Informed Consent for Therapy Services – Adult
L.O. Aranye Fradenburg, Ph.D.

PSYCHOANALYST–PATIENT SERVICE AGREEMENT

Welcome to my practice. This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.

PSYCHOANALYTIC AND PSYCHOTHERAPEUTIC SERVICES
Psychoanalysis and psychoanalytic psychotherapy are both relationships between people that work in part because of clearly defined rights and responsibilities held by each person. As a patient in psychoanalysis/therapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your analyst/therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.

Psychoanalysis/therapy 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 psychoanalysis/therapy often requires discussing the unpleasant aspects of your life. However, psychoanalysis/therapy has been shown to have benefits for individuals who undertake it. Psychoanalysis/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. But, there are no guarantees about what will happen. Psychoanalysis/therapy requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions.
The first 2-4 sessions will involve a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some initial impressions of what our work might include. 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. 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.

APPOINTMENTS
Appointments will ordinarily be 50 minutes in duration, at a time and frequency we agree on. The time scheduled for your appointment is assigned to you and you alone. 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 charge you for the full session. (If you are an analytic patient, you have 28 days out of a year when the 24-hour notice is in effect. If you cancel more than 28 days in a given year, whether or not you have called me 24 hours previously, I will charge you for those missed sessions.) If you miss an appointment, I will try to find another time to reschedule the appointment, but cannot guarantee this will be possible. If I have to cancel an appointment with you 24 hours or less in advance thereof, your next session will be free of charge. 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.

PROFESSIONAL FEES
Our first consultation is free. Thereafter, my standard fee is $125.00. (This is because I have a Ph.D. in Psychoanalysis, which required 4 years of classes, 3 years of training in infant observation, an additional four years of conducting control cases under the supervision of a Training Analyst, a three-year analysis of my own, and a thesis.) You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by check or cash; I am not able to process credit card charges as payment. Any checks returned to my office are subject to an additional fee of up to $25.00 to cover the bank fee that I incur. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment.
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.
Please note also that I do use a “sliding scale” for students and very low-income patients. You will need to report to me your monthly income and the amount you pay monthly for rent/mortgage, in order for me to calculate your fee.

INSURANCE
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. I do not take insurance; insurance companies do not pay for psychoanalysis, and usually limit their customers to a certain number of psychotherapy sessions a year. I am usually willing to accept as my fee what your co-payment would be for the number of sessions your insurance company allots you. In that way, you will not have to pay me any more than you would if I did take insurance. For example, if your co-pay is $40 per session and you are allotted 12 sessions a year, then for 12 of your sessions with me you will only have to pay me $40. The rest will be at full fee. Analytic patients in that case will be allowed 1 payment of $40 per month, the rest at full fee. I will need to documentation from your insurance company to provide this discount.
PROFESSIONAL RECORDS
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.

CONFIDENTIALITY
I am obliged to keep the content of our discussions strictly confidential. You should know, however, that there are some exceptions to this rule. I also have a legal duty to report abuse and threats to harm yourself or another person or animal. Under certain quite specific circumstances I may be ordered by a judge to reveal some aspects of our discussions. We can discuss this matter at any time you have concerns about confidentiality.
PARENTS & MINORS
While privacy in psychoanalysis/therapy is crucial to successful progress, parental involvement can also be essential. It is my policy not to provide treatment to a child under age 13 unless s/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 patient and the parents allowing me to share general information about treatment progress and attendance, as well as a treatment summary upon completion of psychoanalysis/ therapy. All other communication will require the child’s agreement, unless I feel there is a safety concern (see also above section on Confidentiality for exceptions), 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.

CONTACTING ME
I am often not immediately available by telephone. I do not answer my phone when I am with patients or otherwise unavailable. 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, call 211, our local hotline for psychological crises, or go to your local hospital Emergency Room, or call 911 and ask to speak to a mental health worker. 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 I am away for a significant period of time.

OTHER RIGHTS
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 patients or with former patients.
CONSENT TO PSYCHOTHERAPY/PSYCHOANALYSIS
Your signature below indicates that you have read this Agreement and the Notice of Privacy Practices and agree to their terms.

_________________________________________
Signature of Patient or Personal Representative
_________________________________________
Printed Name of Patient or Personal Representative _________________________________________
Date _____________________________________
Description of Personal Representative’s Authority:_____________________________
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