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Informed Consent

When starting a therapeutic or medical relationship it is important that know your provider's qualifications, and understand the potential benefits and risks, privacy, financial terms, and office policies.  These clarifications are provided within this page, and by setting an appointment, you indicate your agreement with these.

 

About me:  

You are free to ask questions at any time about your  therapist’s background, experience and professional orientation.  

I m a: Licensed Marriage and Family Therapist.  In addition to practicing as a therapist, I have trained and taught therapists, contributed to bio-psycho-social research, led programs at the executive level, and developed organizations. You can view additional certifications and credentials at  Https://www.alexmackenziemft.com 

Benefits of Psychotherapy:

  1. Emotional Well-being: Psychotherapy can help individuals understand and manage their emotions more effectively. It provides a safe space to explore and express feelings, leading to improved emotional well-being.

  2. Improved Coping Skills: Therapists teach practical coping strategies to deal with stress, anxiety, depression, or other mental health challenges. Clients can learn healthier ways to manage difficulties in their lives.

  3. Enhanced Relationships: Psychotherapy often focuses on improving communication and interpersonal skills, which can lead to healthier and more satisfying relationships with others.

  4. Increased Self-awareness: Through self-reflection and exploration, individuals can gain a deeper understanding of themselves, their motivations, and their patterns of behavior. This self-awareness can be empowering and facilitate personal growth.

  5. Symptom Reduction: Psychotherapy is effective in treating a range of mental health conditions, such as depression, anxiety, and PTSD. It can help alleviate symptoms and improve overall functioning.

  6. Supportive Environment: Therapy provides a non-judgmental and confidential space where individuals can openly discuss their thoughts and feelings. This support can be particularly valuable during challenging times.

  7. Behavioral Change: Therapists help clients identify and modify negative behaviors or thought patterns. This can lead to positive changes in various aspects of life.

Risks and Challenges of Psychotherapy:

  1. Emotional Discomfort: Exploring deep-seated emotions and unresolved issues may initially cause discomfort or distress. It's essential for clients to be prepared for this and work collaboratively with the therapist to manage such emotions. (That said, self discovery should be a joyful pursuit, and not consistently painful or difficult)

  2. Not Suitable for Everyone: Some individuals may not benefit from or be ready for psychotherapy. Factors such as readiness for change, motivation, and the therapeutic relationship's quality play a role in its effectiveness.

  3. Potential for Misunderstanding: Communication can sometimes be challenging, leading to misunderstandings between the therapist and the client. Clear and open communication is crucial to address and resolve such issues.

  4. Financial and Time Commitment: Psychotherapy can be time-consuming and may require a financial investment. Some individuals may find it challenging to commit to regular sessions due to time constraints or financial considerations.

  5. Lack of Immediate Results: Psychotherapy is often a gradual process, and positive changes may take time. Some individuals may feel discouraged if they do not see immediate results.

  6. Reliance on Therapist: There is a risk of developing dependency on the therapist. A good therapist will work towards empowering the client and fostering independence rather than creating dependency.

The benefits of psychotherapy often outweigh the risks, especially when it is delivered by a qualified and experienced therapist. Individuals considering psychotherapy should discuss any concerns with their potential therapist and collaboratively address them throughout the therapeutic process.

Fees, Insurance, and Office Policies

Fees and Insurance

Privacy

Scheduling and Cancelation

Availability/Emergency

Fees and Insurance The fee for service is $200 per therapy hour (50 minute session). 

Individual Sessions and conjoint (marital /family) sessions are approximately 50, or 90 minutes if you choose. Fees are payable at the time that services are rendered.  

By this agreement, you acknowledge that the therapist is not on any insurance preferred  provider panels and has no relationship with insurance companies, nor Medicare, and aside from providing you  with a receipt which you may elect to use to get reimbursement commensurate with your  coverage, the therapist does not engage in insurance billing. Any amount of reimbursement and  the amount of any co-payments or deductible depends on the requirements of your specific  insurance plan. You should be aware that insurance plans generally limit coverage to certain  diagnosable mental conditions. You should also be aware that you are responsible for verifying  and understanding the limits of your insurance coverage. As such, we are unable to guarantee  whether your insurance will provide payment for the services provided to you. 

If for some reason you find that you are unable to continue paying for your therapy, you should  inform your therapist. Your therapist will help you to consider any options that may be available  to you at that time.  

You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health 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 expected charges for medical services, including psychotherapy services. 

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services.

You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a 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, visit www.cms.gov/nosurprises.

 

YOUR GOOD FAITH ESTIMATE

 

Provider Name Alexander J Mackenzie, MFT

License/#: MFT29374

 

Provider Phone #: ( 408   ) 359-7427
 

 

For Psychotherapy – individual, group, family, and/or conjoint couple therapy, You are entitled to receive this “Good Faith Estimate” of what the charges could be for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of psychotherapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you.

There may be additional items or services I may recommend as part of your care that must be scheduled or requested separately and are not reflected in this good faith estimate. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here. 

You have the right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges).

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit https://www.cms.gov/nosurprises/consumers or call 1- 800-985-3059. The initiation of the patient-provider dispute resolution process will not adversely affect the quality of the services furnished to you.

