Informed Consent & Release of Liability


(Hello!  if you are joining one of my educational support groups, and not entering into therapy, the following forms do not specifically apply to you; however, some of the information may be useful.) 

 

Thank you for you considering working with me as your therapist. I need you to know about the risks, benefits and agreements we make should we choose to continue together.  When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future. 

1. Hi.  My name is Jo Levkoff.  I have a MA in Counseling Psychology from Antioch/New England, an accredited graduate program; I am licensed as a professional counselor (LPC) in TN.

 

2. Risks and Benefits - Psychotherapy describes a relationship between you and your therapist, devoted to your well being, psychological and spiritual healing.  Therapy works best when people are honest, trusting and agree to abide by clearly defined rights and responsibilities held by each person. As a client in psychotherapy, you have certain rights and responsibilities that are important to understand. There are also legal limitations to those rights that you should be aware of.  As your therapist, I have corresponding responsibilities to you. 

 

Possible risks of therapy may include discussing challenging aspects of your life, experiencing uncomfortable feelings, making changes. A client may initially feel worse before feeling better.  

 

There are lots of benefits for individuals who undertake the process. Therapy can help relieve emotional pain and feelings of distress, reduce symptoms, improve relationships, increase personal awareness, insight and skills for managing stress and resolving specific issues. You may trust your intuition more and experience more peace and joy.  Psychotherapy requires a very active effort on your part. To get the most out of the experience, you have to work on what we discuss in therapy outside of sessions.  Meeting online through video conferencing also includes the benefits of saving time driving and money for gas.  

 

There are no guarantees.

 

3. In case of emergency -  I am not available for emergencies. If you need an additional appointment during a week and we can schedule a time, that’s possible. I’m otherwise not available between our scheduled sessions. If you are having an emergency, if you become extremely emotionally distressed or are in danger of hurting yourself or someone else, please go to your local hospital Emergency Room, or call 911 and ask to speak to the mental health worker on call. 

 

4.  Communication  -  Because we'll be meeting virtually, online, and need an internet connection, technical issues are possible.  I have a fiber optic connection; when the power goes out, I have no internet or phone.  Thank you in advance for your patience if this happens.  If we're scheduled to meet, and I'm not there within 15 minutes, no power is likely the reason.  Please don't wait longer than 15 minutes.  I'll reach out to reschedule when the power is back.

 

I'm often not immediately available by telephone. I don't answer my phone when I'm with clients or otherwise unavailable. If we need to communicate between sessions about scheduling changes, you can text through the TherapyZen client portal or leave a message on my confidential voicemail 865 661 3877.  I will return your call or text as soon as possible. If, for any number of unseen reasons, you do not hear from me or I am unable to reach you, and you feel you cannot wait for a return call or if you feel unable to keep yourself safe, again, please go to your local hospital Emergency Room, or call 911 and ask to speak to the mental health worker on call. 

 

I will make every attempt to inform you in advance of planned absences and provide you with the name and phone number of the mental health professional covering my practice.

 

5. Fees and Cancellations - The standard fee for sessions with me is $130 for individual therapy. Couples therapy is $170; family therapy is $200. I do have a sliding scale (+/- $40). 

If we spend more than 10 minutes on the phone, or texting, based on the hourly rate we've agreed on, I will bill you at 15 minute intervals (so 10 - 15 minutes is ¼ of the hourly rate, 16 - 30 minutes is ½, 31- 45 is ¾ and 46 - 50 is the full hourly rate.  The same is true if I need to provide any additional service (e.g. write a report, attend an online meeting, etc.).

 

Appointments are approximately 50 minutes in duration, once per week at a time we both agree on; at times, some sessions may be more or less frequent, or longer or shorter, as needed. We decide this together.  The time scheduled for your appointment is for you and you alone. 

 

If you need to cancel or reschedule a session, I need 24 hours notice. If you miss a session without canceling, or cancel with less than 24 hour notice, my policy is to collect half of the fee we’ve agreed on [unless we both agree that you were unable to attend due to circumstances beyond your control]. 

 

You are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.

 

After your session has taken place, you will be invoiced and charged for services within 24-48 hours using the credit card on file. You may obtain your invoices by logging into your free client portal account or by request. I do not deal directly with insurance companies.  If you wish to be reimbursed by your insurance company, a statement of reimbursement or 'superbill' can be printed from your client portal account or emailed to you by request. 

 

Showing up regularly gets the best results.  You and I are free to discontinue therapy at any time. Meeting for a final closure/summary session is highly recommended to get the greatest benefits.

 

6. Limitations of Confidentiality - My policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled Notice of Privacy Practices.

 

As a client, I understand that my counseling records & conversations with my therapist are kept confidential except where disclosure is required by law (i.e. abuse of a child, elderly or disabled person; potential harm or threat to self or others and specific information subpoenaed by a court of law.)   If you disclose intent to harm to yourself or others, child abuse and elder abuse, I am a mandated reporter.

 

Please remember that you may reopen this conversation at any time during our work together.

 

7.  Other Rights and Responsibilities - When we meet online, it is each of our responsibility to have a private, safe space where we will not be interrupted or overheard.  

 

If you are unhappy with what is happening in therapy, I hope you will talk with me so that I can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist and are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect that I will not have social or sexual relationships with clients or with former clients.

 

8. I know of no reasons that I should not undertake this therapy and I agree to participate fully and voluntarily.

My signature below indicated that I grant informed consent to receive counseling services to myself and or minor members of my family.