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Linda J. Hill, LCSW, DCSW
9812 Shelbyville Road – Suite 4
Louisville, Kentucky 40223
 

INFORMED CONSENT CONTRACT

Informed Consent

 Confidentiality:  Please understand that all records, written information, or any electronic data are marked CONFIDENTIAL and are kept under lock and key.  No one inside or outside the office will have access to your case except my office assistant and me.  This applies as well to the other therapists in the office.  Each one of us keep separate locked file cabinets. Computer files are also confidential and kept on our individual computers; that, includes insurance records, all password protected.  All sessions, including telephone or email contacts are confidential to persons outside of the therapy with some exceptions, I am required by law to report:
 
-- threats of harm to another or oneself
-- domestic violence
-- child or elder abuse
-- by court order
-- per your signed release
 
Therapy is a unique and highly individual experience with the outcome determined by the effort and motivation you bring to work towards a change in yourself and how you see the world around you. In the beginning, we will discuss your concerns and goals for therapy. If possible, I will give you an approximate time for length of therapy.  Because feelings will be explored, you may feel a range of emotions that can be intense at times. This is part of a normal process and does not mean there is something bad or wrong with you.  The hope is that the experience and expression of feelings will bring to the surface “what is right” with you.  While therapy should end through mutual agreement once desired goals have been reached, you have the right to end therapy at any time. Please feel you always have the right to ask questions of me. Therapy only works if you have trust and confidence in me and feel my respect and concern for you.
 
As a therapist, I participate in case consultations and supervision, to provide excellence in the service I give and in accordance with accepted professional behavior.
 
I will discuss a fee with you at the first session. Sessions normally last 50 minutes, but occasionally a longer session may be recommended.
 
(In counseling children or adolescents, confidentiality is a necessity; as much as possible, in order for the therapeutic process to work.  While you as parent or guardian have a legal right to information, I will speak with you in a general way unless there is a danger to the child’s life. This is conveyed to the child as well. Usually I ask the child and parent to meet with me together so that the parent can voice concerns or ask questions.  Sessions with minors may only last 30-45 minutes, depending upon age.)

Client Agreement & Policies

Payment policy: I agree to make payment at the time of service. Because some insurance companies pay many months in arrears or not at all, I understand that I am responsible for the total fee.
 
Cancellation policy: I agree to cancel appointments only in the event of extreme necessity. I understand I will be charged full fee unless I provide 24 hours advance notice. In the case of insurance, last minute cancellations will need to be paid in full by you since insurance is not responsible for a late cancel or “no show.”
 
Permission to treat: I acknowledge that it is my choice to participate in psychotherapy (or have my child participate). I realize that the outcome of therapy depends upon my personal investment in the therapy process. If I decide to terminate treatment I will discuss termination before ending treatment.
 
Before you sign below, please ask any questions you may have of this document. Your signature acknowledges agreement and understanding:

 
________________________________ _________________
        Signature of client                                                     date
 
________________________________ _________________
        Signature of therapist                                               date
 

Please read and sign, if applicable:

I authorize Linda J. Hill, LCSW, to file my insurance and authorize her to provide the necessary diagnostic/treatment information, as well as any information related to my psychotherapy that my insurance company and/or managed care organization may require. 

 
________________________________ _________________
        Signature of client                                                    date 
 

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