402 Clyde Street, Ste. 3,

Knoxville, TN 37921

Amy: 865-407-0215 or Alicia: 865-321-9425

Amy.dilworth@traumawellness.com or Alicia.stipes@traumawellness.com or Aimee.finegan@traumawellness.com

Website: traumawellness.com

Informed Consent for Psychotherapy

General Information

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document or if in office, you may sign a hardcopy.

All Therapists at Trauma Wellness have either a Master’s or Doctoral level degree. They are either a Professional Counselor, Marriage and Family Therapist, Psychologist, or Social Worker. Some may still be working under supervision with a Licensed therapist while working toward their own license.

The Therapeutic Process: You have taken a very positive step by deciding to seek therapy. The outcome of your or your child’s treatment depends largely on your and/or their willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. We cannot promise that your and/or their behavior or circumstance will change. We can promise to support you and/or them and do our very best to understand you and your repeating patterns, as well as to help you clarify what it is that you want for yourself and/or your chid(ren).

It is important to note that for mental health care in TN, adolescents at age 16 and 17 have the same rights as adults, they are in charge of their treatment. We cannot share information about their treatment or their progress without written authorization from that individual. Therefore, they should read this and sign as it is the 16 or 17 year old consenting to treatment.

Discharge Process: There are several reasons why we may eventually end our professional relationship.  You may decide you would prefer to work with a different provider.  The therapist may reach the conclusion you would be better served working with someone else.  Regardless of the case, we will first discuss with you the reasons for discharging, and if you request, provide you with a list of other qualified providers.  We will also extend the discharge process length if necessary based on your treatment needs, including continuing to provide support for a time-limited period after you have been notified of the end of our treatment relationship.

Please note that ongoing failure to pay for treatment, attend sessions, or communicate with us in a respectful and timely manner can also result in discharge from the practice.  In these instances, to ensure you have continued access to care, we will still make every reasonable effort to get in touch with you and provide referrals to a new provider before we consider the professional relationship ended.

Confidentiality

The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist (where we would be required to share information regardless of consent) and are itemized below:

1.     If a client threatens or attempts to commit suicide or otherwise conducts him/herself in a manner in which there is a substantial risk of incurring serious bodily harm.

2.     If a client threatens grave bodily harm or death to another person.

3.     If the therapist has a reasonable suspicion or knowledge that a client or other named individual is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.

4.     Suspicions as stated above in the case of an elderly person or a person with a disability who may be subjected to these abuses.

5.     Suspected neglect of the parties named in items #3 and # 4.

6.     If a court of law issues a legitimate subpoena for information stated on the subpoena.

7.     If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

Occasionally therapists may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

In this new era of Artificial Intelligence (AI) it is important to note that having smartphones in a room with you means that AI is listening to what is said.  Most clients and the therapist will have smartphones in the counseling room during session.  You can both turn them off during session to avoid the AI collecting information, it is on you, the client, to ask your therapist each session if this is what you prefer.  Otherwise assume the therapist’s phone may be on even if you turn yours off.

Additionally, some of the therapists utilize HIPAA compliant AI notetaking programs where the session is recorded, a note generated, and the recording deleted.  The therapist will ask you if that is ok with you and if so, you will sign a release approving that AI notetaking is acceptable to you.  You do not have to agree to this, it will not effect your treatment.  You can also revoke the consent at any time in writing to the therapist.

If you see your therapist accidentally outside of the therapy office, the therapist will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to us, and we do not wish to jeopardize your privacy. However, if you acknowledge the therapist first, they will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

Treatment Approaches Utilized:

We utilize a number of treatment approaches at Trauma Wellness such as Cognitive Behavior Therapy (CBT), Dialectical Behavior Therapy (DBT), Mindfulness, Somatic Therapy, Expressive Arts Therapies, and Eye Movement Desensitization Reprocessing Therapy (EMDR) among others.

Signing this consent means you are agreeing to the treatment strategies your provider recommends. 

EMDR does require a bit more information in order to agree:

·       This is a treatment approach that has been widely validated by research for the treatment of PTSD.  Research is in progress for other applications of EMDR.

·       Distressing, unresolved memories may surface through the use of the EMDR procedure.  Some clients have experienced reactions during the treatment sessions that neither they nor the administering clinician may have anticipated, including a high level of emotion and/or physical sensations.

·       Subsequent to the treatment session(s), the processing of incidents/material may continue, and other dreams, memories, flashbacks, feelings, etc., may surface.

·       If you agree to EMDR as an option for your treatment, please put your initials on the line stating so before the signature section.

·       You can read Francine Shapiro’s “Getting Past Your Past” to gain more knowledge of EMDR.