The fee for a 50-minute psychotherapy visit (in-person or via telehealth) is $___200____.  Most clients will attend one psychotherapy visit per week, but the frequency of psychotherapy visits that are appropriate in your case may be more or less than once per week, depending upon your needs. Based upon a fee of $___200____ per visit, if you attend one psychotherapy visit per week, your estimated charge would be $800_______for four visits provided over the course of one month; $__1600_____for eight visits over two months; or $___2400_____for 12 visits over three months.  If you attend therapy for a longer period, your total estimated charges will increase according to the number of visits and length of treatment.

This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist.  You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.

You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in this Good Faith Estimate.

Date of this Estimate : Estimate is dated in accordance with e-signature or verbal acceptance of informed consent terms and conditions.     

 

Confidentiality:  As with all HIPAA-protected records, All communications between you and your therapist will be held in strict  confidence unless you provide written permission to release information about your treatment. If  you participate in marital or family therapy, your therapist has a "no secrets" policy, which means that he will not keep secrets between participants in a conjoint (relationship) therapy. When you participate in family, and/or marital/couples therapy, your  therapist is permitted to use information obtained in an individual session or other communication that you may have had  with him or her, when working jointly or individually with other members of your family. Please feel free to ask your  therapist about his or her “no secrets” policy and how it may apply to you.  (For example, if you disclose infidelity, I may not keep that secret.)

 

There are exceptions to confidentiality. For example,  therapists are required to report instances of suspected child, dependent adult or elder abuse. 

 

Therapists may also be required or permitted to break confidentiality when they have determined  that a patient presents a serious danger of physical violence to another person or when a patient  is dangerous to him or herself. 

If you participate in marital or family therapy, your therapist will not disclose confidential  information about your treatment unless all person(s) who participated in the treatment with you  provide their written authorization to release such information.  

Minors and Confidentiality Communications between therapists and patients 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, your  therapist, in the exercise of his or her professional judgment, may discuss the treatment progress  of a minor patient with the parent or caretaker. Patients who are minors and their parents are  urged to discuss any questions or concerns that they have on this topic with their therapist.  

Appointment Scheduling and Cancellation Policies:  Sessions are typically scheduled to occur one  time per week at the same time and day if possible. Your therapist may suggest a different  amount of therapy depending on the nature and severity of your concerns, and you are free to accept or reject that recommendation. Your consistent  attendance greatly contributes to a successful outcome.

 

In order to cancel or reschedule an  appointment, notify your therapist at least 24 hours in advance of your  appointment. If you do not provide at least 24 hours’ notice in advance, you  are responsible for payment for the missed session.  Please understand that your insurance  company will likely not pay for missed or canceled sessions.  

Therapist Availability/Emergencies: You are welcome to phone, text, or email your therapist in between  sessions. However, as a general rule, it is our belief that important issues are better addressed  within regularly scheduled sessions. You may leave a message for your therapist at any time on  his confidential voicemail. If you wish your therapist 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 the therapist’s normal workdays within 24  hours. If you have an urgent need to speak with your therapist, please indicate that fact in your  message and follow any instructions that are provided by your therapist’s voicemail. In the event  of a medical or psychiatric emergency or an emergency involving a threat to your safety or the  safety of others, please call 911 to request emergency assistance. Please be sure to leave your  name and phone number(s), along with a brief message concerning the nature of your call. In the  event of a medical or psychiatric emergency or an emergency involving a threat to your safety or  the safety of others, please call 911 to request emergency assistance.

Electronic Communications

Potential Risks

Electronic Communications: Potential risks of using electronic communication may include, but are not limited to; inadvertent  sending of an e-mail or text containing confidential information to the wrong recipient, theft or  loss of the computer, laptop or mobile device storing confidential information, and interception  by an unauthorized third party through an unsecured network. E-mail messages may contain viruses or other defects and it is your responsibility to ensure that it is virus-free. In addition, e mail or text communication may become part of the clinical record.  

You further understand and agree that any virtual  (zoom sessions) may be electronically summarized by the Zoom AI Meeting Summary technology.  You will receive a notification on your screen each time, and can ask the therapist not to use this if you object

Our Partnership/Advice

We believe that therapists and patients are partners in the therapeutic process. You have the right  to agree or disagree with your therapist’s recommendations. Your therapist will also periodically  provide feedback to you regarding your progress and will invite your participation in the  discussion. Your therapist will work with you to develop an effective treatment plan. Over the  course of therapy, your therapist will attempt to evaluate whether the therapy provided is  beneficial to you. Your feedback and input is an important part of this process. It is the goal of  your therapist to assist you in effectively addressing your problems and concerns.  

However, due to the varying nature and severity of problems and the individuality of each  patient, your therapist is 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 your  therapist. Your therapist will discuss a plan for termination with you as you approach the  completion of your treatment goals. You may discontinue therapy at any time. If you or your  therapist determines that you are not benefiting from treatment, either of you may elect to initiate  a discussion of your treatment alternatives. Treatment alternatives may include, among other  possibilities, referral, changing your treatment plan, or terminating your therapy. Your signature  indicates that you have read this agreement for services carefully and understand its contents.  

Please ask your therapist to address any questions or concerns that you have about this  information before you sign.   (Your electronic signature in the form of electronic message stating you agree is acceptable in lieu of a physical signature)

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