Kira Lieberman, Psy. D.
P. O. Box 2788
Bellingham, WA 98227
INFORMED CONSENT FORM
Washington State law and professional ethics mandates that each client be provided with the following disclosure information at the commencement of any program of treatment by a licensed psychologist and licensed marriage and family therapist. You are free to ask questions and to discuss concerns regarding this form with me. Your feedback is welcome.
I have been a licensed psychologist in Washington State since 2010. My license number is PY60184276. Licensure indicates that a practitioner has met basic education, competency, and supervision standards. If more information is needed, contact the Department of Health, PO Box 47890, Olympia, Washington 98504-7890, (360) 236-4030.
In 2001, I obtained a doctorate in psychology from Massachusetts School of Professional Psychology, since renamed William James College. I have been practicing as a psychologist since 2002, first in Massachusetts and now in Washington State.
I have experience with the evaluation and treatment of the following issues: depression, anxiety, Bipolar Disorder, trauma, post traumatic stress disorder, autism spectrum disorder, Attention Deficit Hyperactivity Disorder, adoption related issues, disordered eating, and relationship issues.
I work with children, parents, adolescents, college students and adults, providing individual therapy, family therapy and parent consultation services.
My therapeutic approach is integrative in nature. This means that I have experience with several modalities of therapy and I use whichever modality I believe will support my client in achieving his or her goals. I also get feedback from you as the client in terms of the impact of different modalities on your emotional well-being and ability to achieve your therapeutic goals.
I use the following modalities:
Internal Family Systems
Cognitive Behavioral Therapy
I hold a developmental context when working with individuals, meaning that I take into account their cognitive, emotional, and social development. I also hold a family systems perspective when working with individuals.
I consider you and I as a team, working together to help you achieve your therapeutic goals. I am always open to feedback if a certain approach does not work for you.
I believe that the integrative model works best in most cases. The exceptions would be Obsessive Compulsive Disorder and other anxiety related disorders, which often are addressed best with a Cognitive Behavioral approach. If I believe that your presenting issues are beyond my scope of education, experience and practice, I will refer you to a therapist in the area who specializes in treating issues such as yours.
If not using health insurance, the fee is $145.00 for a 55-minute session. My fees go up $5.00 every three years and I will remind you of this increase in advance. Unless there is a prior arrangement, full payment is required at the end of each session. The fee for returned checks is $35. If you are using health insurance for which I am preferred provider (Regence Blue Shield, Premera Blue Cross, Uniform Medical Plan, and Health Care Management) then the fee is determined by my contract with the health insurance and you are responsible for the co-pay or co-insurance fee. Before the initial session, please contact your health insurance for specific information on your responsibility.
If I spend more than 10 minutes on the phone or reading and responding to emails from you during a given week I will bill you on a prorated basis for that time. I may end the therapeutic relationship if the client has a significantly overdue balance, the client is non-compliant with treatment recommendations or the client is not consistently showing up for appointments. A minimum of 24 hours notice is required for rescheduling or cancelling an appointment or you may be charged the full fee. Emergency circumstances resulting in last minute cancellations do not apply. If you fail to make or arrange for payment of the outstanding balance, you agree to pay the legal costs incurred in the collection of said debt.
Benefits and Risks of Therapy
As with any treatment, there are some risks as well as many benefits with therapy. You should think about both the benefits and risks when making any treatment decisions. For example, in therapy, there is a risk that clients will, for a time, have uncomfortable feelings. Clients may recall unpleasant memories. Clients may uncover problems with people important to them. Therapy may disrupt a marriage, although my approach is to enhance relationships, not harm them. At times, a client’s symptoms may temporarily increase after beginning treatment. Most of these risks are to be expected when people are making important changes in their lives. Finally, even with our best efforts, there is a risk that therapy will not work for you.
While you consider these risks, you should know also that the benefits of therapy have been shown by scientists in hundreds of well-designed research studies. Therapy can help people feel less depressed or anxious. Clients’ relationships and coping skills may improve greatly. Their personal goals and values may become clearer. They may feel greater life satisfaction and greater well-being overall.
Client Rights and Responsibilities
You have a right to confidentiality. The only exceptions are: the reporting of child abuse as required by law, reporting of patient’s potential danger to self or others, reporting of patient’s grave mental disability (i.e., inability to properly care for self due to severe disability) or when ordered by a court of law to release information.
