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Informed Consent

HEIDI F. YODER, mfc 47168
Psychotherapy & Life Skills


5655 College Ave.
Ste. 315B
Oakland, CA 94618

Telephone 415.378.7506
Email hfymft@gmail.com
www.heidifyodermft.com


 

COUNSELOR-CLIENT SERVICE AGREEMENT
Welcome to my practice. Your first visit to a therapist can be very overwhelming for many reasons. That iswhy taking the time to read through this information before we meet can be more effective than reading at your session. It also allows me to introduce myself and gives you a chance to prepare any questions you might have for me.

This document (the Agreement) contains important information about my professional services and business policies. Although these documents are long and sometimes complex, it is very important that you read them carefully before ourfirst session. We can discuss any questions you have about the procedures atthat time. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement inwriting at any time. That revocation will be binding on me unless Ihave taken action in reliance on it or if you have not satisfied any financial obligations you have incurred.

About Me Relevant Education
I took Bachelor Degrees in Ethnic and Women’s Studies at San Francisco State University in 1996while also studying Psychology. Itook a Masters Degree in Clinical Psychology from The New College of California in 2005. Idid my clinical research working with individuals, couples, mandated clients, and working as a school counselor for several years while serving as the Director of Schools and managing all of the other counselors inthe Jefferson School District. I developed and presented sensitivity workshops for the probation officers, lawyers, and judges atthe San Mateo County Youth Probation Services Center. I was also chosen and trained as one ofthe San Mateo County’s Disaster First Responders Team.

In my private practice I work from an integrative technique relying on a broad range of techniques including Mindfulness Based Cognitive Therapies, Cognitive Behavioral Therapies, Psychodynamic Psychotherapy, Somatic Therapies, Object Relations Therapy, Attachment Theory, and Family Systems Interventions, among others. I also continue to study and stay abreast of current information about developments and efficacy of theories in my field, especially Neuroscience. As an MFT with a strong medical and social justice background, I bring expertise and education to our collaboration while you bring self- knowledge, a clear idea of what hasn’t been working, your own original strengths the ability to learn from your life experiences, and a unique vision (and one of what your want your life to be in there somewhere). I enjoy working with a diverse range of individuals, couples, multiple partners in relationships, and families.

Psychological Services
Therapy is a relationship between people that works in part because of the 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 create change. As a client in psychotherapy, you have certain rights and responsibilities that are important for you to know about. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These respective rights are described in the following section. Psychotherapy has both benefits and risks. Risks sometimes include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness. Psychotherapy often requires discussing unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress, and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy requires a very active effort on your part. In order to be most successful, you will have to work on things that we discuss outside of sessions.Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise.

Appointments
If psychotherapy has begun, I will usually schedule one 45-50-minute session (relationship, family, and group appointments can be longer) per week at a set time we agree on, although sessions may be longer or more frequent. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, it is required that you provide more than 48 hours notice. If you miss a session without canceling, or cancel with 48 hours notice, you still pay for the missed session. In addition, you are responsible for coming to your session on time. If you are late, your appointment will still need to end on time. If you find yourself running late for your appointment, please call and let me know. If I do not hear from you after fifteen minutes, I will have to assume that you are not coming to your appointment. If we are able to arrange it, rescheduling at a different time within the same week or a phone session is a possibility, but not guaranteed. I became trained and certified as an Online Therapist so I could help my Clients recapture some of the value of sessions lost when the unexpected happens as it does in life.

