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Informed Consent

Mantra Counseling, LLC

4230 South MacDill Ave. Suite 209 Tampa, FL 33611

813-808-1956 * therapy@amydatla.com * www.amydatla.com

 

Informed Consent

 

Amy Datla, LMHC, LMFT, CAP, DCC, NCC

 

About Me

 

  • Master’s degree in Professional Counseling from Georgia State University in 2003.
  • Licensed in the state of Florida as a Licensed Mental Health Counselor since 2006 (MH 8831).
  • Licensed in the state of Florida as a Licensed Marriage and Family Therapist since 2013 (MT 2809).
  • Earned Certified Addiction Professional certification in 2008 (#4385).
  • National Certified Counselor since 2003 (#83286).
  • Distance Credentialed Counselor since 2014 (#1448).

 

I am a psychotherapist who specializes in providing therapy to adults, adolescents, couples and families in the Tampa Bay area with various mental health and/ or substance abuse problems. My specialties, include, marital conflict, parent- child conflict, acculturation issues, trauma, addictions, depressive and anxiety disorders, adjustment problems to major life changes and parenting skills training.

 

Goals and Outcomes

 

My goal is to enhance the well- being of adults, adolescents and families in the community. I provide services that encourage increased personal happiness and health and satisfying relationships. My core values include fostering compassion, promoting cultural sensitivity and encouraging the development of a collaborative relationship with my clients, that leads to effective treatment and client autonomy. In general, counseling is most useful in helping individuals help themselves or improve their relationships by changing feelings, thoughts and/ or behaviors.

Usually, the first session involves an in-depth discussion of your background and the problem that led you to seek therapy as well as affording you an opportunity to become acquainted with me. Following a thorough assessment, including a review of your own treatment goals, therapy can be initiated. The range of psychotherapy services, include:

  • Individual Psychotherapy
  • Couples/Marital Psychotherapy
  • Family Psychotherapy
  • Group Psychotherapy

The treatment strategies I utilize have received research support for their effectiveness.  These interventions stem from numerous therapeutic approaches, including: Acceptance & Commitment Therapy, Emotionally Focused Therapy, the Gottman Method, Prolonged Exposure Therapy, Cognitive Behavioral Therapy, Dialectical Behavior Therapy, Rational Emotive Behavior Therapy and Brief Therapies, including, Narrative Therapy & Solution- Focused Therapy. Therapy is individualized to meet your specific treatment needs and goals and is an effective and efficient form of intervention. Ongoing assessment occurs during the therapy process to assist in identifying problems accurately as well as to monitor your progress in treatment.  I am culturally sensitive and respectful to the struggles you are experiencing. I will encourage and support you in making changes.

 

Payment Policy

My private pay rate is $185 for the initial 90- minute assessment and $115 per 55- minute session. Couples therapy sessions are usually 85 minutes at a rate of $165 per session. The group therapy rate is $45 per hour session. My practice is “fee for service” and that means that fees are due at the time of your appointment. Additional time will be charged in one- half hour increments. Payments are to be made immediately following each session or previous to the session if distance counseling. I accept cash, checks, debit cards and credit cards. If there is a returned check, the charge will be $35. If you indicate that a third party will be paying for any portion of your bill, an Authorization for Release of Confidential Information would need to be signed. This would allow me to contact that individual and share information regarding your billing/ payment arrangements. Please be aware that if your outstanding balance exceeds $95, I will not be able to schedule further appointments until the balance is paid.

 

I am also on the following insurance panels as an in-network provider: Humana (Lifesynch), TriCare, Value Options and MH Net. I am an out-of-network provider for Blue Cross Blue Shield. I issue receipts with diagnostic criteria and other information necessary in order for my services to be reimbursable when communicating with clients’ insurance and EAP companies.

 

You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a payment installment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I would release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim.

In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf.

Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that your contract with your health insurance company or Employee Assistance Program (EAP) requires that I provide it with information relevant to the services that I provide to you. I am usually required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company or EAP files and will probably be stored in a computer. Though all insurance and EAP companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier or Employee Assistance Program. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above. Your signatures below acknowledge that you have received this agreement and HIPAA notice and that you have read this agreement and you agree to its terms during our professional relationship.

