This form is called a Consent for Services (the "Consent"). Your therapist, Julia Averna, LICSW, provides psychotherapy services through Commonwealth Psychotherapy PLLC (“Commonwealth Psychotherapy” or “the practice”). Please review this Consent carefully and ask any questions you may have before signing. By signing this Consent, you acknowledge that you have had an opportunity to ask questions and that you consent to receive psychotherapy services from your Provider under the terms described in this Consent.
THE THERAPY PROCESS
Therapy is a collaborative process where you and your Provider will work together on equal footing to achieve goals that you define. This means that you will follow a defined process supported by scientific evidence, where you and your Provider have specific rights and responsibilities. Therapy generally shows positive outcomes for individuals who follow the process. Better outcomes are often associated with a good relationship between a client and their Provider. To foster the best possible relationship, it is important you understand as much about the process before deciding to commit.
Therapy begins with the intake process. First, you will review your Provider's policies and procedures, talk about fees, identify emergency contacts, and decide if you want health insurance to pay your fees depending on your plan's benefits. Second, you will discuss what to expect during therapy, including the type of therapy, the length of treatment, and the risks and benefits. Psychotherapy may provide benefits such as increased self-awareness, improved coping skills, improved relationships and functioning, and reduction or management of emotional or behavioral symptoms. However, psychotherapy also involves potential risks. Discussing difficult experiences, thoughts, emotions, or memories may temporarily increase distress or discomfort. Therapy may also result in changes in how you understand yourself or your relationships, which may be challenging at times. There is no guarantee that psychotherapy will achieve a particular outcome. If your Provider is practicing under the supervision of another professional, your Provider will tell you about their supervision and the name of the supervising professional.
Third, you will form a treatment plan, including the type of therapy, how often you will attend therapy, your short- and long-term goals, and the steps you will take to achieve them. Over time, you and your Provider may edit your treatment plan to be sure it describes your goals and steps you need to take.
After intake, you will attend regular therapy sessions at your Provider's office or through video, called telehealth. Participation in therapy is voluntary - you can stop at any time.
At some point, you may achieve your goals. At this time, you will review your progress, identify supports that will help you maintain your progress, and discuss how to return to therapy if you need it in the future.
If at any point during treatment, you or your Provider determine your needs would be best met through additional or alternative services, your Provider will make associated recommendations. If it is determined that your clinical needs are outside the scope of your Provider's training or expertise, or you require additional services to support your well-being, you and your Provider will determine adjustments to your treatment plan. Appropriate referrals will be provided and treatment with your Provider may be terminated depending on the circumstances.
Reasonable alternatives to psychotherapy may include seeking services from another mental health professional, psychiatric evaluation or medication management, support groups or community-based services, or choosing not to pursue treatment. Your Provider can discuss available alternatives with you as appropriate.
You may ask questions about your treatment at any time and may refuse or discontinue a particular service or psychotherapy altogether. The anticipated length and frequency of treatment will be discussed with you and may change as your needs and treatment goals change.
IN-PERSON SERVICES
When in-person services are available, you are expected to follow reasonable health and safety procedures communicated by the practice. If you are experiencing an illness or other circumstance that makes attending an in-person appointment inappropriate, please contact your Provider as soon as possible to discuss whether the appointment can be conducted by telehealth or rescheduled.
TELEHEALTH SERVICES
To use telehealth, you need an internet connection and a device with a camera for video. Your Provider can explain how to log in and use any features on the telehealth platform. If telehealth is not a good fit for you, your Provider will recommend a different option.
There are some risks and benefits to using telehealth:
Risks
Privacy and Confidentiality. You may be asked to share personal information with the telehealth platform to create an account, such as your name, date of birth, location, and contact information. Your Provider uses a telehealth platform selected with consideration of applicable privacy and security requirements. However, no electronic communication or technology platform can be guaranteed to be completely secure.
Technology. At times, you could have problems with your internet, video, or sound. If there are technical issues during a session, you and your Provider will determine how to best proceed, either using another method of communication or determining the session is unable to be conducted given the technological issues at hand.
