Informed Consent for Treatment


Therapy is a relationship that works in part because of clearly defined rights and responsibilities held by each person. This frame helps to create the safety to take risks and the support to become empowered to change. As the client, it is important that you are aware of your rights, and also any legal limitations to those rights. And your therapist has corresponding responsibilities for you to know about.

Your Therapist’s Responsibilities to You

I. Confidentiality.

With the exception of certain specific exceptions described below, you have the absolute right to confidentiality in your therapy. Your therapist cannot and will not tell anyone else what you have told them or even that you are in therapy without your prior permission. (The Notice of Privacy Practices informs
you more about HIPAA law regarding confidentiality issues). If you have any significant medical conditions that might impact your therapy, or are being prescribed medication by a medical doctor, your therapist may ask you to sign a release form allowing them to speak with that doctor for coordination of care. You may direct your therapist to share information with whomever you choose, and you can change your mind and revoke that permission at any time. You may also request anyone you wish to attend a therapy session with you.

The following are legal exceptions to your right to confidentiality:

1. If your therapist has good reason to believe that you will harm another person, they must attempt to inform that person and warn them of your intentions. They must also contact the police and ask them to protect your intended victim.

2. If your therapist has good reason to believe that you are abusing or neglecting a child or vulnerable adult, or if you give them information about someone else who is doing this, they must contact appropriate authorities right away.

3. If your therapist believes that you are in imminent danger of harming yourself, they may legally break confidentiality and call the police or the county crisis team. They would explore other options with you before taking this step.

4. If you are filing a complaint or are a plaintiff in a lawsuit where you bring up the question of your mental health, you will have already automatically waived your right to the confidentiality of these records in the context of the complaint or lawsuit. In spite of that, your therapist will not release information without your signed consent or a court order. You can also discuss obtaining a protective order to help maintain confidentiality of records. Please let your therapist know if you are in this kind of situation so they can take the utmost care possible to protect your privacy in their records.

5. If you are under 14, your parents must sign official documents to consent to your treatment, and they have a right to be kept informed about your progress. It is the practice policy to come up with a reasonable arrangement so that parents can stay informed while at the same time maintaining confidentiality for the individual in therapy. It is important to respect your right to privacy as much as possible, and to keep you informed about what will be shared with a parent. Therefore, in the beginning of treatment, if you are under age 14, you all need to agree (parents, adolescent, child) on some guidelines about what information will be kept private and what will be shared.

6. If you are over 14 but under 18, your parents might want to be involved in your treatment in some way. If that is the case, you will discuss it early on in treatment to arrive at a mutually agreeable way to balance your needs for privacy with your parents’ needs to know how well treatment is going for you. You have the same legal rights to confidentiality as adults over 18 do, but it may be mutually beneficial to have your parents involved in some way, so this is a treatment decision you and your therapist will make together.

7. Disclosure of confidential information may be required by your health insurance company in order to process claims, and under HIPAA, the practice is permitted to release information needed for the processing of insurance claims to your insurance company. This is explained in depth in our Notice of Privacy Practices (NPP). Only the minimum necessary information will be communicated to insurance companies.

The next is not a legal exception to your confidentiality. However, it is a policy you should be aware of if you are in couples therapy:

If you and your partner have individual sessions as part of the couples therapy, what you say in those individual sessions will be considered part of the couples therapy, and may be discussed in joint sessions. Do not tell your therapist anything you wish kept secret from your partner. Your therapist will remind you of this policy before beginning such individual sessions.

II. Communication.

Your therapist has a legal and ethical responsibility to make their best efforts to protect all communications that are a part of telehealth. However, the nature of electronic communication technologies is such that it cannot be guaranteed that your communications will be kept confidential or that other people may not gain access to your communications. You have the right to know how we protect our electronic communication, and the right to request preferred communication modalities. In order to protect the privacy and confidentiality of your information, the practice uses:

     ● A password protected voicemail system.
     ● Firewall and virus protection
     ● Google Workspace with HIPAA protected internal communication.
     ● Signal App for end to end encrypted texting.
     ● Secure wifi with VPN (virtual private network)
     ● HIPAA compliant telehealth platform

Your therapist also takes measures to protect their communication and they will share these with you in session. You can then discuss options that work best for you. The administrative team uses Google Workspace email to communicate non-sensitive billing and insurance issues. If you would prefer not to use email they can discuss options with you including using Signal for end to end texting encryption.

