Policy & ConsentPractice Policy & Informed Consent for My Therapy Services
PSYCHOTHERAPIST-CLIENT SERVICE AGREEMENT
Welcome to my practice. This document contains important information about my professional services and business policies. Although this information may seem long and sometimes complex, it is very important that you understand it because when you agree to engage in therapy with me it represents a formal agreement between us. We can discuss any questions you have before we start therapy or at any time during therapy.
Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to have many positive benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. However, there are no guarantees about what will happen—there are so many variables I cannot predict anyone’s outcome from the beginning of therapy. Psychotherapy requires a very active effort on your part, in fact you are the major change agent for whatever situation we are addressing in therapy. In order to be most successful, you will have to work on things we discuss outside of sessions and take an active role in your own transformation.
The first session or two will involve a comprehensive evaluation of your needs and your goals. By the end of the evaluation, I will be able to offer you some initial impressions of what our work might include to make forward progress. At that point, we will discuss your treatment goals and create an initial treatment plan. You should evaluate this information and make your own assessment about whether you feel comfortable working with me or not. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. My priority is for your wellbeing, and if that means referring you to someone more compatible with yourself and your particular needs then that is the direction I would take.
Appointments will ordinarily be 55 minutes in duration, typically once per week at a time we agree on, although some sessions may be more or less frequent as needed, and we can assess this as we go along. The time scheduled for your appointment is assigned to you and you alone. Do not bring anyone else along to a session without first talking it through with me. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours notice. If you miss a session without canceling, or cancel with less than 24-hour notice, my policy is to collect the amount for that session [unless we both agree that you were unable to attend due to circumstances beyond your control]. If it is possible, I will try to find another time to reschedule the appointment. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time, as I would normally have others scheduled after you.
The standard fee is $130.00 for a 55 min session (this amount includes GST) unless otherwise negotiated. A discounted price of $80/session is available for students, pensioners, mental health care plans and other low income earners—You must be able to present your student, pension or health care card. You will be invoiced for each session. Payment must be made by electronic transfer, or cash, and details will be on my invoice.
In addition to weekly appointments, it is my practice to charge this amount on a prorated basis (I will break down the hourly cost) for other professional services that you may require such as report writing, telephone conversations that last longer than 15 minutes, attendance at meetings or consultations which you have requested, or the time required to perform any other service which you may request of me. If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required even if another party compels me to testify.
I am required to keep appropriate records of the services that I provide. Your records are maintained in a secure location and kept confidential. I keep brief records noting that you were here, your reasons for seeking therapy, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records I receive from other providers, copies of records I send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them with me, or have them forwarded to another mental health professional to discuss the contents. If I refuse your request for access to your records, you have a right to have my decision reviewed by another mental health professional, which I will discuss with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request.
As a rule, I will disclose no information about you, or the fact that you are my patient, without your written consent. My records describe the services provided to you and contain the dates of our sessions, your diagnosis, functional status, symptoms, prognosis and progress, and any psychological testing reports. If there is any reason to share your information with other health care providers I will require your permission in advance, either through your consent at the onset of our relationship or through your written authorization at the time the need for disclosure arises. You may revoke your permission, in writing, at any time, by contacting me. We will always talk about any sharing of your information first, before asking you for consent.
II. “Limits of Confidentiality”
Possible Uses and Disclosures of Your Records Without Consent or Authorization
There are some important exceptions to this rule of confidentiality – some exceptions created voluntarily by my own choice, and some required by law. If you wish to receive mental health services from me, you must sign this form indicating that you understand and accept my policies about confidentiality and its limits. We will discuss these issues now, but you may reopen the conversation at any time during our work together.
I may use or disclose records or other information about you without your consent or authorization in the following circumstances, either by policy, or because legally required:
· Emergency: If you are involved in a life-threatening emergency and I cannot ask your permission, I will share information if I believe you would have wanted me to do so, or if I believe it will be helpful to you. I am a former paramedic and I may be privy to important medical information about you that emergency personnel may need to know to optimize their care of you in the case of a medical emergency.
· Child Abuse Reporting: If I have reason to suspect that a child is abused or neglected, I am required by law (Family Law Act 1975) to report the matter immediately to the relevant authorities.
· Adult Abuse Reporting: If I have reason to suspect that an elderly or incapacitated adult is abused, neglected or exploited, I will make a report and provide relevant information to the relevant authorities.
