Therapy Informed Consent

Kristin Minto-Snowden, MA, LMFT, CDWF

Lic. Marriage & Family Therapist #814135743

Corsa Avenue, Suite 221Westlake Village, CA 91362

Introduction

 

This Agreement is intended to provide the above named (Herein “Client”) with important information regarding the practices, policies, and procedures of Kristin Minto Snowden, LMFT (herein “Therapist”), and to clarify the terms of the professional relationship between Therapist and Client.

 

Any questions and concerns regarding the contents of this Agreement should be discussed with Therapist prior to signing it.

 

Therapist Background and Qualifications

 

Therapist is a Licensed Marriage and Family Therapist (LMFT) in California and has been working with individuals, couples, and families since 2005.

 

Therapist mainly works with clients who have been struggling with addiction, intimacy, mood disorders, betrayal, and attachment issues.

 

Therapist has worked in substance abuse and mental health treatment centers, military installations, hospitals, and private practice settings.

 

Therapist is a Certified Daring Way™ Facilitator (based on Dr. Brené Brown’s research on shame resiliency).

 

Therapist has received specialty training in process addiction recovery, love/intimacy issues, mental health disorders, and LGBTQIA+ affirmative therapy.

 

Therapist is also a Certified Sex Addiction Therapist (CSAT) candidate through the International Institute of Trauma and Addiction Professionals (IITAP).

 

Therapist is certified in Seeking Safety, a trauma and addiction treatment model.

 

Risks and Benefits of Therapy

 

Psychotherapy is a process in which Therapist and Client discuss a myriad of issues, events, experiences, and memories for the purpose of creating positive change so Client can experience his/her life more fully.

 

There are a number of benefits from participating in therapy. Therapists can provide support, problem-solving skills, and enhanced coping strategies for issues such as depression, anxiety, relationship troubles, unresolved childhood issues, grief, stress management, and creative blocks. Simply put: It is often helpful to have someone on the "outside" looking in.

 

Therapists can provide a fresh perspective on a difficult problem or point you in the direction of a solution. Often clients are unable to identify certain patterns or themes on their own and a therapist can assist with that process.

 

People find counselors can be an asset to managing personal growth, interpersonal relationships, family concerns, marriage issues, and the hassles of daily life. The benefits you obtain from therapy depend on how well you use the process and put into practice what you learn.

 

Some of the benefits available from therapy include:

  • Attaining a better understanding of yourself, your goals, and values

  • Developing skills for improving your relationships

  • Finding resolution to the issues or concerns that led you to seek therapy

  • Learning new ways to cope with stress, anxiety, depression, anger, or grief

  • Improving communications and listening skills along with problem-solving skills

  • Changing old behavior patterns and developing new ones

  • Improving your self-esteem and boosting self-confidence

 

Participating in therapy may also involve some discomfort, including remembering and discussing unpleasant events, feelings, and experiences. The process may evoke strong feelings of sadness, anger, fear, etc.

 

There may be times in which Therapist will challenge Client’s perceptions and assumptions and offer different perspectives. The issues presented by Client may result in unintended outcomes, including changes in personal relationships. Client should be aware that any decision on the status of his/her personal relationships is the responsibility of the Client.

 

During the therapeutic process, many clients find that they feel worse before they feel better. This is generally a normal course of events. Personal growth and chance may be easy at times but may also be slow and frustrating. Client is encouraged to address any concerns he/she has regarding his/her progress in therapy with Therapist.

 

Confidentiality

 

The information disclosed by Patient is generally confidential and will not be released to any third party without written authorization from Patient, except where required or permitted by law. Exceptions to confidentiality, include, but are not limited to, reporting child, elder and dependent adult abuse, when a patient makes a serious threat of violence towards a reasonably identifiable victim, or when a patient poses a danger to him/herself or a person or property of another.

 

Psychotherapist-Client Privilege

 

The information disclosed by Client, as well as any records created, is subject to the psychotherapist-client privilege. The psychotherapist-client privilege results from the special relationship between Therapist and Client in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the client is the holder of the psychotherapist-client privilege.

 

If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-client privilege on Client’s behalf until instructed, in writing, to do otherwise by Client or Client’s representative. Client should be aware that he/she might be waiving the psychotherapist-client privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding.

 

Client should address any concerns he/she might have regarding the psychotherapist-client privilege with his/her attorney.

 

Therapy via Email/Telephone/Skype/FaceTime/Other internet video medium.

 

Therapist will conduct sessions via telephone and videoconference when deemed appropriate and safe. This is considered “telemedicine” and includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education via interactive audio, video, or data communications. Such telemedicine practices will be conducted with the same agreement of confidentiality as established in previous paragraphs (Confidentiality and Psychotherapist-Client Privilege).