Crisis Management. It may be difficult for your Provider to provide immediate support during an emergency or crisis. You and your Provider will develop a plan for emergencies or crises, such as choosing a local emergency contact, creating a communication plan, and making a list of local support, emergency, and crisis services.
Benefits
Flexibility. You can attend telehealth sessions from a location that is convenient for you, provided that you are physically located in Massachusetts at the time of the session and are in a quiet, unmoving, private space conducive to the therapeutic process.
Ease of Access. You can attend telehealth sessions without worrying about traveling to and from your appointment. Telehealth may also allow you to attend sessions during inclement weather or when you have a mild illness that does not interfere with your ability to participate meaningfully in treatment.
Recommendations
Make sure that other people cannot hear your conversation or see your screen during sessions. Make sure you are stationary and have a stable internet connection.
Do not use video or audio to record your session unless you ask your Provider for their permission in advance.
Make sure to let your Provider know if you are not in your usual location before starting any telehealth session.
Your Provider may ask you to confirm your identity and physical location at the beginning of a telehealth session, as well as a telephone number where you can be reached if the telehealth connection is interrupted or an urgent safety concern arises.
Your Provider will use professional judgment to determine whether telehealth remains clinically appropriate for you. If your Provider determines that telehealth is no longer appropriate for your clinical needs, safety, or ability to participate effectively, your Provider may recommend an in-person service, referral, or another appropriate level of care.
CONFIDENTIALITY
Your Provider generally will not disclose confidential information without your prior written authorization unless disclosure is permitted or required by applicable law. When disclosure without your authorization is permitted or required, your Provider will disclose only the information reasonably necessary for the purpose of the disclosure. However, there are a few exceptions.
If you report that another healthcare provider is engaging in conduct that may be subject to professional or licensing oversight, your Provider may be required by law to report the information to the appropriate licensing authority. When circumstances permit, your Provider will discuss the potential disclosure with you beforehand and will disclose only information that is legally required or authorized.
If your Provider believes there is a serious, foreseeable, and imminent risk of harm to another person, your Provider may take reasonable steps to protect safety, which may include contacting emergency services, crisis services, law enforcement, or another appropriate person or provider, consistent with applicable law.
Your Provider is a mandated reporter under Massachusetts law. Your Provider may be required to make a report to the appropriate authorities when legally required, including when there is reasonable cause to believe that a child has been abused or neglected or when reporting is otherwise required by law regarding abuse, neglect, or exploitation of certain vulnerable or older adults. Your Provider will make disclosures consistent with applicable law and will disclose only information permitted or required to be disclosed.
If your Provider determines that you present a serious, foreseeable, and imminent risk of harm to yourself or another person, your Provider may take reasonable steps to protect safety, which may include contacting emergency services, crisis services, law enforcement, or another appropriate person or provider, consistent with applicable law. When circumstances permit, your Provider will discuss safety concerns and available options with you before making such disclosures.
Confidentiality may also be limited when disclosure is required or authorized by law, including in response to a valid court order or certain legal proceedings. If a request for your records or confidential information is received, your Provider will take reasonable steps to protect your confidentiality and will disclose only information that is legally required or authorized to be disclosed.
In Massachusetts, confidential information includes communications and information obtained during treatment, as well as information about whether or not you are a client or prospective client of the practice. Your Provider will take reasonable steps to protect the confidentiality of your information.
RECORD KEEPING
Your Provider is required to keep records about your treatment. These records help ensure the quality and continuity of your care, as well as provide evidence that the services you receive meet the appropriate standards of care.
Your clinical record is maintained electronically through TherapyNotes, an electronic health record platform used by the practice. The practice takes reasonable steps to safeguard your health information and maintain the confidentiality and security of your records. No electronic system can be guaranteed to be completely secure.
Massachusetts law requires clinical treatment records to be maintained for at least seven years from the date of the last client encounter or professional consultation. For minor clients, records must be maintained for at least seven years from the last client encounter or professional consultation, or at least three years after the client reaches the age of majority, whichever is longer.