**If you communicate confidential or private information via unencrypted email, texts or phone messages, it will be assumed that you have evaluated the risks and made an informed decision to do so. Please do not use texts or email for emergencies.

III. Record Keeping.

Your therapist is required to keep records about your treatment. These records help ensure the quality and continuity of your care, as well as provide evidence that the services you receive meet the appropriate standards of care. Your records are maintained in an electronic health record provided by TherapyNotes. Therapy Notes has several safety features to protect your personal information, including advanced encryption techniques to make your personal information difficult to decode, firewalls to prevent unauthorized access, 2-factor authentication for providers, and a team of professionals monitoring the system for suspicious activity. Therapy Notes keeps records of all log-ins and actions within the system.

IV. Diagnosis. If a third party such as an insurance company is paying in full or for part of your bill, the practice is required to give a diagnosis to that third party for billing purposes. Also, according to the laws of the Pennsylvania Licensing Board your therapist must have a diagnosis on record even if insurance is not involved. Diagnoses are technical terms that describe the nature of your problem. If you would like to know about the diagnosis your therapist is using, feel free to ask and your therapist will explain it to you.

V. Other Rights.

You have the right to ask questions about anything that happens in therapy. You can always ask how and why your therapist has made certain clinical decisions, and you can look at alternatives that might work better. You can ask if your therapist has specialized training for working with your concerns, and you can request a referral to someone else if you feel your therapist isn’t the right fit for you. You are free to leave therapy at any time.

VI. Managed Mental Health Care.

If your therapy is being paid in full or in part by an insurance company, there are usually limitations to your rights as a client that are imposed by the insurance company. These may include limiting the number of sessions available to you, limiting the time period within which you must complete your therapy, or making treatment recommendations as they see fit. Sometimes they require progress reports in order to authorize continued treatment, and on rare occasions they request a copy of your case file. The administrative team is happy to assist you in advocating with the insurance company if needed.

VII. Consultation with Colleagues.

There are times when therapists consult with professional colleagues to gain greater insight and feedback for their work. The therapists in the practice participate in regularly scheduled consultation groups and do not use full names or other identifying information in those meetings. If you feel that your therapist is in need of getting more information about a topic of concern to you, please let them know; they are always open to your suggestions and concerns.

VIII. Time Issues: Length of Sessions, Timeliness of Sessions, Time off.

Session length is 53 minutes, unless otherwise specified. Your therapist will make every effort to begin sessions at the scheduled time. If you are late to your appointment, you will still need to end at the regular time. Your therapist will tell you in advance of any planned absences and will provide you with the name/contact information of a therapist you can reach out to, if needed.

IX. Administrative and Billing Issues

Whether you are paying privately or using insurance benefits, the practice uses TherapyNotes for billing purposes. During your initial intake consultation you will be asked to join the portal and complete forms necessary for billing.

There are times when insurance companies deny claims for sessions where you clearly had coverage and we billed for your session correctly. In these cases we have not had success wit hfiling appeals but when the client (i.e., customer) calls the mistake gets corrected right away. We will provide you with the inforamtion needed for this.

If you need assistance with insurance or billing related issues feel free to contact: Cecilia Ortiz, Administrative and Billing Specialist, Lisa Vinnacombe, Insurance Eligibility and Benefits, Ellen Ostroff, Administrator,

It is necessary for you to inform the practice of any upcoming changes in your insurance coverage. If your insurance has already changed or is terminated at the time of service you are financially responsible for the balance in full.