· Court Proceedings: If you are involved in a court preceding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and I will not release information unless you provide written authorization or a judge issues a court order. If I receive a subpoena for records or testimony, I will notify you so you can file a motion to quash (block) the subpoena. However, while awaiting the judge’s decision, I am required to place said records in a sealed envelope and provide them to the Clerk of Court. In civil court cases, therapy information is not protected by patient-therapist privilege in child abuse cases, in cases in which your mental health is an issue, or in any case in which the judge deems the information to be “necessary for the proper administration of justice.” In criminal cases, there is no statute granting therapist-patient privilege, although records can sometimes be protected on another basis. Protections of privilege may not apply if I do an evaluation for a third party or where the evaluation is court- ordered. You will be informed in advance if this is the case.
· Serious Threat to Health or Safety: If I am engaged in my professional duties and you communicate to me a specific and immediate threat to cause serious bodily injury or death, to an identified or to an identifiable person, and I believe you have the intent and ability to carry out that threat immediately or imminently, I am legally required to take steps to protect third parties. These precautions may include 1) warning the potential victim(s), or the parent or guardian of the potential victim(s), if under 18, 2) notifying a law enforcement officer, or 3) seeking your hospitalization. By my own policy, I may also use and disclose medical information about you when necessary to prevent an immediate, serious threat to your own health and safety. If you become a party in a civil commitment hearing, I can be required to provide your records to the magistrate.
Other uses and disclosures of information not covered by this notice or by the Australian laws that apply to me will be made only with your written permission.
III. Patient’s Rights and Provider’s Duties:
Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information (PHI) about you. You also have the right to request a limit on the medical information I disclose about you to someone who is involved in your care or the payment for your care. If you ask me to disclose information to another party, you may request that I limit the information I disclose. However, I am not required to agree to a restriction you request. To request restrictions, you must make your request in writing, and tell me: 1) what information you want to limit; 2) whether you want to limit my use, disclosure or both; and 3) to whom you want the limits to apply.
Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send your bills to another address. You may also request that I contact you only at work, or that I do not leave voice mail messages.) To request alternative communication, you must make your request in writing, specifying how or where you wish to be contacted.
Right to an Accounting of Disclosures: You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in section III of this Notice). On your written request, I will discuss with you the details of the accounting process
Right to Inspect and Copy: In most cases, you have the right to inspect and copy your medical and billing records. To do this, you must submit your request in writing. If you request a copy of the information, I may charge a fee for costs of copying and mailing. I may deny your request to inspect and copy in some circumstances. I may refuse to provide you access to certain psychotherapy notes or to information compiled in reasonable anticipation of, or use in, a civil criminal, or administrative proceeding.
Right to Amend: If you feel that protected health information I have about you is incorrect or incomplete, you may ask me to amend the information. To request an amendment, your request must be made in writing, and submitted to me. In addition, you must provide a reason that supports your request. I may deny your request if you ask me to amend information that: 1) was not created by me; I will add your request to the information record; 2) is not part of the medical information kept by me; 3) is not part of the information which you would be permitted to inspect and copy; 4) is accurate and complete.
Right to a copy of this notice: You have the right to a paper copy of this notice. You may ask me to give you a copy of this notice at any time. Changes to this notice: I reserve the right to change my policies and/or to change this notice, and to make the changed notice effective for medical information I already have about you as well as any information I receive in the future. The notice will contain the effective date. A new copy will be given to you or posted in the waiting room. I will have copies of the current notice available on request.
Minors: It is my policy not to provide treatment to a child under age 13 unless she/he agrees that I can share whatever information I consider necessary with a parent. For children 14 and older, I request an agreement between the client and the parents allowing me to share general information about treatment progress and attendance, as well as a treatment summary upon completion of therapy. All other communication will require the child’s agreement, unless I feel there is a safety concern, in which case I will make every effort to notify the child of my intention to disclose information ahead of time and make every effort to handle any objections that are raised.
I am often not immediately available by telephone. I do not answer my phone when I am with clients or otherwise unavailable. The most expedient way to contact me is to email me at email@example.com At these times, you may leave a message on my confidential voice mail and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters. If, for any number of unseen reasons, you do not hear from me or I am unable to reach you, and you feel you cannot wait for a return call or if you feel unable to keep yourself safe, 1) call Lifeline on 13 11 14 and ask for help, or 2) go to your Local Hospital Emergency Room. I will make every attempt to inform you in advance of planned absences, and provide you with the name and phone number of the mental health professional covering my practice.
If you are unhappy with what is happening in therapy, I hope you will talk with me so that I can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist and are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect that I will not have social or sexual relationships with clients or with former clients.