After Hours

First and foremost, we are not an emergency service so we do not typically respond to calls, texts, or emails during off hours.  You may find a need to speak with someone or give them information after hours for varying reasons. You can leave a message or send a text to any of our phone numbers listed at the start of this document or you can email us, or send a message through the Simple Practice or Headway Portal. Each therapist has a business card with their information, just ask them for one. However, if an emergency…

If it is an emergency please contact one of the numbers below (we have stickers for the back of cell phones with these numbers, ask if you would like one):

1.     If you are in immediate danger, call 911

2.     If you are feeling hopeless, not knowing where to turn, considering harming yourself, call the national suicide prevention lifeline: 1-800-273-8255 (988) or you can call Mobile Crisis (for all ages) who can locally assess the situation and provide options for care: 865-539-2409

3.     If you are not safe in your home, call the local Domestic Violence hotline: 865-637-8000

4.     If you have been sexually assaulted and do not wish to involve the police at this time, you may call the local Sexual Assault Hotline: 865-522-7273

5.     If you or your child(ren) have runaway and need help, you can call the local Youth Homeless/Runaway Hotline: 865-523-2689

6.     Otherwise, if not an emergency, you may send a message to your therapist through the portal to call when we can.

Communication between you and your therapist:

Trauma Wellness utilizes two Electronic Medical Records (EMR) systems called Simple Practice and Headway.  These programs are HIPAA compliant and have a portal for communication and payment.  Utilizing either of these portals allows all messaging to be HIPAA compliant.  Please note that the therapists are typically in sessions back to back and have little time to call you back so utilizing the portal makes it easier and faster to connect and will be responded to within 24 business hours.

If you are utilizing your insurance then your portal is Headway.  If not then your portal is Simple Practice.

TELEPHONE ACCESSIBILITY: If you need to contact your therapist between sessions, please leave a message on your therapists voicemail, text, office email or message through the portal, all of these options are HIPAA compliant. We are often not immediately available; however, we will attempt to return your call within 24 business hours. We do not answer our phones when we are with clients or after hours.  At these times you may leave a message on the therapists confidential voicemail or text them (it is a HIPAA compliant number).  Please note that Face- to-face sessions are highly preferable to online or phone sessions. However, in the event that you are out of town, sick or need additional support, phone or online sessions are available. If a true emergency situation arises, please contact 911 or any local emergency room. Your informed consent includes numbers you could need in an emergency or urgent situation.

SOCIAL MEDIA AND TELECOMMUNICATION: Due to the importance of your confidentiality and the importance of minimizing dual relationships, we do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). We believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.

ELECTRONIC COMMUNICATION: We cannot ensure the confidentiality of any form of communication through electronic media, including text messages. However, we do utilize HIPAA compliant email, voicemail, text, and the portals.  If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, We will do so. While we try to return messages in a timely manner, we cannot guarantee immediate response.  If it is an emergency we refer you back to the list of numbers for varying emergencies earlier in this document.

Scheduling of Appointments

You can go to the Simple Practice portal at: https://trauma-wellness.clientsecure.me

Or if you are utilizing insurance, Headway portal  for Amy is: https://headway.co/providers/amy-dilworth?utm_source=pem&utm_medium=direct_link&utm_campaign=95489

And for Alicia the Headway link is: https://headway.co/providers/alicia-stipes?utm_source=pem&utm_medium=direct_link&utm_campaign=99986

When you go to the Simple Practice link, you can click on either “I am a new client” or “I am an existing client.”  If you are a new client it will give you options of therapists to pick from for an appointment.  You can go to our website to see information on each:  www.traumawellness.com.  If you are an existing client it will have you either put your email in to send you a link to access the portal or you can sign in with Google.  Once you are signed in you can message your therapist as well and it is HIPAA compliant.

The standard meeting time for psychotherapy for adults and adolescents is 50 minutes and for children it is 30-45 minutes (therapist decides 30 or 45).  Please ask your therapist about any other options and cost if different than the standard.  

Cancellations:  Please cancel or reschedule 24 hours in advance.  You will be responsible for the entire fee if cancellations are less than 24 hours or you do not show to a session.

Should you cancel or not show for your appointment for three consecutive appointments, unless other arrangements have been made in advance, your reoccurring appointment may be removed from the schedule and you will have to schedule again yourself via a text, call, email or the portal.

Inclement Weather and Sick Policy

Trauma Wellness has a separate informed consent for telehealth.  It is included in the initial paperwork.  We ask that you sign it so we can utilize it when the weather is dangerous for either of us to be on the road OR when either of us is sick, especially if it could be contagious.  Of course, telehealth is only used when the sick person feels well enough to do therapy.

To switch your appointment to telehealth, you can text your therapist at their phone number or use the portal.  You will not be charged for switching to telehealth or cancelling when sick, even if you do so within 24 hours or less of your appointment.

Explanation of Charges

Trauma Wellness charges a fee for the 50-minute hour session, we meet with individuals and some groups. Our fees are based on the following things: Education, Experience, Pre-Licensure, and Licensure.

Base fee for therapists under supervision for licensure is: $150

Base fee for licensed therapists is: $165

Experience can lead to higher fees for some therapists.

Children are often 30 minute sessions and those cost half of the 50-minute hour session.

