INFORMATION, AUTHORIZATION, & CONSENT TO TREATMENT
I am very pleased that you have selected me to be your social worker/marriage and family therapist, and I am sincerely looking forward to assisting you. This document is designed to inform you about what you can expect from me regarding confidentiality, emergencies, and several other details regarding your treatment.
Although providing this document is part of an ethical obligation to my profession, more importantly, it is part of my commitment to keep you fully informed of every part of your therapeutic experience. Please know that your relationship with me is a collaborative one, and I welcome any questions, comments, or suggestions regarding your course of therapy at any time.
The following information regarding my educational background and experience as a therapist is
an ethical requirement of my profession. If you have any questions, please feel free to ask.
Stephanie Robins, LCSW has a Master’s of Social Work with a specialty of Children, Adolescents, and Families from the University of Alabama. I am a Licensed Clinical Social Worker in the state of Georgia. Additionally, I have had extensive work experience and training in children and adolescents with chronic/terminal illnesses, ADHD interventions, behavior modification, play therapy, family counseling, parent and patient education, anxiety and depression, and grief and loss counseling.
I have provided counseling services since 1997 at such facilities as Children’s Healthcare of Atlanta Egleston—Atlanta, GA, Georgetown University Medical Center—Washington, D.C, and DCH Medical Center—Tuscaloosa, AL.
Theoretical Views & Client Participation
It is my belief that as people become more aware and accepting of themselves, they are more capable of finding a sense of peace and contentment in their lives. However, self-awareness and self-acceptance are goals that may take a long time to achieve. Some clients need only a few sessions to achieve these goals, whereas others may require months or even years of therapy. As a client, you are in complete control, and you may end your relationship with me at any point.
In order for therapy to be most successful, it is important for you to take an active role, both during and between sessions. This also means avoiding any mindaltering substances including but not limited to alcohol and nonprescription drugs for at least eight hours prior to your therapy sessions. Generally, the more of yourself you are willing to invest, the greater the return.
Furthermore, it is my policy to only see clients who I believe have the capacity to resolve their own problems with my assistance. It is my intention to empower you in your growth process to the degree that you are capable of facing life’s challenges in the future without me. I also don’t believe in creating dependency or prolonging therapy if the therapeutic intervention does not seem to be helping. If this is the case, I will direct you to other resources that will be of assistance to you. Your personal development is my number one priority. I encourage you to let me know if you feel that transferring to another therapist is necessary at any time. My goal is to facilitate healing and growth, and I am very committed to helping you in whatever way seems to produce maximum benefit.
Confidentiality & Records
Your communications with me will become part of a clinical record of treatment, and it is referred to as Protected Health Information (PHI). Your PHI will be kept in a file stored in a locked cabinet in my office. Additionally, I will always keep everything you say to me completely confidential, with the following exceptions: (1) you direct me to tell someone else and you sign a “Release of Information” form; (2) I determine that you are a danger to yourself or to others; (3) you report information about the abuse of a child, an elderly person, or a disabled individual who may require protection; or (4) I am ordered by a judge to disclose information. In the latter case, my license does provide me with the ability to uphold what is legally termed “privileged communication.” Privileged communication is your right as a client to have a confidential relationship with a therapist. The state of Georgia has a very good track record in respecting this legal right. If for some reason a judge were to order the disclosure of your private information, this order can be appealed. I cannot guarantee that the appeal will be sustained, but I will do everything in my power to keep what you say to me confidential.
Please note that in couple’s counseling, I do not agree to keep secrets. Information revealed in any context may be discussed with either partner.
Structure and Cost of Sessions STRUCTURE AND COST OF SESSIONS: FEES:
$175: Intake/Initial Session: 4550 minute Session $150: Individual Therapy 4550minute Session $150 Couples Therapy 4550minute Session $150: Family Therapy 4550minute Session $150: Parent Meeting and/or Feedback Session $75: Group 4550minute session
$150$250: For Collaborative Divorce Coach/Child Specialist, Parent Coordination, Mediation
PHONE SESSIONS: Doing psychotherapy by telephone is not ideal, and needing to talk to me between sessions may indicate that you need extra support. If this is the case, you and I will need to explore adding sessions or developing other resources you have available to help you. Telephone calls that exceed 10 minutes in duration will be billed at $10 per minute.