As a client, you have the right to choose a therapist who best suits your needs and goals. If you work with me, you have a right to raise questions about my therapeutic approach and to request a referral if you believe you might make better progress with another therapist. If you believe I have engaged in unethical or unprofessional conduct, you also have the right to report your concerns to the Department of Health by calling 360-236-4700.
You should also know that I am one of many therapists in the Bellingham area. If you feel that our work together is not helpful, please discuss this with me. I may change our approach or refer you to another professional in the area. My goal is for you to feel healthier and happier. To assure quality of care, it is your responsibility to keep me fully up-to-date about any changes in your feelings, thoughts, and behaviors and to cooperate with treatment to the best of your ability.
Termination of Service
I may terminate therapy with you in the following situations: 1) you fail to pay the negotiated fee; 2) you are not cooperating with my appropriate treatment recommendations; 3) there is a discovered conflict of interest (for example, I later learn that you are close friends with one of my relatives); 4) I am moving or closing my practice.
In an emergency, please call 911. For urgent or crisis situations, I can be reached 24 hours a day at (360) 389-3678.
If I am on vacation or otherwise unavailable, I will continue to be available on my work number. Should I go on vacation to an area that does not have cell reception, I will have someone cover my practice and you will be provided with their name and phone number. This covering therapist will have access to your client information and is bound by the same laws and rules as I am to protect your confidentiality.
If you ever become involved in a divorce or custody dispute, I want you to understand and agree that I will not provide evaluations or expert testimony in court unless expressly discussed and agreed to. You should hire a different professional for that service.
I can only be your therapist. It is unethical for a therapist to be a close friend or socialize with a client. Therapists cannot ever have a sexual or a romantic relationship with any client before, during or after the course of therapy.
If you are unhappy with what is occurring in therapy, I hope you will talk about it with me so that I can respond to your concerns. If you believe that I've been unwilling to listen and respond, or that I have behaved unethically, you can submit a complaint to the Washington State Department of Health, Health Systems Quality Assurance, Complaint Intake, P.O. Box 47857, Olympia, WA 98504-7857, or by calling 360-236-4700.
Distance therapy includes telephone-based therapy, video-based therapy, email-based therapy, and chat-based therapy. Clients may find it necessary or convenient to engage is these forms of therapy. There are a number of drawbacks to distance therapy such as the loss of non-verbal communication and increased risk of miscommunication. I would only engage in distance therapy with established clients with whom I typically see in my office setting. If I you or I are traveling and you wish to engage in distance therapy, I would need to follow the laws in Washington as well as the laws in the state in which you or I are visiting.
Confidentiality and Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The Health Insurance Portability and Accountability Act (HIPAA) mandates the protection and confidential handling of protected healthcare information. This statement informs you of your rights regarding your healthcare information under HIPAA. Your health information includes any information that I record or receive about your past, present, and future healthcare. HIPAA regulations require that I maintain this privacy and provide you a copy of this statement.
Record Keeping Practices
Standard practice requires me to keep a record of your treatment. This includes relevant data about dates of service, payments for service, insurance billing, and relevant treatment information. This record of treatment is your protected health information (PHI). I may use or disclose your PHI for payment, treatment, and healthcare operation purposes:
· Payment: I will disclose your PHI if you request that I bill a third party. An example of payment is when I disclose your PHI to your health insurer to obtain reimbursement or to determine eligibility or coverage. If your account with me is unpaid and we have not arranged a payment plan, I can use legal means to get paid. The only information I will give to the court, a collection agency, or a lawyer will be your name and address, the dates we met, and the amount you owe me.
· Treatment: I may use or disclose your PHI to coordinate or manage your treatment. An example of treatment would be when I consult with another healthcare provider or therapist. Consultation with colleagues is an important means of ensuring and maintaining the competence of my work. APA ethical standards permit discussion of client information with colleagues without prior consent as long as the identity of the client can be adequately protected. In some instances, the obligation to provide the highest quality service may require consultation that reveals a person’s identity without prior consent; such disclosures occur only when it cannot be avoided and I only disclose information that is necessary.
· Healthcare operations: I may disclose your PHI during activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment activities, case management, audits, and administrative services.