You may request access to or a copy of your clinical treatment record in accordance with applicable Massachusetts and federal law. Requests should be made in writing to your Provider. In limited circumstances permitted by law, access to certain records may be restricted or a treatment summary may be provided instead.
If your Provider becomes unable to maintain client records due to death, incapacity, or another circumstance that prevents the Provider from continuing to practice, a designated records custodian may assume responsibility for the secure maintenance and appropriate disposition of client records in accordance with applicable law. The records custodian's role is limited to maintaining records and facilitating lawful access to or disposition of records and does not create a therapeutic relationship with the client.
COMMUNICATION
You decide how to communicate with your Provider outside of your sessions. You have several options:
Texting/Email
Texting and email are not secure methods of communication and should not be used to communicate personal information. You may choose to receive appointment reminders via text message or email. You should carefully consider who may have access to your text messages or emails before choosing to communicate via either method.
Secure Communication
Secure communications are the most secure way to communicate personal information, though no method is entirely without risk. Your Provider will discuss options available to you. If you decide to be contacted via non-secure methods, your Provider will document this in your record.
Routine electronic communication should generally be limited to scheduling, administrative matters, and brief matters related to ongoing treatment. Electronic messages may not be reviewed or answered immediately.
Your Provider does not provide 24-hour monitoring or emergency services. Do not use email, text messaging, or other electronic communication to request emergency assistance.
If you are experiencing an emergency or believe that you or someone else is in immediate danger, call 911 or go to the nearest emergency department. You may also call or text 988 to reach the Suicide & Crisis Lifeline. Do not wait for a response from your Provider in an emergency.
Social Media/Review Websites
If you attempt to communicate with your Provider through personal social-media accounts or review websites, your Provider will not respond through those platforms. This includes any form of friend or contact request, @mention, direct message, wall post, and so on. This is to protect your confidentiality and ensure appropriate boundaries in therapy.
Your Provider may publish content on various social media websites or blogs. There is no expectation that you will follow, comment on, or otherwise engage with any content. If you do choose to follow your Provider on any platform, they will not follow you back.
If you see your Provider on any form of review website, it is not a solicitation for a review. Many such sites scrape business listings and may automatically include your Provider. If you choose to leave a review of your Provider on any website, they will not respond. While you are always free to express yourself in the manner you choose, please be aware of the potential impact on your confidentiality prior to leaving a review. It is often impossible to remove reviews later, and some sites aggregate reviews from several platforms leading to your review appearing other places without your knowledge.
FEES AND PAYMENT FOR SERVICES
You may be required to pay for services and other fees. You will be provided with these costs prior to beginning therapy, and should confirm with your insurance if part or all of these fees may be covered.
Your standard fee for psychotherapy is $215 for a 50-minute session. Your specific financial responsibility may vary depending on your insurance coverage, benefits, deductible, copayment, coinsurance, or whether you are paying privately.
You should also know about the following:
Annual Fee Adjustment
To account for increases in operating costs, the practice's standard fee for psychotherapy may increase by $5 per 50-minute session each January. Clients will be notified of any fee change in advance. This annual fee adjustment applies to self-pay and out-of-network fees and does not change fees established by insurance contracts or other third-party payers.
No-Show and Late Cancellation Fees
Please provide at least 48 hours' notice if you need to cancel or reschedule your appointment. Otherwise, you may be subject to a $100 late-cancellation fee. A $100 fee also applies to missed appointments. If you do not arrive for your session within 15 minutes of the scheduled start time, the appointment will be considered a missed appointment and the $100 fee will apply.
Insurance does not cover these fees, and these fees are the client's responsibility. Exceptions may be made at the Provider's discretion based on the circumstances of the late cancellation, no-show, or late arrival.
Balance Accrual
Self-pay clients are responsible for payment of the applicable fee at the time of service unless other arrangements have been made in advance.
For clients using insurance, any amount that remains the client's responsibility after insurance processing, including applicable deductibles, copayments, coinsurance, and other permitted charges, is due according to the practice's payment policies.
Administrative Fees
Your Provider may charge administrative fees for writing a letter or report at your request; consulting with another healthcare provider or other professional outside of normal case management practices; or for preparation, travel, and attendance at a court appearance.