X. In-Person Sessions & COVID 19.

When guidance from public health authorities allows and your Provider offers, you can meet in-person. If you attend therapy in-person, you understand:

• You can only attend if you are symptom-free (For symptoms, see:;
• If you are experiencing symptoms, you can switch to a telehealth appointment or cancel. If you need to cancel, you will not be charged a late cancellation fee.
• You must follow all safety protocols established by the practice, including: Washing or sanitizing your hands upon entering the practice; Adhering to appropriate social distancing measures; Wearing a mask, if required; Telling your Provider if you have a high risk of exposure to COVID-19, such as through school, work, or commuting; and Telling your Provider if you or someone in your home tests positive for COVID-19.
• Your Provider may be mandated to report to public health authorities if you have been in the office and have tested positive for infection. If so, your Provider may make the report without your permission, but will only share necessary information. Your Provider will never share details about your visit. Because the COVID-19 pandemic is ongoing, your ability to meet in person could change with minimal or no notice. By signing this Consent, you understand that you could be exposed to COVID-19 if you attend in-person sessions. If you have any questions, or if you want a copy of this policy, please ask.

XI. Telehealth Services.

Benefits and Risks of Telehealth:

Telehealth refers to providing psychotherapy services using telecommunications technologies, such as video conferencing or telephone. One of the benefits of telehealth 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 are unable to continue to meet in person. It is also more convenient and takes less time. Telehealth, however, requires technical competence on both our parts to be helpful. Although there are benefits of telehealth, there are some differences between in-person psychotherapy and telehealth, as well as some risks.

For example:

- Risks to confidentiality. Because telehealth 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 their end, your therapists will take reasonable steps to ensure your privacy. But it is important for you to make sure you find a private place for your session where you will not be interrupted. It is also important for you to protect the privacy of your 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. Also, when your session has ended make sure to sign out of the meeting and your therapist will do the same on their end.

- Issues related to technology. There are many ways that technology issues might impact telehealth sessions. For example, technology may stop working during a session, other people might be able to get access to your private conversation, or stored data could be accessed by unauthorized people or companies. Although the practice uses a HIPAA compliant platform for video sessions (e.g., Zoom, or TherapyNotes), technology has its vulnerabilities.

- Crisis management and intervention. It is not ideal to do telehealth with clients who are currently in a crisis situation and require high levels of support and intervention. In these cases you and your therapist will develop an emergency response plan to address these concerns.

- Efficacy. Most research shows that telehealth 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

It may be necessary for you to have access to certain types of computers or cell phone systems in order to use telehealth services. You are solely responsible for any cost to obtain necessary equipment, accessories, or software to take part in telehealth services.


Your therapist has a legal and ethical responsibility to make their best efforts to protect all communications that are a part of telehealth. You should also take reasonable steps to ensure the security of your communications (for example, only using secure networks for telehealth sessions and having passwords to protect the device you use for telehealth).

Appropriateness of Telehealth

Your therapist will let you know if they decide that telehealth is no longer the most appropriate form of treatment for you. You will discuss the options of engaging in in-person counseling or referrals to another professional in your location who can provide appropriate services.

Emergencies and Technology

Assessing and evaluating emergencies can be more difficult when conducting telehealth than in traditional in-person therapy. To address some of these difficulties, your therapist will ask you to identify an emergency contact person who is near your location and who can be contacted in the event of a crisis or
emergency to assist in addressing the situation. If the session is interrupted for any reason, such as the technological connection fails, and you are having an emergency, do not call yor therapist
back; instead, here are options for helping yourself: call 911, call National Suicide Prevention Lifeline, 1(800)273-TALK (8255) text the Crisis Text Line 741741, or go to your nearest emergency room. Please call your therapist 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 your therapist will re-contact you via the telehealth platform you were using. If you do not receive a call back within two (2) minutes, email or text your therapist at the number you have for them. If there is a technological failure and you are unable to resume the telehealth connection, you can complete the session via telephone.


The same fee rates will apply for telehealth as apply for in-person psychotherapy. However, insurance or other managed care providers may or may not cover sessions that are conducted via telecommunication. If your insurance does not cover telehealth sessions, you will be responsible to pay for the sessions at a rate discussed with your therapist, with the possibility of a sliding fee arrangement if appropriate.


The telehealth sessions shall not be recorded in any way. Your therapist will maintain a record of your session in the same way they maintain records for in-person sessions in accordance with practice policies.

XII. Emotional Risks of Psychotherapy.

Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior.

