psychotherapist our financial responsibility for any copayment, and the plans limits on the number of therapy sessions. We have discussed with the psychotherapist our options for continuation of treatment when our managed care benefits end. If we are not participating in a managed care program, we understand that we are fully financed responsible for treatment and include any portion of the fees not reimbursed by the health insurance.

We understand that we have a right to ask the psychotherapist about the psychotherapist training and qualifications and about where to file complaints about the psychotherapist confessional conduct.