These fees will be discussed with you in advance, when reasonably possible, and are listed in the practice's fee agreement. Payment may be required in advance.
Insurance Benefits
Before starting therapy, you should confirm with your insurance company if:
Your benefits cover the type of therapy you will receive;
Your benefits cover in-person and telehealth sessions;
You may be responsible for any portion of the payment; and
Your Provider is in-network or out-of-network.
When your Provider is out-of-network with your insurance company, you are responsible for payment according to the practice's fee and payment policies. If applicable, the practice may provide documentation, such as a superbill, to assist you in seeking reimbursement from your insurance company. Any reimbursement is determined by your insurance plan and is not guaranteed. If your insurance company does not reimburse you or reimburses you for only part of the fee, you remain responsible for the amount due under the practice's fee and payment policies.
Sharing Information with Insurance Companies
If you choose to use insurance benefits to pay for services, you authorize the practice to submit claims and provide information reasonably necessary for billing and payment. This may include your diagnosis, treatment information, dates of service, and other information required by your insurance company to process claims.
Covered and Non-Covered Services
When your Provider is in-network, they have a contract with your insurance company. Your insurance plan may cover all or part of the cost of therapy. You are responsible for any part of this cost not covered by insurance, such as deductibles, copays, or coinsurance. You may also be responsible for any services not covered by your insurance.
When your Provider is out-of-network, they do not have a contract with your insurance company. You can still choose to see your Provider; however, all fees will be due at the time of your session to your Provider. If applicable, the practice may provide documentation, such as a superbill, to assist you in seeking reimbursement from your insurance company. Any reimbursement is determined by your insurance plan and is not guaranteed. If your insurance company decides that they will not reimburse you, you are still responsible for the full amount.
GOOD FAITH ESTIMATES
If you are uninsured or choose not to use insurance for your care, you may be entitled to receive a Good Faith Estimate of expected charges for scheduled services under applicable federal law. When required, a Good Faith Estimate will be provided separately from this Consent.
PAYMENT METHODS
The practice requires that you keep a valid credit or debit card on file. Your card may be charged for amounts that are your responsibility under this Consent and the practice’s financial policies, including applicable copayments, coinsurance, deductibles, self-pay fees, and permitted late-cancellation or no-show fees.
Unless otherwise arranged in advance, applicable charges will be processed at the time of service or when the amount becomes due. It is your responsibility to keep your payment information up to date and to provide updated information if your card expires, is replaced, or otherwise changes, or if a payment is declined or cannot be processed.
ENDING OR TERMINATING TREATMENT
You may choose to end psychotherapy at any time. When clinically appropriate, you and your Provider will discuss the reasons for ending treatment, your progress toward treatment goals, and any recommendations for continued care or follow-up.
Your Provider may determine that treatment should end when your treatment goals have been met, when the services provided are no longer clinically appropriate, when your needs require a level or type of care outside the scope of this practice, or under other circumstances in which continuation of treatment is not appropriate.
When services are ending and you continue to need care, your Provider will make reasonable efforts to discuss appropriate referrals or options for continued treatment and to avoid an abrupt interruption in clinically necessary care.
SCOPE OF SERVICES AND LEVEL OF CARE
Psychotherapy services are provided based on an assessment of your clinical needs and the level of care that can be safely and appropriately provided within an outpatient private-practice setting.
If your clinical needs exceed the scope of services, expertise, or level of care that can appropriately be provided through this practice, your Provider may recommend consultation, referral, additional services, or a higher level of care. Your Provider will discuss these recommendations with you whenever clinically and legally appropriate.
COMPLAINTS
If you have a concern about your treatment, privacy, billing, professional conduct, or any other aspect of the services you receive, you are encouraged to discuss the concern with your Provider so that it can be addressed when possible.
You may also contact the Massachusetts Board of Registration of Social Workers regarding concerns about professional conduct or licensure, your insurance company regarding insurance-related concerns, or the U.S. Department of Health and Human Services, Office for Civil Rights, regarding concerns about privacy rights under HIPAA.