Professional Fees
The standard sliding scale for individual sessions, which generally last for 50 minutes, is $130-$150 and the month’s fees are collected by the 5th or at the first session of the month. Couples and family’s sliding scale is from $150-$200. I take cash, credit cards, (PayPal ~3% fee) and FSA/HAS cards (Square ~2.5% fee) for which I will offer the usual generic invoice. I also offer other financial solutions such as The Catastrophic 3 Aid, discounts for packages of multiple months paid in advance, and sessions that are sliding scale. They are $100 and up and during off-peak hours. I generally ask for a minimum of a three-month commitment up front. This is so we can actually have a chance to set and meet some goals. The month’s fees are due by the 5th or your first session of the month. I send a reminder the last week of each previous month for the total for the upcoming month based on information you’ve given me about your availability. This way the financial piece is not one that takes up a lot of time in the Therapeutic space. My Clients come to my practice to work on specific things and I do al I can to support keeping that time as focused as possible. If you made a special arrangement for a lower fee based on paying for a package of sessions this is obviously not applicable to you unless your payment happens to fall at the beginning of the month and you get sent a reminder at the end of the previous month as everyone else does. If your payment does not happen to fall at the beginning of the month, the full amount will be due before the first session of the package. If you have questions about this Concierge Method of Payment, you may inquire at any time. This method usually minimizes all possibility of late bills, but if you happen to incur one anyway I reserve the right to charge a 1.5% late fee after the first month of non- 5 PROFESSIONALFEES (con) payment and to seek redress in small claims court after three. In addition to weekly appointments, it is my practice to charge this amount on a prorated basis for other professional services that you may require such as report writing, telephone conversations that last 15 minutes or more, emails that require more than 20 minutes, attendance at meetings or consultations with other professionals which you have requested, or the time required to perform any other service which you may request of me. If the time line is crossed and additional fees are going to be incurred, of course you will be informed so that you can make a decision at that point.

If you become involved in a legal matter that requires my participation (although it is recommended that we discuss this fully before you waive your right to confidentiality), you will be expected to pay for the professional time required even if I am compelled to testify by another party.

Insurance
My payment policy is fee-for-service only. I do not accept payment directly from insurance companies and therefore I am not on any managed care or preferred provider plans. However, my services are typically reimbursable and I will provide you with a basic monthly invoice that you may submit to your insurance to obtain out-ofnetwork reimbursement Insurance companies often require a formal diagnosis with their claims. Diagnoses are technical terms that describe the nature of your problems, probable prognosis, and whether they are considered short-term or long-term problems. All diagnoses come from a book entitled the DSM-IV. (soon the DSM-V) There is a copy in my office and I will be glad to let you see it to learn more about your diagnosis, if applicable. Clients sometimes have questions about why I do not accept insurance payments and I would like to discuss it with you, as it is a decision that I have not made lightly. (This is a dynamic that is changing with the new landscape and we are not exactly sure how yet)

1) Clients are often unaware of the fact that insurance companies require me to diagnose them according to the DSM to continue to receive coverage for sessions. I find this problematic for many reasons, especially as a diagnosis will then follow a client in their health history.

2) The Clientʼs insurance company is privy too much of the information included in the sessions which I believe, ethically, should be private. Furthermore they can make decisions to extend or cut short the number of sessions based on perceived “compliance” with prescribed behaviors/medications.

3) Finally, continued sessions are also based on the Therapistʼs reports of enough progress to show the therapy is working, yet enough remaining problems to show that the therapy is still necessary. Some of my colleagues who take insurance simply fill out the insurance notes during the session and that shapes the session. I don’t work that way. I believe that notes should be based on what is actually happening in the therapy and not accessible to others unless subpoenaed by a court of law for some reason. There are many reasons I am not comfortable using insurance, but these are just a few for you to think about

Dual Relationships
Therapy never involves sexual, business, or any other dual relationships that could impair my objectivity, clinical judgment or therapeutic effectiveness or could be exploitative in nature. Please discuss this with me if you have questions or concerns.

Discussing Goals Reached, Closure, and Follow-up
Deciding when to stop our work together is meant to be a mutual process. Before we stop, we will discuss how you will know if or when to come back or whether a regularly scheduled “check-in” might work best for you. If it is not possible for you to phase out of therapy, I recommend that we have closure on the therapy Process with at least two termination sessions. If finances are a problem I would rather have a Closure session without finances involved. Noncompliance with treatment recommendations may necessitate early termination of services. I will look at your issues with you and exercise my educated judgment about what treatment will be in your best interest. Your responsibility is to make a good faith effort to fulfill the treatment recommendations to which you have agreed. If you have concerns or reservations about my treatment recommendations, I strongly encourage you to express them so that we can resolve any possible differences or misunderstandings. If during our work together I assess that I am not effective in helping you reach your therapeutic goals, I am obliged to discuss this with you and, if appropriate, terminate treatment and give you referrals that may be of help to you. If you request it and authorize it in writing, I may talk to the psychotherapist of your choice in order to help with the transition. If at any time you want another professional’s opinion or wish to consult with another therapist, I will assist you in finding someone qualified. You have the right to terminate treatment at any time. If you choose to do so, I will offer to provide you with names of other qualified professionals whose services you might prefer. If you commit violence to, verbally or physically threaten or harass the office, my family, or me I reserve the right to terminate your treatment unilaterally and immediately. Failure or refusal to pay for services after a reasonable time is another condition for termination of services. Please contact me to make arrangements any time your financial situation changes. 8 CONFIDENTIALITY Law generally protects the confidentiality of all communications between a client and a psychologist and I, as your therapist, cannot and will not tell anyone else what you have discussed or even that you are in therapy without your written permission. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. With the exception of certain specific situations described below, you have the right to confidentiality of your therapy. You, on the other hand, may request that information is shared with whomever you choose and you may revoke that permission in writing at any time. There are, however, several exceptions in which I am legally bound to take action even though that requires revealing some information about a client’s treatment. If at all possible, I will make every attempt to inform you when these will have to be put into effect. The legal exceptions to confidentiality include, but are not limited, to the following:

