Consent For Treatment I authorize Elizabeth A. Platé LCSW-R to carry out psycho-therapeutic exams, treatments and or diagnoses during my care as a patient. The purpose of all services will be explained to me upon my request and subject to my agreement.
Informed Consent and Confidentiality Information about therapy is always confidential and will not be given without my written consent except:
A. When required by NY State Law: suspected child abuse or neglect.
B. When I indicate that I will/might hurt someone or myself, My therapist is required to warn/protect all necessary persons and speak to authorities including family, police, and other health care providers.
C. If I am in litigation, my therapist may be required by law to reveal information.
D. If my health insurance or managed care plan will be paying the therapist, I waive confidentiality to process the health claim.
Consent to Telemental Health I consent to participate in telemental health as part of my psychotherapy and understand the practice of delivering clinical care services via technology assisted media or other electronic means between the practitioner and client located in two different locations.
A. I understand there are risks, benefits & consequences associated with telemental health, including disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
B. I understand that during a telemental health session, we could encounter technical difficulties resulting in service interruptions. If this occurs, we can reconnect the session or we can move to alternative platforms.
C. I understand that there is no recording of online sessions by either party. Information disclosed within sessions & written records pertaining to sessions are confidential and may not be disclosed without written authorization, except where the disclosure is permitted and/or required by law.
D. I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telemental health unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others).
E. I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telemental health services are not appropriate and a higher level of care is required. My therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency.
Financial Terms I am fully responsible for health care payments. My payment is due at time of session. If I choose to use health insurance, I am responsible for the coverage & determination of benefits, and understand that private information is given to my carrier.
Cancelled/ Missed Appointments Scheduled appointment means that time is reserved only for ME, to work best with my personal schedule.
A. If an appointment is missed or canceled with less than 48 hour notice, I will be billed at full rate of the session.
B. My therapist would prefer to reschedule me at another time during the same week, if possible, or make other arrangements so that we can focus on our work together. My therapist would rather work with me than bill for empty sessions.
C. Please call me at 516-702-3013 and leave a message. I will call to “confirm” your message. Phones do not always interface well, or send texts in a timely manner.
Emergencies As your therapist, I am available by phone 24/7. If I'm unable to answer, leave a message so I can respond to you. If I'm away, another therapist will call. In an emergency and you can not reach me, go to the local emergency room or call 911 for immediate support.
Phone/ Email/ Text Consults As a service, telephone sessions are offered. Clients often use this if a situation comes up that needs immediate attention. If you use e-mail or text, note that personal information can sometimes be compromised. This service fee is based on your session fee, billed in 15 minute increments. Note insurance does not pay for this.
CONSENT FOR TREATMENT AND OFFICE POLICY
Elizabeth Platé Therapy 516.702.3013 elizabethplatetherapy@gmail.com
Mailing address: PO Box 1592, Quogue, NY 11959
Offering Teletherapy for your busy life!
RELATIONSHIps...understanding, listening, supporting
Elizabeth A. PlatÉ L.C.S.W.R. PSYCHOTHERAPIST
P:516.702.3013 f:631.653.5774
Westhampton/quogue www.elizabethplate.org