 

Session payments and co- pays via credit or debit card can be processed through a National Bankcard terminal, Google Wallet or PayPal.  Sessions are generally purchased in 30 and 60-minute increments. Therapeutic e- mail exchanges can be purchased one at a time or as a package.

 

Cancellation of Appointment

 

Since scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24-hour notice is required for re- scheduling or canceling an appointment. Unless we reach a different agreement, the full fee ($100) will be charged for sessions missed without such notification.

 

 

 

 

 

 

 

 

Benefits and Risks

 

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, the 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 you 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, a decision that is positive for one family member is viewed quite negatively by another family member. 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.  Length of therapy will vary on an individual basis; however, on average you can expect treatment to last approximately 12 to 25 sessions.  A better estimate on the length of therapy can be provided after the initial assessment is completed.

 

During the course of therapy, I will utilize various psychological and motivational 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), psycho- educational and/ or coaching techniques.

 

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 any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, 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 as your therapist, I do not provide, I have an ethical obligation to assist you in obtaining those treatments.

 

Not all dual relationships are unethical or avoidable. However, sexual involvement between a therapist and client is never part of the therapy process as well as other actions or dual relationship situations that might impair the therapist’s objectivity, clinical judgment or therapeutic effectiveness or that could be exploitive 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 such as Facebook or LinkedIn, nor will I respond to blogs written by clients or accept comments on my blog from clients.

 

During the initial intake process and the first couple sessions, I will assess if I can be of benefit to you.  If you have requested on- line counseling, my assessment will include your suitability to psychotherapy delivered via technology.  If I assess that you would benefit more by receiving services from another provider, I will give you multiple 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 obligated to discuss this with you up to and including termination of treatment. 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, I will provide him or her with the essential information needed. You have the right to terminate therapy at any time.

 

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 disclosure is required by law. 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 Amy Datla, LMHC, LMFT, CAP, DCC, NCC (Mantra Counseling, LLC). Verbatim material from therapy sessions remains in the client record, and should never be revealed publicly unless both client and therapist agree.

 

Most of the provisions explaining when the law requires disclosure were described to you in the Notice of Privacy Practices that you received with this Informed Consent form.

 

Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent or elder, abuse or neglect; and where 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).

 

Clients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. Children between 13 and 17 may independently consent to (and control access to the records of) diagnosis and treatment in a crisis situation. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, and parental involvement, is also essential, it is usually my policy to request an agreement with minors and their parents about access to information. This agreement states that during treatment, I will provide parents with only general information about the progress of the treatment, and the client’s attendance at scheduled sessions. Any other communication will require the child’s authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.

 

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 couple 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.

 

If there is an emergency during our work together, or in the future after termination, in which 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 the police, hospital or an emergency contact whose name you have provided.

 

Confidentiality of Online, Cell Phone and Fax Communication

 

Therapeutic e- mail is delivered via Hushmail. You agree to work with me online using Hushmail.com or another encrypted email/ chat service determined to be suitable by Amy Datla. Additionally,

  • Text messaging via mobile phone is acceptable for appointments and housekeeping issues only.
  • If you call me or I call you, please be aware that unless we are both on landline phones, the conversation may not be secure. Therefore, I try to limit phone conversations to appointments and housekeeping issues only as much as possible.
  • If you send a fax to me, my fax is secure.
  • Any computer files referencing our communication are maintained using secure and/ or encrypted measures.
  • I will not respond to personal and clinical concerns via regular e- mail.
  • If you wish to use e-mail as a way to “journal” information between sessions, you understand that I may not have the opportunity to review your journal e-mails until our next scheduled session.
  • You understand that e-mails between sessions that contain confidential information will be sent via encryption.

 

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 and whether or not confidentiality from your work or personal computer may be compromised due to such programs as a keylogger. 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 you used location- based services on your mobile phone, you may wish to be aware of the privacy issues related to using these services.  I do not place my practice as a check- in location on various sites such as Foursquare. However, if you have GPS tracking enabled on your device, it is possible that others may surmise that you are a therapy client due to regular check- ins at my office on a weekly basis. Please be aware of this risk if you are intentionally “checking in”, from my office or if you have a passive LBS app enabled on your phone.

