Informed Consent, Confidentiality Agreement, and Disclosure Statement
The therapeutic relationship is unique in that it is highly personal, and, at the same time, a contractual agreement. Therefore, it is important that we have a clear understanding about how our relationship will work and what each of us can expect.
This document is intended to provide important information to you regarding your treatment. Please read the entire document carefully and be sure to ask me any questions you have regarding its contents.
Background / Orientation
Please feel free to ask questions at any time about my background, experience and professional orientation. Information on my background can be viewed on the Services page of this website.
All communications between us during therapy will be held in strict confidence unless you provide written permission to release information about your treatment.
There are both mandatory and permissive exceptions to confidentiality. For example, therapists are required to report instances of suspected child, elder or dependent abuse. Therapists may be required or permitted to break confidentiality when they have determined that a client presents a serious danger of physical violence to another person or when a client is dangerous to him or herself. I may also break confidentiality when you make your mental or emotional state an issue in a legal proceeding; with regard to the last case, I will not voluntarily become involved in a court proceeding (e.g. by writing letters, signing declarations and the like), except in response to a subpoena, as required by law. In addition, a federal law known as The Patriot Act of 2001 requires therapists (and others) in certain circumstances, to provide FBI agents with books, records, papers and documents and other items and prohibits the therapist from disclosing to the client that the FBI sought or obtained the items under the Act.
Confidentiality in Individual, Pre-Marital, Marital, and Family Therapy If you participate in individual or family therapy, I will not disclose confidential information about your treatment to third parties unless all person(s) who participated in the treatment provide their written authorization to release. In couples therapy, I will discuss with you and your partner my "NO SECRETS" policy regarding information provided by either you or your partner to me outside the therapeutic setting.
Minors and Confidentiality
Communications between therapists and clients who are minors (under the age of 18) are confidential. However, parents and other guardians who provide authorization for their child’s treatment are often involved in their treatment. Consequently, in the exercise of my professional judgment, I may discuss the treatment progress of a minor client with you as the parent or caretaker. Clients who are minors and their parents are urged to discuss any questions or concerns that they have on this topic.
Appointment Scheduling and Cancellation Policies
Sessions are typically scheduled to occur one time per week, at the same time and day if possible. I may suggest a different amount of therapy depending on the nature and severity of your concerns. Your consistent attendance greatly contributes to a successful outcome.
Occasionally you may need to miss or reschedule a session. In order to cancel or reschedule an appointment, you are expected to provide notification at least 24 hours in advance of your appointment. Provided you contact me at least 24 hours in advance, you will not be charged for the missed session.
Please understand that insurance companies will not pay for missed or cancelled sessions, and you are responsible for payment if you don’t cancel at least 24 hours in advance. That means, for a late cancellation, you will not pay simply your co-pay. The payment you will be responsible for will be equal to the total fee amount for that session.
Telephone consultations between office visits are welcome. However, I will attempt to keep those contacts brief due to my belief that important issues are better addressed within regularly scheduled sessions. There may be additional billing for phone consultation and/or sessions.
You may leave a message for me at any time on my confidential voicemail or confidential email. If you wish me to return your call, please be sure to leave your name and phone number(s), along with a brief message concerning the nature of your call. Non-urgent phone calls are returned during normal workdays (Monday through Friday) within 24 hours to 48 hours. If you have an urgent need to speak with me, please indicate that fact in your message. If you feel it is an emergency, please contact 911 or go to your nearest emergency room.
Periodically, I will be unavailable for consultation due to travel or while attending professional workshops and conferences. In this event, I will provide advance notification and provide an alternate therapist for contact in emergencies. Also because of travel, occasionally I will be unavailable for phone consultation. About the Therapy Process
It is my intention to provide services that will assist you in reaching your goals. Based upon the information that you provide and the specifics of your situation, I will provide recommendations to you regarding your treatment. I believe that therapists and clients are partners in the therapeutic process. You have the right to ask questions at any time during your treatment, and agree or disagree with my recommendations. I will also periodically provide feedback to you regarding your progress and will invite your participation in the discussion. Due to the varying nature of problems and the individuality of each client, I am unable to predict the length of your therapy or to guarantee a specific outcome or result.
Termination of Therapy
The length of your treatment and the timing of the eventual termination of your treatment depend on the specifics of your treatment plan and the progress you achieve. It is a good idea to plan for your termination in collaboration with me. We can discuss a plan for termination as you approach the completion of your treatment goals.
You may discontinue therapy at any time. If either of us determine that you are not benefiting from treatment, a discussion can take place about your treatment alternatives. Treatment alternatives may include, among other possibilities, referral, changing your treatment plan, or terminating your therapy.
Legal and Ethical Information
According to California laws, professional therapy never includes sex. Sexual misconduct or sexual relations by a therapist with a client is unprofessional, illegal, as well as unethical as set forth in Business and Professions Code sections 726, 729, 2960(o), 4982(k) and 4992.3(k). Additionally, with regard to former clients, sexual contact within two years after termination of therapy is also illegal and unethical. If you have questions on this topic, you can ask me for a copy of the booklet published by the State of California, Professional Therapy Never Includes Sex, or read it online at: http://www.psychboard.ca.gov/pubs/proftherapy.pdf
You are responsible for verifying and understanding the limits of your insurance coverage. Although I will be happy to assist your efforts to seek insurance reimbursement, most insurance companies do not guarantee that they will pay for your therapy sessions – even if they approve them in advance. Also, be aware that insurance plans generally limit coverage to certain diagnosable mental conditions. And, although I will make every effort to keep your records completely confidential, your insurance company has access to some of your records. They require your diagnosis, and sometimes request your treatment plan and progress reports for reimbursement purposes. If you decide to use your health insurance coverage, make sure that your insurance plan allows you to use Janis Powell, LCSW and also about your eligibility under your plan for mental health services.
Prior to your first session, we will discuss and mutually determine the fee for services. Periodically the fee arrangement will be discussed and arrangements may be made for an adjustment. Fee adjustments will be discussed well in advance.
Janis Powell, LCSW Licensed in California & New Jersey CA #70414 NJ #44SC05633500 Offices located at: 4405 Riverside Drive #209, Burbank, CA 91505 24328 Vermont Avenue #210, Harbor City, CA 90710 2820 Glendale Blvd., Los Angeles, CA 90039 and 2001 Barrington Ave., Los Angeles, CA 90025 Telephone: 818-643-1836 Email: email@example.com