Therapy has potential emotional risks. Approaching feelings or thoughts that you have tried not to think about for a long time may be painful. Making changes in your beliefs or behaviors can be scary, and sometimes disruptive to the relationships you already have, or even to your current functioning at times. You may find your relationship with your therapist to be a source of strong feelings. This is something They welcome you to talk about and it is a normal occurrence in psychotherapy. Also, it is important that you consider whether the emotional risks are worth the benefits of changing. This is wholly your choice. You can discuss this in therapy too. Most people who take these risks find that therapy is helpful, and your therapist will do what they can to help you minimize risks and maximize positive outcomes.

XIII. Emergencies.

If you are having an emergency, please call your therapist at the number they have given you and leave a message explaining the situation. They will get back to you as soon as they are able. However, if you are in immediate danger and not able to wait for a return phone call, contact your local emergency room or call 911. There are also Crisis Hotline numbers on our website for you to reach out to if needed. After you have done that, you can also call 215-280-9649 for further assistance from our practice.

XIV. Termination.

You have the right to terminate treatment at any time. You and your therapist will most likely decide together when therapy will end, with the following exceptions:

● If you have contracted for a specific short-term piece of work, you will normally finish therapy at the end of that contract.
● If your therapist is not in their judgment able to help you reach your therapy goals, either because the kind of problem you have is outside the scope of their skill base or because they are experiencing you as non-compliant or non-responsive. If this is the case, your therapist is required by professional ethics to inform you of this and refer you to another therapist who might better meet your needs. Should this situation occur, your therapist will offer assistance by providing referrals to other therapists/treatment programs for you.
● If you break a safety contract that was agreed upon, by trying to harm yourself either directly, such as through a suicide attempt, or indirectly such as a through severe symptoms, or reject treatment recommendations such that you continue to endanger your life regardless of various options that have been offered to you (e.g. such as hospitalization, medication, etc.), your therapist reserves the right to discontinue therapy with you. They will try first to work with you and look at all options. If you cannot maintain a safety agreement and continue to endanger yourself regardless of attempts to help you prevent that, your therapist may attempt to hospitalize you involuntarily. They also reserve the right to refer you to another therapist who may be more able to work with your symptoms of self harm.

● If you verbally or physically threaten to harm your therapist, or are repeatedly verbally abusive towards them, or in any other way threaten them, they reserve the right to terminate your therapy relationship. They will do all that they can to work with you to prevent such an episode from occurring if it appears possible.

XV. Social Networking.

Therapists do not accept friend requests from current or former clients on social networking sites, such as Facebook. Adding clients as friends on these sites and/or communicating via such sites is likely to compromise privacy and confidentiality. For this same reason, we request that clients not communicate with therapists via any interactive or social networking websites.

XVI. Litigation Limitation.

Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that, should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you nor your attorney(s), nor anyone else acting on your behalf will call on your therapist to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested unless otherwise agreed upon.

Your Responsibilities as a Therapy Client

You are responsible for coming to your session on time and at the time we have scheduled. If you are late, you will end on time and not run over into the next person's session.

Financial Responsibility.

Please Note - Missed Session/Late Cancellation Fee: If you miss a session without canceling, or cancel with less than 24 hours notice, there is a fee (based on the degree and credentials of your therapist). Thank you in advance for letting your therapist know if you are sick or otherwise unable to make your appointment. You are responsible for paying for your session (or paying your copay, co-insurance, and/or deductible payment). The practice uses a secure credit card system through TherapyNotes for your convenience. It is your responsibility to keep this information up to date, including providing new information if the card information changes or the account has insufficient funds to cover these charges.

In cases of financial hardship, we offer sliding fee arrangements. Please ask your therapist for the practice sliding scale fee form. If/when fees go up the practice will inform you of this in advance.


If you're unhappy with what's happening in therapy, we hope you'll talk about it with your therapist so they can respond to your concerns. We take such feedback seriously, and with care and respect. Your therapist will make every attempt to work with you to your satisfaction, but there are times that a client-therapist relationship doesn’t work well even if both people try their best. If your therapist believes that they are not the best person to help you, they will provide you with referrals to other therapists who they believe to be more suitable. Likewise, if after trying to talk out a problem with your therapist you still feel unsatisfied, you may ask for referrals to other therapists if you wish and you may terminate therapy.