Uses and Disclosures That Do Not Require Your Authorization or an Opportunity to Object
You have the right to confidentiality. Under most circumstances, I cannot release any information to anyone without your prior written permission, and you can change your mind and revoke that permission at any time. The following are legal exceptions to your right to confidentiality. I will do my best to inform you of any time I have to break confidentiality.
· Abuse and threat to health: In the instance when you or someone else is in imminent danger of harm I may disclose your PHI for the purposes of safety.
a. If I have good reason to believe that you will imminently and seriously harm another person, I may legally give this information to the police or the disclosed victim.
b. If I believe you are in imminent danger of harming yourself, I may legally break confidentiality by calling the police, calling the county crisis team, or contacting your family.
c. In an emergency where your life is in danger, and I cannot get your consent, I may give another professional some information to protect your life.
d. If I have reasonable cause to believe that a child or vulnerable adult has suffered abuse or neglect, I am required by law to report it to the proper law enforcement agency or the Washington Department of Social and Health Services within 48 hours.
· Court proceedings: I may be required to disclose your PHI if a court of competent jurisdiction issues an appropriate order. I will comply with this order if (a) you and I have each been notified in writing at least fourteen days in advance of a subpoena or other legal demand, (b) no protective order has been obtained, and (c) I have satisfactory assurances that you have received notice of an opportunity to have limited or quashed the discovery demand. In these cases, I am required to submit information to the court unless I have reason to believe that this disclosure will harm the client.
· Criminal activity: I may disclose your PHI to law enforcement officials if you have committed a crime on my premises or against me.
Uses and Disclosures of Healthcare Information with Your Written Authorization
I will make other uses and disclosures of your PHI only when your appropriate authorization is obtained. An authorization is written permission that permits specific disclosures. You may revoke this authorization in writing at any time.
Your Rights Regarding Your Protected Health Information
1. You have the right to inspect and copy your PHI, which may be restricted in certain limited circumstances, for as long as I maintain it. I will charge you a reasonable cost-based fee for copies.
2. You have the right to ask that I amend your record if you feel that the PHI is incorrect or incomplete. I am not required to amend it; however, you have the right to file a statement of disagreement with me, to which I am allowed to prepare a rebuttal and it will all go into your record.
3. You have the right to request the required accounting of disclosures that I make regarding your PHI. This documents any non-routine disclosures made for purposes other than your treatment, as well as disclosures made pertaining to your treatment for purposes of quality of care.
4. You have the right to request a restriction or limitation on the use of your PHI for treatment, payment, or operations of my practice. I am not required to agree to your request; and in instances where I believe it is in the best interest of quality care, I will not honor your request.
5. You have the right to request confidential communication with me. An example of this might be to send your mail to another address or not call you at home. I will accommodate reasonable requests and will not ask why you are making the request.
6. If you believe I have violated your privacy rights you have the right to file a complaint in writing with me and/or the Secretary of Health and Human Services. I will not retaliate against you for filing a complaint.
7. You have the right to have a paper copy of this disclosure.
Children. When I treat children 12 and under, the parents or guardians have access to the child’s PHI.
Secrets. In the case of couple and family therapy, I reserve the right to discuss information with other members involved in the therapy that you have shared if I believe it helps facilitate the achievement of the goals set forth in therapy. In most cases, I will not reveal secrets for you but will help you to speak to your family about it – if it is necessary for therapy to progress.
See each other in public. If I see you in outside of therapy (e.g., the grocery store), I will protect your confidentiality by not acknowledging that I know you, however, you are free to initiate communication if you choose to do so.
Email and text. If you elect to communicate with me by email or phone text, please be aware that email and phone text are not completely confidential. And please be aware that I may not be able to respond quickly to your emails and phone texts.
These confidentiality rules apply after the death of the client. The privilege passes to the executor or legal representative of the client.
The following uses and disclosures of PHI will be made only with a client’s (or authorized representative’s) written authorization: 1) most uses and disclosures of psychotherapy notes, if applicable; 2) uses and disclosures of PHI for marketing purposes; 3) uses and disclosures that constitute a sale of PHI; and 4) other uses and disclosures not described in the Notice of Privacy Practices. Individuals will be notified if there is a breach of unsecured PHI. You have the right to restrict certain information to health plans when you pay out-of-pocket. Additionally, if I intend to send fundraising communications to you, I must specify this and give you the right to opt out of the fundraising communications.