Jack D. Williams, Ph.D.
Clinical
Psychologist
INFORMED CONSENT
FOR COUPLES/FAMILY PSYCHOTHERAPY
About family therapy with couples.: Family therapy with couples is designed to heal the interpersonal problems that contribute to relationship dysfunctions or the physical/mental health of one or both of its members. With the exception of evaluation sessions, nearly all of our sessions will be conjoint. The first session will be to evaluate the interactions and problems in your relationship, the second and third session will be individual sessions for individual evaluations, and the last session is to discuss whether you want to work with me, and if and how I can be helpful. If we all agree to work together, we will set therapy goals and parameters and decide on our approach during that fourth meeting.
Confidentiality: Your confidentiality is protected by law, but there are a few exceptions. If you are a clear danger to yourself or another person, the law allows me to break confidentiality and intervene. If I believe a child has been or will be abused, the law requires a report. If you pay by
insurance, I may need to communicate with them about treatment, and your payment records are handled online and therefore may not be totally secure. I also have to testify if a court orders me to do so. In addition, unless a judge rules otherwise, the records of your conjoint sessions require that both of you give me signed permission to release them to another therapist or entity.
Appointments: Our meetings will be weekly and 50 minutes long unless we agree on another arrangement. Your appointment time belongs to you, so you will be charged $50 for missed appointments that are not cancelled by phone 24 hours in advance.
Fees and payments: Fees that are not covered by insurance should be paid at the time of treatment. I generally charge $125 for regular sessions
and $140 for the two evaluation sessions, unless your insurance has negotiated a different fee. Many insurances do NOT cover family/couples therapy unless one member has a diagnosis, nor do they cover pro-rated charges for phone calls, letters, and reports that take longer than 10 minutes. Call the office at 814-861-3300 if you have billing questions.
Please contact your insurance company ahead of time to be sure I am in their network, to check on your deductible and co-pay, to make sure your treatment is covered, to see if you need pre-authorization, and to update any other information they need. If your insurance company refuses to cover you, you are responsible for the charges. Be sure to bring your insurance card to your first appointment.
Contacting me: You may leave a confidential voice-mail message on my phone (814-441-5738) at any time. I will return your call as soon as I can. If you have a true mental-health emergency, please contact the Centre County Crisis Line at 1-800-643-5432, call 911, or go to your closest emergency room. If we communicate by email, remember that email is not a secure medium. Please don’t put anything in email that you would not put on a postcard. Please cancel appointments by phone only.
About the office: I am located in Suite 303 and share office space with the Center for Child and Adult Development (CCAD). CCAD is an association of practicing professionals that shares expenses, administrative functions, and office space. I want you to know that I am completely independent of CCAD in providing your clinical services. My professional records are separately maintained.
28Sep2011
