AGREEMENT FOR ONLINE PSYCHOTHERAPY AND PARTICIPATION IN ONLINE SUPPORT GROUP SERVICES CONDUCTED BY DR. ARTHUR S. TROTZKY, LPC, DCC. THE FOLLOWING FORM WILL RELATE SPECIFICALLY TO TELEMENTAL HEALTH.
THE PROCESS OF THERAPY/EVALUATION
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 requires effort on your part. Psychotherapy requires your very active involvement, honesty and openness in order to change your thoughts, feelings and/or behavior. I will ask for your feedback and views on your therapy, its progress and other aspects of the therapy and I will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings or thoughts can result in your experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc. or experiencing anxiety, depression, insomnia, etc. I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel upset, angry, depressed, challenged or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing or relationships. Sometimes another family member views a decision that is positive for one family member quite negatively. Change will sometimes happen quickly, but more often it will take time and patience on your part. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, I will utilize various therapeutic approaches according, in part, to the problem that is being treated and my assessment of what will best benefit you. These approaches include but are not limited to behavioral, cognitive-behavioral, psychodynamic, existential, system/family, developmental (adult, child, family) or psycho-educational.
DISCUSSION OF TREATMENT PLAN
During the first session and throughout this process, I will discuss with you your understanding of the problem, treatment plan, therapeutic objectives and your view of the possible outcomes of treatment. If you have unanswered questions about any of the procedures used in the course of your therapy, their possible risks, and my expertise in employing them or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits. If you could benefit from any treatment that I do not provide, I have an ethical obligation to assist you in obtaining those treatments.
DUAL RELATIONSHIPS
Not all dual relationships are unethical or avoidable. However, sexual involvement between therapist and client is never part of the therapy process, nor are any other actions or dual relationship situations that might impair my objectivity, clinical judgment, or therapeutic effectiveness or that could be exploitative in nature. In addition, I will never acknowledge working therapeutically with anyone without his/her written permission. In some instances, even with permission, I will preserve the integrity of our working relationship. For this reason I will not accept any invitations via social networking sites nor will I respond to blogs written by clients or accept comments on a blog from clients.
TERMINATION
During the initial intake process and the first couple of sessions, I will assess if I can be of benefit to you. If you have requested online counseling, my assessment will include your suitability to psychotherapy delivered via technology. I do not accept clients who, in my opinion, I cannot help. In such a case, I will give you a number of referrals that you may contact. If at any point during psychotherapy, I assess that I am not effective in helping you reach your therapeutic goals, I am obliged to discuss this with you, up to and including termination of treatment. In such a case, I would give you a number of referrals that may be of help to you. If you request and authorize in writing, I will 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 and, if I have your written consent, will provide her or him with the essential information needed. You have the right to terminate therapy 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.
PRIVACY & CONFIDENTIALITY
All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where law requires disclosure. Likewise, you are expected to keep our communications confidential and you understand that all records of communication between client and therapist remain the property of Dr. Arthur S. Trotzky. Most of the provisions explaining when the law requires disclosure were described to you in the Notice of Privacy Practices that you reviewed with this form.
When Disclosure Is Required By Law: Some of the circumstances in which disclosure is required by the law include 1) when there is a reasonable suspicion of child, dependent or elder abuse or neglect; 2) when a client presents a danger to self, to others, to property or is gravely disabled (for more details see also Notice of Privacy Practices form).
When Disclosure May be Required: Disclosure may be required pursuant to a legal proceeding. If you are involved in a custody dispute or if you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by me. In couples and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. I will use my clinical judgment when revealing such information. I will not release records to any outside party unless I am authorized to do so by all adult family members who were part of the treatment or unless compelled to do so by law or a valid court order.
Harm to Self or Others: If there is an emergency during our work together or in the future after termination I become concerned about your personal safety, the possibility of you injuring someone else or about you receiving proper psychiatric care, I will do whatever I can within the limits of the law to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, I may also contact law enforcement, hospital or an emergency contact whose name you have provided.
Confidentiality of audio and video communications in individual and group therapy is protected by encryption and on a secure site. Please limit the contents of email to me from your personal email account, to housekeeping issues such as appointment times, cancellation or change in contact information. I will not respond to personal and clinical concerns via regular email. If you call me, please be aware that unless we are both on landline phones, the conversation is not confidential. Likewise, text messages are not confidential. Any computer files referencing our communication are maintained using secure and encrypted measures. A secure site to maintain confidentiality handles the information on the intake questionnaire.
I make every effort to keep all information confidential. Likewise, if we are working online together, I ask that you determine who has access to your computer and electronic information from your location. This would include family members, co-workers, supervisors and friends. I encourage you to only communicate through a computer that you know is safe, i.e. wherein confidentiality can be ensured. Be sure to fully exit all online counseling sessions and emails. If we are unable to connect or are disconnected during a session due to a technological breakdown, please try to reconnect. If reconnection is not possible within ten minutes, email to schedule a new session time.
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 (client) nor your attorney, nor anyone else acting on your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.
Consultation: I consult regularly with other professionals regarding my clients; however, the client’s name or other identifying information is never disclosed. The client’s identity remains completely anonymous and confidentiality is fully maintained.
* Considering all of the above exclusions, if it is still appropriate, upon your request, I will release information to any agency/person you specify unless I conclude that releasing such information might be harmful in any way.
TELEPHONE & EMERGENCY PROCEDURES
If you need to speak with me between sessions to alert me of an emergency, please call 404-316-5056. Your call will be returned as soon as possible. Messages are checked daily If an emergency situation arises that requires immediate attention, you may call the emergency National Suicide Hotline at 800-784-2433 or dial 911. If a life-threatening crisis should occur, you agree to contact a crisis hotline, call 911 or go to a hospital emergency room.
PAYMENTS
Session payments via credit or debit card can be processed through PayPal via this website. Individual sessions are generally purchased in 60-minute increments. Joining an online Support Group requires a four- session commitment and can be purchased in four-session increments.
FEES
Current rates for therapeutic services are posted on my website.
MEDIATION & ARBITRATION
All disputes arising out of or in relation to this agreement to provide online or face to face psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of Dr Arthur S. Trotzky, LPC and the client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in accordance with the rules of the American Arbitration Association that are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, I can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys fees. In the case of arbitration, the arbitrator will determine that sum.
CANCELLATION
Since scheduling of an individual appointment involves the reservation of time specifically for you, a minimum of 24 hours notice is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification.
You as the client understand that online sessions may have limitations, and the fact that most insurance companies will not cover this type of therapy. You understand that online psychotherapy with me is not a substitute for medication under the care of a psychiatrist or doctor. You understand that online and is not appropriate if you are experiencing a crisis or having suicidal or homicidal thoughts. As stated previously, if a life-threatening crisis should occur, you agree to contact a crisis hotline, call 911, or go to a hospital emergency room. You also understand that I follow the laws and professional regulations of the State of Georgia (USA) and the psychotherapy treatment will be considered to take place in the state of Georgia (USA).
Check the box for “I agree” In the Form that will be presented to you in order confirm your electronic signature
We will discuss this Informed Consent during our first session.