We review fees annually in November to see if changes need to occur in January. We will put a notice out in the waiting room and via HIPAA compliant email to inform clients in December if fees are going up.  The raising of fees will only apply to new clients (not existing clients).  Existing clients will maintain the fees they last agreed upon with their therapist. 

Our fees cover the overhead (Rent, Electronic Medical Record software, internet, accountant for taxes, supplies, and other office needs) and our time and expertise. 

We do offer a sliding scale, ask your therapist if needed.

Extra Charges

We charge additional fees for requested letters. This is new due to the care and time letters can take which are not part of all clients needs. We charge by the time it takes to prepare the letters based on our base session fee with a maximum cost of $225 per letter.

A service charge of $10.00 will be charged for any checks returned for any reason for special handling.

Due to the time commitment made to you when an appointment is scheduled, we charge the full fee for no shows and cancellations made with less than 24 hours notice. 

Payment options and Insurance

Trauma Wellness offers the following options for payment. Please note: Our fee and/or your copay/coinsurance is due at time of service and our rates vary depending on service. Payment options are:

1.     Self pay

a.      Paying at each session via debit/credit card/check/cash

                                                  i.     Debit/credit cards are charged by midnight of the day the session occurs unless arrangements are made ahead of time with your therapist

                                                ii.     If a debit/credit card has a non-payment and does not go through we will run it again in a few days and at the end of the month.

1.     An invoice will be emailed to you from the portal

2.     A new credit card form will be sent to you from the portal

3.     After 3 sessions of non-payment you could be removed from the recurring appointments and have to contact your therapist to get back on the schedule

b.     Make arrangements with your therapist to receive monthly statements to be paid via debit/credit card/check/cash

c.      If you have insurance but prefer to self-pay instead of using your insurance, please put your initials on the line before the signature section stating you choose to opt-out of filing insurance.

2.     Insurance (only licensed therapists can be credentialed with insurance, the list of insurance companies that we are credentialed with changes so ask your therapist to be sure

a.      We accept most Tennessee Insurance (ask your therapist about whether or not they are credentialed)

b.     The EHR portal for insurance clients is Headway at the following link(s):  for Amy: https://headway.co/providers/amy-dilworth?utm_source=pem&utm_medium=direct_link&utm_campaign=95489

c.      All of your interactions (requesting appointments, payment, etc) will occur in this portal.

d.     If you have insurance but prefer to self-pay instead of using your insurance, please put your initials on the line before the signature section stating you choose to opt-out of filing insurance.

Other Issues of Policy:

In the event that a client of Trauma Wellness becomes verbally or physically threatening to anyone on-site, Trauma Wellness reserves the right to call for help from law enforcement or other emergency services as needed.  We also reserve the right to file a police report and to pursue charges as appropriate to the situation.  In the event of a client having a medical emergency, we reserve the right to call appropriate emergency services.

When a parent or parents or legal custodians come to Trauma Wellness to discuss issues related to their child(ren), the consultation sessions cannot be charged to insurance under the child’s name.  The child cannot receive a diagnosis (required for insurance payments) until they are seen.  If you do plan to file insurance claims, please be aware that the initial consultation session will likely not be reimbursed by the insurance company.  Please be aware that if the guardians/parents are in a session without the client, their child, then it is a consultation rather than a therapeutic session and payment is due at the session.

There are many laws related to mental health treatment of minors (under age 18).  A very notable one is that once a minor reaches the age of sixteen (16), they have all of the rights an adult has.  Therefore, the 16 or 17 year old must sign this form.  No information can be shared with the parent(s) other than that of being a third party payor.  The parents cannot know how therapy is going unless the 16 or 17 year old signs a release of information.

If the minor is 15 or under, we recommend that the parents allow the children to have a safe space to express themselves.  This means not asking the therapist for information, they will tell you if anything threatens the minor.  It also means not asking your child to tell you what happens in therapy.  Of course you are entitled to the information as parent or custodian and we will share if asked but your child benefits best by feeling the information they discuss in therapy is confidential.

If the parents of a minor 15 and under, want their child to have treatment, we need both parents to sign an additional consent form for consent to treat that includes both of their signatures.  Even if divorced, both must sign UNLESS there is a court order stating otherwise (such as only one has medical decision making).  We will need a copy of that court order.

________ By putting my initials here, I agree to EMDR as a potential treatment approach

________ By putting my initials here, I am opting out of utilizing my insurance and instead agreeing to self-pay and that I will not file claims with my insurance company.

I acknowledge that I have read, understood and agree to consent for treatment, including anything initialed above, by signing below:

______________________________________________________________                                _____________________

Signed  by Client                                                                                                                              Date

_____________________________________________    

Print  Name

____ My initials indicate I am 16 or 17 & consent to my parents knowing my attendance for payment.                                                                       

______________________________________________________________                                _____________________

Signature of Guardian   (if client is 15 or under)                                                                 Relationship to Client