OUT OF SESSION SERVICES: I am happy to make phone calls, emails, and communication with professionals to make sure you and/or your child have the best multidisciplinary treatment and has a caring team of professionals who are all on the same page. The following are my fees for this communication: $150 per hour for any communication exceeding 10 minutes in a week between therapist and collateral contacts (including lawyers, guardian ad litem, psychiatrists, school counselors, teachers, or any other professionals) $150 per hour for phone calls, emails and letter writing exceeding 10 minutes per week.
COURT APPEARANCES: I discourage sharing confidential client information regarding specific statements by the client for use of court procedures. In my experience this diminishes the therapeutic relationship and the trust that the client has in the therapist. If court appearances are required however, please note the fee below. $250 per hour, 4 hour minimum required with a $1000 retainer paid at least 2 weeks prior to appearing in court.
LATE ARRIVALS: Therapy sessions are scheduled to be 4550 minutes. I understand if traffic and other reasons cause you to be late; however, I still must conclude the session at the scheduled stop time (meaning if you are 10 minutes late, your session will be 3540 minutes).
CANCELLATIONS/NO SHOWS: Your appointment time is reserved exclusively for you. If you are unable to attend your appointment please notify me by phone, text message is sufficient when applicable. I require a full business day’s notice (24 hrs to 48 hrs preferred notice) for any cancelled appointment. Failure to follow cancellation policy will result in being billed $95 to $150 for the time that was reserved for you. This will not be covered by your Insurance carrier or EAP provider. Payment for late cancellations/no shows will be required prior to continued services.
GOING OVER THE SESSION TIME: The 4550 minute therapy session includes the parent check in at the end (if applicable). Any additional time spent in the therapist’s office will be billed at a rate of $150 an hour. Once the 50 minutes has been reached, a therapist will inform you and give you the option to continue the conversation (if the therapist has time available) but please note that if you choose to extend the session time, you will be billed at a prorated rate. Please pick up your child on time. I am not responsible for unaccompanied children after the scheduled session time.
The fee for each session will be due at the conclusion of the session. Cash, personal checks, Visa, MasterCard, Discover, or American Express are acceptable for payment. Please note that there is a $55 fee for any returned checks. I will provide you with a receipt upon request.
The receipt of payment may also be used as a statement for insurance or for use of Flexible Spending Account, if you so choose. Insurance companies have many rules and requirements specific to certain plans. Unless otherwise negotiated, it is your responsibility to find out your insurance company’s policies and to file for insurance reimbursement if I am considered OUT OF NETWORK provider. I will be glad to provide you with a statement for your insurance company and to assist you with any questions you may have in this area.
Will gladly file claims for when I am IN NETWORK. If I am in network with your insurance company, please be aware that I must provide your insurance company with a diagnosis as well as information about your progress in treatment. They also may have right to audit your entire chart, depending upon your insurance company.
In Case of an Emergency
My practice is considered to be an outpatient facility, and I am setup to accommodate individuals who are reasonably safe and resourceful. I do not carry a beeper nor am I available at all times. If at any time this does not feel
like sufficient support, please inform me, and we can discuss additional resources or transfer your case to a therapist or clinic with 24hour availability. Generally, I will return phone calls within 48 hours. If you have a mental health emergency, I encourage you not to wait for a call back, but to do one or more of the following:
∙ Call Ridgeview Institute at 770.434.4567 or Peachford Hospital at 770.454.5589.
∙ Call 911.
∙ Go to your nearest emergency room.
Psychotherapy is a professional service I will provide to you. Because of the nature of therapy, your relationship with me has to be different from most relationships. It may differ in how long it lasts, the objectives, or the topics discussed. It must also be limited to only the relationship of therapist and client. If you and I were to interact in any other ways (e.g., social, business, etc.), we would then have a "dual relationship." Dual relationships may compromise our treatment and, therefore, are discouraged in the mental health profession. In order to offer all of my clients the best care, my judgment needs to be unselfish and purely focused on your needs. This is why your relationship with me must remain professional in nature.
Additionally, there are important differences between therapy and friendship. Friends may see your position only from their personal viewpoints and experiences. Friends may want to find quick and easy solutions to your problems so that they can feel helpful. These short-term solutions may not be in your longterm best interest. Friends do not usually follow up on their advice to see whether it was useful. They may need to have you do what they advise. A therapist offers you choices and helps you choose what is best for you. A therapist helps you learn how to solve problems better and make better decisions. A therapist's responses to your situation are based on tested theories and methods of change.
