Ask A Behaviorist

ASK A BEHAVIORIST

Informed consent and Authorization for Behavioral Assessment, Intervention and Psychotherapy

ASK A BEHAVIORIST was created to address the needs of families struggling with behavioral issues. The approach to behavioral intervention that we utilize is based on Applied Behavior Analysis (ABA). ABA is the use of behavioral methods to measure behavior, teach functional skills, and evaluate progress. Our goal is to create a unique plan for each family that results in long-lasting positive outcomes and an enhanced quality of life.

Should you choose to proceed, a positive outcome then becomes our mutual responsibility. Behavioral treatment involves the intensive participation and commitment of caregivers. Without caregiver participation, the chances of improving socially significant behavior is strongly reduced.

Psychotherapy and behavioral treatment are clinical processes that involve a professional arrangement. Therapy is regulated by laws, ethics, your rights as a client, and by our standard business practices. Before intervention can begin, your agreement to the business practices described herein is required by initials at six (6) specified places and your signature.

Payment of Fees

California law requires that all fees are established and agreed to before we can begin. This section clarifies all fees, and defines your financial responsibilities.

1. The standard fee is $125.00 per fifty (50) minute session, payable each session and beginning at your first appointment. A $20.00 returned-check fee will be assessed.
2. Canceling or rescheduling appointments requires a twenty-four (24) hour notice by telephone to avoid having to pay the entire fee for a missed session (no emails please).
3. Written reports are billed to you at $125.00 per hour.
4. Telephone conversations between us in excess of fifteen (15) minutes per day will be billed proportional to your hourly fee.
5. Appearing at meetings or legal proceedings on your behalf is billable to you at $125.00 per hour, including travel time.

Your initials here agreeing to the Payment of Fees ___________

Confidentiality Limits and Exceptions

1. Normally, everything we discuss will be held confidential. Unless you provide a signed authorization, we will not speak to or correspond with anyone about you.
2. If you choose to break confidentiality in any way (i.e. sending us an email, applying for insurance reimbursement, telling anyone about your therapy, use an analog cell phone), we cannot control or be held liable for the outcome.
3. California law and professional ethics either mandate or permit therapists to break client confidentiality under certain circumstances. Some exceptions to confidentiality include situations in which there is reasonable suspicion that any of the following has ever occurred or is occurring now:
   • you or your child present a danger to self or others
   • a child or dependent adult is the victim of emotional, sexual or physical abuse, neglect or unjustified mental suffering
   • a dependent adult or any person over the age of 65 years is the victim of physical abuse, emotional abuse, abandonment, forced isolation, fiduciary abuse or neglect.

   Note: The above is a sample, and not a complete list of exceptions to confidentiality.

Your initials here agreeing to Confidentiality Limits and Exceptions: ___________

Medical, Psychiatric and Psychological Evaluations

1. If medical, psychiatric and/or psychological evaluations seem warranted, we will discuss the nature of these evaluations and appropriate referrals will be provided. If the need for evaluations by other professionals is established and you do not follow these recommendations, your therapy may be suspended or terminated.
2. Your doctor or other medical professional may have prescribed medications that ease emotional or physical suffering for you or for your child. In this case, medication compliance may be a condition of treatment.

Your initials here agreeing to "Medical, Psychiatric and Psychological Conditions" ___________

Limits of Communication

1. Every effort will be made to assist you, especially during crisis. However, there may be times when contacting you won’t be possible. Therefore, you must agree to first call 911 or go to the nearest hospital Emergency Room for assistance, any time you suspect you are in crisis.
2. As a standard business practice, each appointment ends fifty (50) minutes from the scheduled start of the appointment, regardless of your arrival time. We are not able to extend sessions since appointments begin on the hour.
3. If necessary, our voice mail will provide the name and telephone number of a colleague you can call for assistance when we are not available.
4. Email and fax machines are not confidential methods of communicating and are not used without your signed consent.
5. We maintain personal boundaries. We reserve the right to terminate treatment if, for any reason, a client obtains our home telephone number or our residential address.

Your initials here agreeing to Limits of Communication ___________

Treatment Termination

If at any time during the course of your treatment we determine we cannot continue, we will terminate treatment and explain why this is necessary. Ideally, therapy ends when we agree your treatment goals have been achieved. Additional conditions of termination include:

• You have the right to stop treatment at any time. If you make this choice, referrals to other therapists can be provided and you will be asked to attend a final termination session.
• Professional ethics mandate that treatment continues only if it is reasonably clear you are receiving benefit. If you are meeting with another therapist, you must first terminate treatment with that therapist before we can begin providing services. If you remain in therapy with someone else and this becomes apparent after we begin, we are ethically required to terminate your treatment.
• Other legal or ethical circumstances may arise and compel us to terminate treatment. In these cases appropriate referrals will be offered. Also, we do not diagnose, treat, or advise on problems outside the recognized boundaries of our competencies.
• Other situations that warrant termination may include: drug abuse, disclosing illegal intentions or actions, inappropriate behavior during sessions.

Your initials here agreeing with Treatment Termination conditions: ___________

Risks Associated with Psychotherapy and Behavioral Treatment

Like many things in life, psychotherapy and behavioral treatment have inherent risks. Some of these risks are:

• disruptions in your daily life that can occur because of therapeutic changes
• emotional pain due to exploring personal issues and family history
• emotional pain due to tolerating your child’s reaction to behavioral intervention
• although treatment begins with the hope of behavioral improvement and positive outcomes in the overall family functioning, there is no guarantee that this will occur. There is, however, a better chance of improvement occurring if all caregivers in the household participate in the therapy.

Your initials here acknowledging Risks Associated with Psychotherapy and Behavioral Treatment ___________

Authorization to Commence Psychotherapy and/or Behavioral Therapy

• Your signature below will verify that you have read the information in this authorization and that you asked questions about anything you have not understood up to this point. By signing, you freely acknowledge your willingness to undergo treatment using psychotherapy methods and/or behavioral therapy methods, as we deem appropriate and in accordance with this Informed Consent.
• You also agree to enter into a professional business arrangement according to all business practices outlined in this agreement. You accept total financial responsibility for payment of all fees and services as described, regardless of insurance coverage or any other third-party payers.
• You will also be releasing us of any liability that directly or indirectly results from disclosure or exchange of any information covered in this agreement. At your request, a copy of this and any other document in your record that bears your signature will be provided.

Signature ____________________ Today’s Date ___________