 

It is not a regular part of my practice to search for client information online through search engines such as Google or social media sites such as Facebook. Extremely rare exceptions may be made during times of crisis.  If I have a reason to suspect that you are in danger and you have not been in touch with me via our usual means (coming to appointments, phone or e- mail) there might be an instance in which using a search engine (to find you, find someone close to you, or to check on your recent status updates) becomes necessary as part of ensuring your welfare. These are unusual situations and if I ever resort to such means, I will fully document it and discuss it with you when we next meet.

 

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 a 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.

 

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.

 

If you need to speak with me between sessions to alert me of an emergency, please call 813-808-1956. Your call will be returned as soon as possible. Messages are checked daily (but never during the night time). Messages are checked less frequently on weekends and holidays. If an emergency situation arises that requires immediate attention, you may call the emergency National Suicide Hotline at 1-800-784-2433, contact Befrienders.org, dial 911, or go to the local emergency room.

 

If we are scheduled for an online synchronous chat, audio or videoconference and we are unable to connect or are disconnected during a session due to a technological breakdown, please try to reconnect within 10 minutes. If reconnection is not possible, contact me to schedule a new session time.

 

You may find my psychotherapy practice on sites such as Yelp, Healthgrades, Yahoo Local, Bing, or other places which list businesses. Some of these sites include forums in which users rate their providers and add reviews. Many of these sites comb search engines for business listings and automatically add listings regardless of whether the business has added itself to the site. If you should find my listing on any of these sites, please know that my listing is not a request for a testimonial, rating, or endorsement from you as my client. Asking for a testimonial from you would be an unethical practice on my part.

 

If you do choose to write something on a business review site, I hope you will keep in mind that you may be sharing personally revealing information in a public forum. I urge you to create a pseudonym that is not linked to your regular email address or friend networks for your own privacy and protection. Please be aware that if you have a complaint that you want me to know about, I may not see your post on a review site. I hope you will discuss your concerns with me personally. If you do have a complaint or concern about my services and you are not comfortable discussing the matter with me you may make inquiry to my license/ certification boards (Florida Board of Clinical Social Work, Mental Health Counseling and Marriage & Family Therapy, Florida Certification Board and National Board of Certified Counselors).

 

All Disputes arising out of or in relation to this agreement to provide 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 Amy Datla and the client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that a 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 which 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.

 

You as the client understand that distance therapy is a different experience as compared to in- person sessions, among those being the lack of “personal” face-to-face interactions and the lack of visual and audio cues in the therapy process to which you may have previously come to expect. You understand that face-to- face or telephone/ online psychotherapy with me is not a substitute for medication under the care of a psychiatrist or physician.  You understand that on- line and telephone therapy 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 Befriender’s.org, a crisis hotline, dial 9-1-1 or go to a hospital or emergency room.

 

You also understand that I follow the laws and professional regulations of the State of Florida (USA) and the psychotherapy treatment will be considered to take place in the state of Florida (USA). Typically, I do not conduct online therapy with clients whose permanent domicile is located outside of my license jurisdiction. By accepting this informed consent required for services electronically you agree to this informed consent. Your request to schedule or confirm an initial therapy appointment after receiving this informed consent suffices as an electronic signature. In addition, you will be required to sign this agreement in person at the beginning of your first appointment.

 

In the event of my death or incapacitation, you understand that I have a professional will that allows a licensed colleague to act on my behalf in making decisions about storing, releasing and/or disposing of my professional records, consistent with relevant laws, regulations and other professional requirements.

 

I have read the above information, and understand that I am encouraged to ask questions, and give input regarding the counseling process at any time. If there is anything in this form that I do not understand, it is my responsibility to seek clarification.

 

I consent to receiving appointment reminders via email (not encrypted).                                             (initials)

 

Email Encryption Question:                                                                    ________­­­_________________      ?

Email Encryption Answer:                                                     

 

Payment arrangements are as follows:

 

           

CLIENT PAY:                                                                      OTHER PAY:                                                                      

 

 

 

                                                                                                                                                                                       

Client Signature & Date                                                            Client Signature & Date

 

 

                                                                                                                                                                                                                                                                             

Client Signature & Date                                                            Witness (Therapist) Signature & Date

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