When you make appointment, you will be emailed a copy of the document below. I am providing it ahead of time for you to read. I will also provide a copy for you to sign when we meet. If someone else will be joining you, please share this information with them before you come in. Make a note of any questions or concerns you have. When we meet I will be happy to answer any questions you have.
Informed Consent, Privacy Practices and Agreement for Services
Welcome to my practice. I provide this information when you begin psychotherapy to help you understand how I work and what I do to maintain your privacy. Please make a note of any questions you have. We can discuss these when we meet in person. Once you sign this document, it represents agreement between us.
My background and how I work
I am a Licensed Marriage and Family Therapist (LMFT), with a Master’s degree in Counseling Psychology, and am also an ASSECT (American Association of Educations Counselors and Therapists) Certified Sex Therapist (CST).
I work in a method called iSolution Focused Brief Therapy, a way of working that is respectful, optimistic, informed by feedback from clients, adult learning theory, and research into what works in therapy.
Solution Focused Brief Therapy uses conversations between the therapist and client to help you describe your best hopes and how to achieve them. I will ask what your best hopes are, what is already working well for you, who and what is important to you. Our conversation will describe your desired outcome in great detail, making it more likely to happen. In other words, this is therapy that works.
When working with more than one person in the room, I aim to be fair if not neutral, which means that while I might be frank in letting you know what I think (when it’s appropriate), I am bringing you my thoughts, opinions and training in a professional capacity, to be of assistance to each you. I make be sure each person has an equal opportunity to speak.
For those who want a roadmap of how to succeed in relationships be they romantic, familial, or friendly and want more of a structured approach, I use Pragmatic Experiential Therapy for Couples. Brent Atkinson, who trained me in it, developed this method. Atkinson studied the work of John Gottman, (the author of 7 Principles for Making Marriage Work). Gottman’s long-term studies of couples revealed the specific, learnable behaviors of those couples that remain together in happy long-term relationships. This method provides a map of what to do, and uses the latest neuroscience research to help clients remain calm enough to have different responses to each other in the moment – a necessity for getting out of stuck cycles of behavior. It is unique in that it offers a combination of information you can understand plus the ability to actually use it. If you choose to work this way, I am likely to schedule individual sessions with you and your partner, to get to know each of you one on one, and coach you in the context of your relationship. I will not share information either of you discloses in those sessions with the other.
Sometimes members of a couple also work with individual therapists. Problems can occur if an individual’s therapist sides with the individual against their partner, so you may want to choose an individual therapist carefully, or even refrain from individual counseling while in relationship counseling. I generally ask permission to collaborate with an individual therapist to be sure we are all working together to give you the absolute best chance of succeeding.
My available appointments can be seen on my calendar page on TherapyAppointment.com. You make or change appointments by logging on to TherapyAppointment.com and accessing my schedule there. There is a 24-hour window in which you can’t cancel an appointment. If you absolutely must cancel, please text me as soon as you can. If you can’t text, please email me. It is very unlikely I will get your voicemail in time. To make a same day appointment, first look on my calendar, and if you see an opening you want to take, text me.
You are responsible to pay for any sessions that you miss or are not covered by your insurance. The fee for missing a session is form$90 - $250. Should you fail to show up or cancel the day of an appointment, I can’t bill your insurance for the missed session or offer it to anyone else. Should you fail to make an appointment 3 times, I will revoke your ability to make appointments until full payment has been made.
I am not available to consult between sessions, though you are free to email me (using the secure email system in therapyappointment.com), with concerns you would like to address when we meet in person. Unless one of us has an attachment to send, please contact me that way. Attachments can be sent to the email listed on the first page of this document / my website.
For other matters you can contact me in order of preference, by: TherapyAppointment email system, text for same day appointments or emergencies, then lastly by phone. I will make every attempt to return your communication within 24 hours. Weekends and holidays, when I may not have easy phone or Internet access, I will take longer to get back to you.
In an emergency, call your family physician, 911, 1- 800-LIFENET (1-800-543-3638) or, the nearest emergency room, where you can ask for the mental health professional on call.
