INFORMED CONSENT

Thank you for choosing LED Career/Inner Focus.   We realize that starting counseling is a major decision and you may have many questions.  This document is intended to inform you of our policies, State and Federal Laws and your rights.  If you have other questions or concerns, please ask and we will try our best to give you all the information you need. 

 
ABOUT OUR COUNSELOR:

Lauri Dishman, M.A., LCPC has earned a Masters of Arts  Degree in Counseling and Organizational Psychology from the Adler University.  She is licensed by the State of IL as a Licensed Clinical Professional Counselor. She has over 13 years of clinical experience in treating adults. Lauri Dishman practices standard cognitive behavioral and existential therapy for most conditions.  Although other treatment approaches are used depending on the person or condition.  Treatment practices, philosophy and plan imitations and risks will be discussed with you at time of session.

 
CONFIDENTIALITY AND EMERGENCY SITUATIONS: Your verbal communication and clinical records are strictly confidential except for:  a) information you and/or you child or children report about physical or sexual abuse; then, by Illinois State Law, I am obligated to report this to the Department of Children and Family Services, b) where you sign a release of information to have specific information shared and c) if you provide information that informs me that you are in danger of harming yourself or others f) information necessary for case supervision or consultation and d) or when required by law.  If an emergency situation for which the client or their guardian feels immediate attention is necessary, the client or guardian understands that they are to contact the emergency services in the community (911) for those services.  LED Career will follow those emergency services with standard counseling and support to the client or the client's family.

 
INFORMED CONSENT FOR TELEPSYCHOLOGY

This Informed Consent for Telepsychology contains important information focusing on doing psychotherapy using the phone or the Internet. Please read this carefully, and let me know if you have any questions.  When you sign this document, it will represent an agreement between us.

 
Benefits and Risks of Telepsychology

Telepsychology refers to providing psychotherapy services remotely using telecommunications technologies, such as video conferencing or telephone.  One of the benefits of telepsychology is that the client and clinician can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the client or clinician moves to a different location, takes an extended vacation, or is otherwise unable to continue to meet in person. It is also more convenient and takes less time. Telepsychology, however, requires technical competence on both our parts to be helpful.  Although there are benefits of telepsychology, there are some differences between in-person psychotherapy and telepsychology, as well as some risks.  For example:

Risks to confidentiality.  Because telepsychology sessions take place outside of the therapist’s private office, there is potential for other people to overhear sessions if you are not in a private place during the session. On my end I will take reasonable steps to ensure your privacy. But it is important for you to make sure you find a private place for our session where you will not be interrupted.  It is also important for you to protect the privacy of our session on your cell phone or other device.   You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation.
Issues related to technology.  There are many ways that technology issues might impact telepsychology.  For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people or companies.
Crisis management and intervention.  Usually, I will not engage in telepsychology with clients who are currently in a crisis situation requiring high levels of support and intervention.  Before engaging in telepsychology, we will develop an emergency response plan to address potential crisis situations that may arise during the course of our telepsychology work.
Efficacy. Most research shows that telepsychology is about as effective as in-person psychotherapy. However, some therapists believe that something is lost by not being in the same room. For example, there is debate about a therapist’s ability to fully understand non-verbal information when working remotely.

 

Electronic Communications

We will decide together which kind of telepsychology service to use.  You may have to have certain computer or cell phone systems to use telepsychology services. You are solely responsible for any cost to you to obtain any necessary equipment, accessories, or software to take part in telepsychology.

 Confidentiality

I have a legal and ethical responsibility to make my best efforts to protect all communications that are a part of our telepsychology.  However, the nature of electronic communications technologies is such that I cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. I will try to use updated encryption methods, firewalls, and back-up systems to help keep your information private, but there is a risk that our electronic communications may be compromised, unsecured, or accessed by others.  You should also take reasonable steps to ensure the security of our communications (for example, only using secure networks for telepsychology sessions and having passwords to protect the device you use for telepsychology).

 The extent of confidentiality and the exceptions to confidentiality that we outlined in our Outpatient Agreement still apply in telepsychology.  Please let me know if you have any questions about exceptions to confidentiality.

Emergencies and Technology

Assessing and evaluating threats and other emergencies can be more difficult when conducting telepsychology than in traditional in-person therapy.  To address some of these difficulties, we will create an emergency plan before engaging in telepsychology services.  I will ask you to identify an emergency contact person who is near your location who I will contact in the event of a crisis or emergency to assist in addressing the situation.  I will ask that you name that person along with their contact information at the bottom of this forms, which will allow me to contact your emergency contact person as needed during such a crisis or emergency.

 If the session is interrupted for any reason, such as the technological connection fails, and you are having an emergency, do not call me back; instead, call 911, and/or any other hotlines local resources that we will identify in our emergency plan or go to your nearest emergency room. Call me back after you have called or obtained emergency services.

 If the session is interrupted and you are not having an emergency, disconnect from the session and I will wait two (2) minutes and then re-contact you via the telepsychology platform on which we agreed to conduct therapy.

If there is a technological failure and we are unable to resume the connection, you will only be charged the prorated amount of actual session time.

Fees

Services through LED Career/Inner Focus are self pay unless otherwise arranged.  

FINANCIAL/INSURANCE ISSUES: At this time, LED Career/Inner Focus does not take health insurance.  We are fee-for-service practice and services can be paid with cash, check or most major credit cards.  A sliding scale is offered for those who are in greater financial need. LED Career/Inner Focus is also a vender of the state of Illinois and accepts referrals from the Department of Rehabilitation Services (DRS).  Cost for care will be based on a given number of sessions multiplied by the fee agreed upon.  (For example if are to meet weekly for 20 weeks at an agreed-upon rate of $120 per hour, your total anticipated cost would be 20 X $120 = $2400.)  There is no minimum or maximum requirement for the amount of sessions to be held.  Termination can be made at any time.

As Per Illinois Law

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost

Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

Make sure to save a copy or picture of your Good Faith Estimate.

For questions or more information about your right to a Good Faith Estimate, visitwww.cms.gov/nosurprises.

Records

The telepsychology sessions shall not be recorded in any way unless agreed to in writing by mutual consent.  I will maintain a record of our session in the same way I maintain records of in-person sessions in accordance with my policies.

 Informed Consent

This agreement is intended as a supplement to the general informed consent that we agreed to at the outset of our clinical work together and does not amend any of the terms of that agreement.

 

Your signature below indicates agreement with its terms and conditions.

 

 APPOINTMENTS

Lastly, if you need to cancel or reschedule an appointment, please give 24 business hours advance notice, otherwise you will be charged $15. We sincerely appreciate your cooperation and at any time you have any questions regarding fees, balances or payments please feel free to ask. You may have a copy of this form if requested.