You should also know that therapists are required to keep the identity of their clients secret. As much as I would like to, for your confidentiality I will not address you in public unless you speak to me first. I also must decline any invitation to attend gatherings with your family or friends. Lastly, when your therapy is completed, I will not be able to be a friend to you like your other friends. In sum, it is my duty to always maintain a professional role. Please note that these guidelines are not meant to be discourteous in any way; they are strictly for your longterm protection.
In our ever changing technological society, there are several ways we could potentially communicate and/or follow each other electronically. It is of utmost importance to me to maintain your confidentiality, respect your boundaries, and ascertain that our relationship remains therapeutic and professional. Therefore, I’ve developed the following policies:
Cell phones: It is important for you to know that cell phones may not be completely secure and confidential. If you would like for me not to use a cell phone when contacting you, please let me know.
Text Messaging and Email: Both text messaging and emailing are not secure means of communication and may compromise your confidentiality. However, I realize that many people prefer to text and/or email because it is a quick way to convey information. If you choose to utilize texting or email, please discuss this with me. However, please know that it is my policy to utilize these means of communication strictly for brief topics such as appointment confirmations. Please do not bring up any therapeutic content via text or email to prevent compromising your confidentiality. You also need to know that I am required to keep a copy of all emails and texts as part of your clinical record.
Facebook, LinkedIn, Etc: It is my policy not to accept requests from any current or former client on social networking sites such as Facebook or LinkedIn because it may compromise your confidentiality. Additionally, my ethics code prevents me from soliciting endorsements from clients, and the concept of “Fanning” is considered to be bordering on such solicitation. However, it is still your prerogative to view or share any content on my professional pages. Please note that you should be able to subscribe to my professional Facebook page via Really Simple Syndication (RSS) without becoming a Fan and without creating a visible, public link to my Page, which I strongly encourage for your privacy.
Google: I do not search for clients on Google. I respect your privacy and make it a policy to allow you to share information about yourself to me as you feel appropriate. If there is content on the Internet that you would like to share with me for therapeutic reasons, please print this material out and bring it to your session.
Twitter & Blogs: I post psychology news on Twitter, and I write a blog on my website. If you have an interest in following either of these, please let me know so that we may discuss any potential implications to our therapeutic relationship. Once again, maintaining your confidentiality is a priority. I would recommend using an RSS feed or locked Twitter list, which would eliminate you having a public link to my content.
In summary, technology is constantly changing, and there are implications to all of the above that I may not realize at this time. Please feel free to ask questions, and know that I’m open to any feelings or thoughts you have about these and other modalities of communication.
Statement Regarding Ethics, Client Welfare & Safety
I assure you that my services will be rendered in a professional manner consistent with the ethical standards of the American Psychological Association / American Counseling Association / National Association of Social Workers/American Association for Marriage and Family Therapists. If at any time you feel that I am not performing in an ethical or professional manner, I ask that you please let me know immediately. If we are unable to resolve your concern, I will provide you with information to contact the Georgia professional licensing board that governs my profession.
Due to the very nature of psychotherapy, as much as I would like to guarantee specific results regarding your therapeutic goals, I am unable to do so. However, with your participation, we will work to achieve the best possible results for you. Please also be aware that changes made in therapy may affect other people in your life. For example, an increase in your assertiveness may not always be welcomed by others. It is my intention to help you manage changes in your interpersonal relationships as they arise, but it is important for you to be aware of this possibility nonetheless.
Additionally, at times people find that they feel somewhat worse when they first start therapy before they begin to feel better. This may occur as you begin discussing certain sensitive areas of your life. However, a topic usually isn’t sensitive unless it needs attention. Therefore, discovering the discomfort is actually a success. Once you and I are able to target your specific treatment needs and the particular modalities that work the best for you, help is generally on the way.
I am sincerely looking forward to facilitating you on your journey toward healing and growth. If you have any
questions about any part of this document, please ask.
Please print, date, and sign your name below indicating that you have read and understand the contents of this “Information, Authorization and Consent to Treatment” form as well as the “Health Insurance Portability and Accountability Act (HIPAA) Notice of Privacy Practices” provided to you separately. Your signature also indicates that you agree to the policies of your relationship with me as your therapist, and you are authorizing me to begin treatment with you.