Disclosure Statement and Agreement for Services
This document is intended to provide important information to you regarding your treatment with Davidia Benavidez, Licensed Marriage and Family Therapist 101244. Please read the entire document carefully and be sure to ask your therapist any questions that you may have regarding its contents.
All communications between you and your therapist will be held in strict confidence unless you provide written permission to release information about your treatment. If you participate in marital or family therapy, your therapist will not disclose confidential information about your treatment unless all person(s) who participated in the treatment with you provide their written authorization to release.
There are exceptions to confidentiality. For example, therapists are required to report instances of suspected child or elder abuse. Therapists may be required or permitted to break confidentiality when they have determined that a patient presents a serious danger of physical violence to another person or when a patient is dangerous to him or herself.
All communications between you and your therapist will be held in strict confidence unless you provide written permission to release information about your therapy. Communications between therapists and patients who are minors (under the age of 18) are confidential; however, parents and other guardians who provide authorization for their child’s treatment are often involved in their treatment. Consequently, your therapist, in the exercise of his or her professional judgment, may discuss the treatment progress of a minor patient with the parent or caretaker. Patients who are minors and their parents are urged to discuss any questions or concerns that they have on this topic with their therapist.
Fee rates: Your therapist will discuss with you their individual fees. If they decide it is necessary to adjust fees, they will discuss it with you beforehand. Please note that time needed for phone calls, emails, or other correspondence with your therapist or by your therapist will be billed in 15 minute increments.
Payment and Insurance: Relationships For Better is considered an Out of Network Provider. We are able to offer an insurance receipt “Superbill” upon request. Payment must be made at the time services are rendered.
If for some reason you find that you are unable to continue paying for your therapy, you should inform your therapist. Your therapist will help you to consider any options that may be available to you at that time.
Appointment Scheduling and Cancellation Policies
Individual and conjoint (marital/family sessions are approximately 50 minutes in length. Sessions are typically scheduled to occur one time per week at the same time and day if possible. Your therapist may suggest a different amount of therapy depending on the nature and severity of your concerns. Your consistent attendance greatly contributes to a successful outcome.
If you are unable to keep an appointment, please notify your therapist immediately. If an appointment is missed or cancelled without 24 hours prior notice, you will be charged a full fee for the session. Individual therapists may bypass this policy in exceptional situations. However, we will ask that you keep a credit card on file, and as a rule, it will be charged for each missed appointment without 24 hours notice.
Telephone consultations between office visits are welcome. However, your therapist will attempt to keep those contacts brief due to our belief that important issues are better addressed within regularly scheduled sessions.
You may leave a message for your therapist at any time on his/her confidential voicemail. If you wish your therapist to return your call, please be sure to leave your name and phone number(s), along with a brief message concerning the nature of your call. If you have an urgent need to speak with your therapist, please indicate that fact in your message. Signing this consent form indicates that you are in agreement with your therapist contacting you via phone, voicemail, or text message. In the event of a medical emergency or an emergency involving a threat to your safety or the safety of others, please call 911 to request emergency assistance.
Telehealth is a mode of delivering psychotherapy services while you and the therapist are in separate locations. Signing this consent form indicates that you consent to your therapist using Zoom for therapy sessions and accept the potential risks to privacy if you participate in these services. Discuss your preferences with your therapist if there is a need to participate in therapy from separate locations.
About the Therapy Process
It is your therapist’s intention to provide services that will assist you in reaching your goals. Based upon the information that you provide to your therapist and the specifics of your situation, your therapist will provide recommendations to you regarding your treatment. We believe that therapists and patients are partners in the therapeutic process. You have the right to agree or disagree with your therapist’s recommendations. Your therapist will also periodically provide feedback to you regarding your progress and will invite your participation in the discussion.
Due to the varying nature and severity of problems and the individuality of each patient, your therapist is unable to predict the length of your therapy or to guarantee a specific outcome or result.
Termination of Therapy
The length of your treatment and the timing of the eventual termination of your treatment depend on the specifics of your treatment plan and the progress you achieve. It is a good idea to plan for your termination, in collaboration with your therapist. Your therapist will discuss a plan for termination with you as you approach the completion of your treatment goals.
You may discontinue therapy at any time. If you or your therapist determines that you are not benefiting from treatment, either of you may elect to initiate a discussion of your treatment alternatives. Treatment alternatives may include, among other possibilities, referral, changing your treatment plan, or terminating your therapy.
Acknowledgement and Consent
Your signature below indicates that you have read and understood the information provided here, and that you agree to these terms. If a credit card is provided for payment of sessions, your signature authorizes Relationships For Better to save your credit card information in Square Register and charge your credit card for scheduled sessions (see cancellation policy above). Additionally, you are consenting to treatment for yourself or your minor child.