Risk Management Strategy for Child Protection
If I work with people under 18 years of age I am required to hold a “Blue Card” issued by the Queensland Government to indicate that I have been screened by the government to ensure I am a safe person to work with children. The policy below outlines my planning and obligations to provide a safe environment to treat children.
Child and Youth Risk Management Strategy
Matthew Dahlitz (Blue Card Registration Number: 805030/2)
1. Statement of commitment to the safety and wellbeing of children and the protection of children from harm
As a professional, I believe that I am a part of a community of care. I am committed to working with children and creating a positive and supportive environment to develop their skills and learning. I am committed to their safety and wellbeing and will treat them with respect and understanding at all times. In order to ensure children and young people are kept safe from harm, I will conduct my business activities in accordance with the following risk management strategies:
- ensure I am unaffected by the use of substances which may compromise the appropriate supervision of children at all times
- gain consent from parents or carers before photographing or videoing any child
- gain consent from parents or carers before communicating by phone or email with any child
- not support bullying or harassment by anyone to anyone, including amongst children
- ensure that no visitors or outsiders have contact with the children; and
- notify you if I am unable to provide services/conduct activities with your child/children.
2. Code of conduct for interacting with children and young people
As the sole business operator, I will:
- foster mutual respect between myself and children and young people regardless of cultural identity and cultural practices/behaviour
- understand children and young people, their ages, stages of development, special circumstances, special needs
- use language which is age/stage appropriate, clear, non-threatening and non-sexual
- use physical contact only in the circumstance where it is completely necessary during the course of my business-related duties and where permission from the child and the child’s parent/carer has been gained in that instance
- will listen to a child or young person’s concerns/issues
- will use a variety of methods to motivate children
- listen to parent/child suggestions, feedback and complaints
- use corrective practices which are not punitive, humiliating or aggressive.
Children are expected to demonstrate:
- a willingness to learn
- a willingness to listen and receive instructions
- respect for other children, young people and adults who may be waiting
- safe and responsible behaviour at all times
- responsibility in reporting inappropriate behaviour and unsafe situations or harm
Parents and caregivers should:
- feel welcome to stay and observe
- raise any issues or concerns with me
- drop off and pick up of child/children in a timely fashion, leaving the child/children in my care only for the time allocated
- receive feedback regarding child/children’s progress
- provide the necessary resources/materials relevant to the activity as requested
- alert me to any concerns as soon as they arise when possible
- give constructive feedback on my policies and procedures
- work with me to ensure their time and money is well spent
- be aware that personal information will be treated confidentially and privacy will be respected
As the sole business operator, I have the right to:
- cease my business activities with a child or young person who is consistently non-compliant or obstructive, in which case the parent/guardian will be contacted immediately
- raise any concerns I may have with child and/or parent
- expect that child/parent make concerns known to me as soon as they arise so that a resolution can occur as quickly as possible
- allow only a parent, guardian or other nominated person to pick up a child from my place of business
- report disclosures and suspicions of harm, as detailed on Page 3 of this risk management strategy
Children and young people have the right to:
- feel safe
- be listened to
- be involved in decisions that affect them
- have their cultural values respected
- have their best interests considered
- be respected
- be understood
- be free from harassment, bullying or abuse of any kind
- ask if they don’t understand
Parents and caregivers have the right to
- receive regular feedback on your child/children’s progress
- ask questions or raise concerns about my business activities or your child/children’s progress
- make complaints as per procedures outlined below
- stay and observe my business activities with your child
3. Recruitment, training and management procedures for staff
As a sole operator, I understand I am required to manage my own behavior and am responsible for my ongoing training. Delivering up to date services to children requires me to undertake ongoing training in order to provide a positive contribution to the development and learning of children in my service.
In addition to the training needed in relation to the specifics of the services I provide, I am committed to developing my skills in providing child safe practices. To do this I will:
- regularly review material on the Blue Card Services website.
- regularly review material provided by the Department of Communities, Child Safety and Disability Services and the Queensland Police in relation to child protection.
- undertake training in relation to the safety and wellbeing of children, and maintain a record of this training.
Volunteers and Staff
In the event I need to engage volunteers or staff to assist with activities, services or special events I will assess their suitability to work with children in my service and ensure they are made aware of their obligations under this child and youth risk management strategy.
4. Reporting guidelines and directions for handling disclosures and suspicions of harm
If confronted with a disclosure of harm from a child or young person, I will respond professionally and in the best interests of the child or young person subjected to the alleged harm.