Limits of Confidentiality (privacy)
I can release information to others about our work together only with your approval and your permission in writing. Using an insurance policy to see a therapist grants the therapist permission to bill using your name, and to provide a diagnosis. It grants the insurer the right to request your medical records and /or review treatment. Each time some one visits me, I take notes. This is what I record: time date and length of meeting, who attended, diagnosis, progress to date, goals for this session, next steps to be taken.
There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about your treatment. They are:
- If I believe that a child, disabled, or elderly person is being harmed
- If a client is actively suicidal or homicidal
- If I believe that a client is threatening serious harm to the person or property of another.
Client-Therapist Privilege and Legal Proceedings
To maintain the integrity of your therapy, I will not communicate with an attorney or anyone else regarding your treatment in any legal or custody dispute you become involved in. Should you ask me to participate in a lawsuit, I will refuse because I sincerely believe it is against your best interest, that bringing therapy into a legal matter will compromise your therapy and is very likely to weaken your case.
Should you, or your attorney, or any attorney in a case you are involved in insist on trying to involve me in legal matters, I will refuse. If for some reason I agree to provide a limited amount of information, I will not take on such work without the prior authorization in writing those who participated in therapy. I will charge my published hourly rate for all the time spent, and will require a retainer before starting any such work.
Privilege in relationship and couples counseling
For relationship counseling to be successful, each person must be able to trust that information shared will not be brought up later in legal proceedings. Therefore, signing this agreement means you will not seek to have my records of our work discussed, nor ask me to disclose any information in any legal proceeding between you. If we do couple or family therapy (where there is more than one client) and you want to have records this therapy sent to anyone, all the adults present will need to sign a release, not just the person requesting it.
We could run in to each other public. If this happens, I will not acknowledge you unless you acknowledge me first. This is out of respect for your right to confidentiality about being therapy and privacy in your life.
I do not accept social media invitations from clients. I do have business pages on FaceBook, LInkedIn and other sites. To protect your privacy, I strongly discourage you from posting anything that that identify you as a client on any of those pages, to keep the fact that you are in therapy private.
I also ask that you not disclose the name or identity of any other client being seen in this office you may see in the waiting room.
To provide the best possible service, I regularly consult with other professionals about my work. It is possible that in that context, your issues, but not identity, could be discussed with colleagues who, like me, are legally bound to keep this information confidential.
If you are working with another healthcare professional, I may ask for your written permission to speak with them, to coordinate treatment. If I do speak to them will let you know when I have spoken to them and, in general terms, what we discussed.
From time to time, I may ask your permission to record our sessions. People have different feelings about being recorded, and you are under no obligation to participate. If you agree, with your written permission, I may use the recordings I make in one, some or all of the following ways:
- to review our work on my own and / or to share parts of sessions with you
- to review some of our work with other mental health professionals with whom I consult to improve the quality of my work
- to present to colleagues at professional conferences or trainings. These colleagues are bound, as I am, to protect your confidentiality and not disclose any information about you to anyone.
Each of us has the right to decide not to continue with therapy. The best reason is that you have reached your goals. Other could include that your needs are outside of my scope of practice or competence (in which case I might refer you to another professional), that progress is not being made, or payments are not being made. If any client persistently misses payments or makes repeated same day cancellations, I will stop seeing them after giving the chance to clear their account with me. If you are ending therapy and would like, I can at your request, make recommendations or referrals, and discuss how to continue. I am also happy to resume therapy with you at a future date if we both judge that we’ve worked well together and you think I am the best helper for you at that time.
FEDERAL REGULATIONS REQUIRE THAT I MAINTAIN YOUR PRIVACY AND PROVIDE YOU WITH A COPY OF THIS NOTICE DESCRIBING HOW I DO SO. THE FOLLOWING DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION.
Understanding your PHI (Protected Health Information)
Each time you visit any medical professional; a record of your visit is made. Federal law requires these records to include the dates of sessions, who attended, length of session, payment information, a diagnosis for insurance billing purposes, goals of treatment, and progress notes appropriate to the modality of therapy used, in this case, Solution Focused Brief Therapy. Each session, I will ask for and record: progress you have made, goals for that session, the out come you wish to achieve, resources and instances of success that will help you achieve that outcome,next step to be taken, any resources offered. This record of treatment is your protected health care information or “PHI”. It serves as a:
- basis for planning your care and treatment
- means of communication among the health professionals who contribute to your care
- legal document describing the care you received
- means by which you or a third-party payer (insurance company) can verify that services billed were actually provided.