 

Telemedicine may not be as complete as face-to-face services but may still be beneficial to client. The transmission could be disrupted or distorted due to technical failures or the transmission of information could be intercepted/interrupted/accessed by unauthorized persons.

 

During telemedicine sessions Therapist may be limited in her ability to respond to the immediate crisis/safety needs of Client. Per new regulations, Therapist is required to obtain the location of the client at each telemedicine session, assess the appropriateness of telemedicine per the client’s condition, and provide the client with local emergency contact information (the latter will be done via email). If Client has any concerns or hesitation about holding a telemedicine session, the Client is encouraged to speak to Therapist immediately. Client should discuss any concerns regarding the risks and benefits of telemedicine with Therapist.

 

Consulting with Others in the Professional Field

 

Professional consultation is an important component of a healthy psychotherapy practice. As such, Therapist may regularly participate in clinical, legal, ethical consultation with appropriate professionals. During such consultations, Therapist will not reveal any personally identifiable information regarding Client.

 

Record Keeping

 

Therapist may take notes during session and will produce other notes and records regarding Client’s treatment. These notes constitute Therapist’s clinical and business records, which by law, Therapist is required to maintain. Such records are the sole property of Therapist.

 

Therapist will not alter his/her normal record-keeping process at the request of any client.

 

Should Client request a copy of Therapist’s records, such a request must be made in writing.

 

Therapist reserves the right, under California law, to provide Client with a treatment summary in lieu of actual records.

 

Therapist also reserves the right to refuse to produce a copy of the record under certain circumstances, but may, as requested, provide a copy of the record to another treating health care provider.

 

Therapist will maintain Client’s records for ten years following termination of therapy. However, after ten years, Client’s records will be destroyed in a manner that preserves Client’s confidentiality.

 

Patient Litigation

 

Therapist will not voluntarily participate in any litigation, or custody dispute in which Client and another individual, or entity, are parties. Therapist has a policy of not communicating with Client’s attorney and will generally not write or sign letters, reports, declarations, or affidavits to be used in Client’s legal matter.

 

Therapist will generally not provide records or testimony unless compelled to do so. Should Therapist be subpoenaed, or ordered by a court of law, to appear as a witness in an action involving Client, Client agrees to reimburse Therapist for any time spent for preparation, travel, or other time in which Therapist has made herself available for such an appearance at Therapist’s usual and customary hourly rate of $300 an hour.

 

Fee and Fee Arrangements

 

The usual and customary fee for service is $250 per 50-minute session. Sessions longer than 50- minutes are charged additional time pro-rata.

 

Therapist reserves the right to periodically adjust this fee and will notify Client in advance.

 

The agreed-upon fee between Therapist and Client is $250 per 50-minute hour. Therapist will provide an invoice or receipt, upon request. Payment is expected prior to the beginning of the session.

 

Therapist accepts cash, checks, credit cards, and payment through the website. www.krsitnsnowden.com.

 

Insurance

 

Therapist is not contracted with any insurance companies or managed care organizations.

 

Cancelation Policy

 

Client is responsible for payment of the agreed-upon fee for any missed session(s).

 

Client is also responsible for payment of the agreed-upon fee for any session(s) for which Client failed to give Therapist at least 12 hours notice of cancellation.

 

Cancellation notice can be left on Therapist’s voicemail or email.

 

Therapist Availability

Therapist’s voicemail is confidential. Therapist will make every effort to call Client back within one business day.

 

Therapist is unable to provide 24-hour crisis service.

 

In the event the Client is feeling unsafe or requires immediate medical or psychiatric attention, he/she should call 911 or go to the nearest emergency room.

 

The National Suicide Prevention Hotline is 1-800-273-8255

 

Termination of Relationship

 

Therapist reserves the right to terminate the business relationship at her discretion. Reasons for termination include, but are not limited to,

  • untimely payment of fees,

  • failure to comply with homework and tasks,

  • and conflicts of interest.

The client has the right to terminate the business relationship at his/her discretion.

 

Therapist will attempt to provide a smooth transition to alternative support programs and provide necessary referrals to client.

 

Acknowledgment

 

By signing below, Client acknowledges that he/she has reviewed and fully understands the terms and conditions of this Agreement.

 

Client has discussed such terms and conditions with Therapist and has had any questions with regard to the terms and conditions of the Agreement and consents to participate in therapy.

 

Client agrees to hold Therapist free and harmless from any claims, demands, or suits for damages from any injury or complications whatsoever, save negligence, that may result from therapy.

I understand that I am financially responsible to Therapist for all charges, including unpaid charges by my insurance company or any other third-party payer.

Thanks for submitting!

Back to New Client Forms