Reporting of disclosures and suspicions of harm will be made in accordance with recommended procedures. In summary:
- I will document the disclosure or suspicion of harm in a non-judgmental and accurate manner as soon as possible, and will not conduct any investigation into the matter.
- I will notify the Department of Communities, Child Safety and Disability Services if I suspect or am told that a child is being harmed at home, and I understand I am under no obligation to inform a parent, carer or guardian that I have done so.
- I will notify the Queensland Police Service if I suspect or am told that a child is being harmed outside the home and I understand I am under no obligation to inform a parent, carer or guardian that I have done so.
- I will notify the Department of Communities, Child Safety and Disability Services/Queensland Police Service if I am concerned that a child is self-harming.
- I will liaise with the Department of Communities, Child Safety and Disability Services or Queensland Police Service if I am unsure as how to respond to any concerns I have about a child in my care.
- Any reports or documentation on disclosures of harm will be kept confidential and secure.
5. Policy for managing breaches of the risk management strategy
Procedure for making complaints
I am committed to conducting my business in an open and accountable way. I will actively encourage parents, carers, guardians or children to discuss any concerns they have with me, with a view to resolving any problems professionally and sensitively.
In the event open discussions do not effectively resolve the parents’, carers’ or guardians’ concerns, I will provide them with information on where they can receive more information in relation to my practices and procedures. For example:
- In relation to blue card matters, or concerns relating to my Child and Youth Risk Management Strategy I will inform parents, carers, guardians or children they can contact Blue Card Services on 1800 113 611.
- In relation to any alleged criminal behaviour on my part I will inform the parents, carers or guardians of their right to contact the Queensland Police Service.
- In relation to any concerns regarding my professional practices I will refer parents, carers or guardians to (add industry specialist/professional standards board or equivalent’s contact details).
Breaches of the Codes of Conduct by Children
All parties are expected to abide by the set codes of conduct. Breaches of these will be addressed promptly. Where a child is misbehaving in class, in the first instance, the matter will be discussed with the child involved and if the matter is not resolved, I will talk with the child’s parent, carer or guardian.
Breaches could result in:
- changes to future session arrangements, including a plan to assist the child to participate in the activity in a safe and supportive way
- termination of further therapy
- notification to external authorities if a breach is considered critical or criminal.
6. Policies and procedures for compliance with requirements
Blue card renewals
Currency of blue card
I will ensure my blue card remains valid and ensure my renewal is submitted at least 30 days prior to it expiring.
I will advise Blue Card Services if:
- I have had a change in my police or disciplinary information and I understand I must not continue to conduct a regulated, child-related business until I have submitted a ‘Change in police information’ form or my business changes address
- I am no longer operating a regulated, child-related business.
Volunteers and staff
In the event I need to engage volunteers or staff to assist with activities, services or special events I will ensure all blue card screening requirements are complied with as outlined on the Blue Card Services Website www.bluecard.qld.gov.au.Blue Card Services can be contacted on 1800 113 611.
Annual review or review after an incident
I will review my child and youth risk management strategy annually as well as after any significant incident to:
- check it remains up-to-date with any changes to the legislation, and make changes if necessary
- ensure it continues to be effective in addressing the risks to children and young people in my service environment.
My review will consider:
- whether the policies and procedures were followed
- whether any incidents relating to children and young people’s risk management issues occurred
- the actual process used to manage any incidents
- the effectiveness of my policies and procedures in preventing or minimising harm to children and young people
- the content and frequency of training in relation to my child and youth risk management strategy.
I will document my review and ensure that any necessary changes are made.
7. Risk management plans for high-risk activities and special events
In the unlikely scenario where a high risk activity (one that requires extra planning/supervision) or special event takes place, parents/guardians will be provided with the relevant information regarding:
- the purpose of the event and its intended outcome for their child
- the venue
- the organiser’s risk management strategy where possible/relevant (if the event is to take place at a venue other than my place of business)
- any potential risks unique to the special event and how they will be mitigated
- the venue’s reputation for conducting special events
- bathroom locations
- estimated attendance numbers
- supervision arrangements
- transportation arrangements.
8. Strategies for communication and support
- A copy of my current risk management strategy will remain here – displayed on my business website.
- A copy of this risk management strategy will be provided to each parent/guardian (if requested).
- Parents/guardians will be notified of any changes and will be provided annually with a new copy of this risk management strategy (if requested).
- Parents/guardians will be kept informed of changes to risk management/blue card legislation, through written or verbal communication.
If a child or young person appears to be having any difficulties, I will discuss my concerns with their parent or carer with an aim to support the child to participate in a safe and supportive manner.