1. If there is good reason to believe you are threatening serious bodily harm to yourself or others. If I believe a client is threatening serious bodily harm to another, I may be required to take protective actions, which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization. If a client threatens harm to him/herself or another, I may be required to seek hospitalization for the client, or to contact family members or others who can provide protection.

2. If there is good reason to suspect, or evidence of, abuse and/or neglect toward children, the elderly or disabled persons. In such a situation, I am required by law to file a report with the appropriate state agency.

3. In response to a court order or where otherwise required by law.

4. To the extent necessary, to make a claim on a delinquent account via a collection agency.

5.To the extent necessary for emergency medical care to be rendered. Finally, there are times when I find it beneficial to consult with colleagues as part of my practice for mutual professional consultation. Your name and unique identifying characteristics will not be disclosed. The consultant is also legally bound to keep the information confidential.

Contacting Me
I am often not immediately available by telephone. While I am usually in the office during normal business hours, I do not answer the phone when I am with a client. If you need to contact me between sessions, please text (which is NOT confidential and I completely erase every 30 mins when not at work and every 50 minutes when at work), or leave a message for me at 415-378-7506. I check my texts btwn sessions, and messages a few times each day, emails (which though encrypted cannot be completely confidential) two or three times a day, unless I am out of town. If I am planning on being out of town, I will let you know in advance. I will also let you know who I have covering for me during my absence.

If we spend more than 15 minutes on the phone checking in or in an emergency situation, I will suggest that we turn it into an online session. If you feel the need for many phone calls during a week and cannot wait for your next appointment, we may need to schedule more sessions to address your needs, and if it’s a difficult time, we may need to discuss some alternative financial solutions. If you need more help, talk to me first and worry about the money later. If an emergency situation arises, please indicate it clearly in your message to me, especially that you need a return call immediately. If your situation is an acute emergency and you need to talk to someone right away, contact the closest 24-hour emergency psychiatric service:

Dial 911 or Go to your nearest Emergency Room: San Francisco Suicide Prevention 415-781-0500 San Francisco General Hospital ER, 1001 Potrero Ave., SF, CA 415-206-8111

I donʼt generally return calls on weekends unless we have a previous agreement during urgent ongoing situations or unless there is a serious emergency. But, if for any number of unforeseeable and/or unavoidable reasons I cannot reach you, it remains your responsibility to take care of yourself until such time as we can talk. If you feel unable to keep yourself safe, go to your nearest emergency room and ask to speak to the psychiatrist or psychologist on call.

Other Rights
If you are unhappy with what is happening in therapy, I hope you’ll talk with me so that I can respond to your concerns. Such concerns will be taken seriously and 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 aspect of the 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.

Confidentiality of E-mail, Voice mail and Text Communication
E-mail, voice mail, and text communication can be accessed by unauthorized people, compromising the privacy and confidentiality of such communication. Although the circumstances are unlikely in which such a breach would take place, and I use services that promise encrypted communications (except texts and cell phone voice mail which cannot be made confidential), it is important to remember that the possibility of a breach does exist. Please notify me at the beginning of treatment if you would like to avoid or limit in any way the use of any or all of these communication devices. Please do not contact me via e-mail or texts for emergencies. Consultation I consult regularly with other professionals regarding my clients in order to provide you with the best possible service. Names or other identifying information are never mentioned; client identity remains completely anonymous and your confidentiality will be fully maintained