Understanding what is in your record and how your health information is used helps you better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure of it to others. I reserve the right to change my practices and to make the new provisions effective for all protected health information I maintain.
I may use or disclose your PHI to coordinate or manage your treatment. For example: information obtained by me will be recorded in your chart. I will record the actions I take and observations about what worked more and less well for you. In that way, I will know how you are responding to treatment. Another example would be when I consult with another healthcare provider or therapist. I may also, with you permission, provide your physician or a subsequent healthcare provider with summaries of our work together to assist them in treating you.
If necessary or in an emergency, I may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, of your location and general condition. If I am unable to reach your family member or personal representative, then I may leave a message for them at the phone number you provided as an emergency contact.
I will disclose some of your health care information if you request that I bill a third party. An example of payment is when I disclose your protected health information to your health insurer to obtain reimbursement or to determine eligibility or coverage.
I may disclose some of your PHI during activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment activities, legal, audits and administrative services.
Your Health Information Rights
Although your health record is the physical property of this practitioner, the information in your health record belongs to you. You have the right to request that I not use or disclose your health information for a particular reason related to treatment, payment, or general health care operations. If so, I ask you to make such requests in writing.
Although I will consider your requests, please be aware that I am not obligated to accept them, as I must first comply first with federal laws. I will do my best to abide by your requests with regard to the disclosure of your clinical and personal records to anyone outside of my practice, except in an emergency, or if disclosure is required by law. Any such requests must be made in writing.
This written summary of my policies about confidentiality and information practices explains many common situations and exceptions to rules governing confidentiality. Please feel free to bring up any questions or concerns you may have, so you will be comfortable agreeing to the terms of our agreement. Some situations involving the limits of confidentiality may require your getting formal legal advice, because the laws governing confidentiality are complex.
What you will be agreeing to when you sign a copy of this document when we meet in person:
- I understand that since Gracie Landes does not provide 24-hour crisis counseling, if I have an emergency necessitating immediate mental health attention, I will call 9-1-1 or go to an emergency room for assistance.
- I understand that while Gracie Landes is not available to communicate or consult between sessions or on weekends, I can email her about our work together, preferably my through my account with her on TherapyAppointment.com, unless one of us is sending an attachment, in which case I will use the email address on her website.
- I agree to schedule using my online scheduling calendar, and to contact Gracie Landes about scheduling only for same day appointments or emergency cancellations, in which case I will text her.
- I understand that our paths may cross in social situations but that our therapeutic relationship comes first, along with protection of my confidentiality; therefore, Gracie Landes will not initiate the greetings.
- I understand that Gracie Landes will not become involved in any client’s legal matters or proceedings, and I agree not ask her to do so.
- If I am using heath insurance, I authorize the release of information to my health plan for the payment of claims and and less likely, record requests .
- I understand that I am responsible to be sure my mental health policy information is up to date, to be responsible for uncovered charges, and to notify the therapist of any changes to my coverage.
- I agree to pay a minimum of $90 and up to the Gracie Landes’s full published current hourly rate (available on the Make an in person appointment page of this website), for missed sessions, same day cancellations or sessions not covered by my insurance. I also agree to pay any bank fees resulting from a check being insufficiently funded.
- I understand that repeated same day cancellations or non-payment of fees could lead to my losing the ability to schedule appointments until those fees are paid.
The following are about whether you would be willing, or not to allow some of our sessions to be videotaped,. You are under no obligation to say yes. For the following Please mark yes/no for each of these possible uses:
__yes ___no for Gracie Landes to review and monitor our progress
__yes ___no for Gracie Landes to share with professional colleagues, for the purpose of getting professional advice and feedback to improve her work with me
__yes ___no for Gracie Landes to show to colleagues or trainees at conferences, trainings, or other educational settings