Consent For Services
This form is called a Consent for Services (the "Consent"). This Consent for Services ("Consent") describes important information about the therapy services provided by Ian Adams, M.S., LMHC, ("Provider") through Ian Adams Therapy Services PLLC ("Practice"). Please read this document carefully and ask any questions you have before beginning services.
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. 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 will 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. You may ask questions about your treatment, discuss concerns about your care, request changes to your treatment plan, or discontinue therapy at any time, subject to any applicable professional or legal requirements concerning continuity of care.
In-Person Visits & Communicable Illnesses
In-person therapy is available when offered by the Practice. If you are experiencing symptoms of a contagious illness, please notify your Provider before attending an in-person appointment. Depending on the circumstances, your Provider may recommend telehealth, rescheduling, or another appropriate arrangement. You are responsible for following reasonable health and safety procedures communicated by the Practice.
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 carefully vets any telehealth platform to ensure your information is secured to the appropriate standards.
• Technology. At times, you could have problems with your internet, video, or sound. If you have issues during a session, your Provider will follow the backup plan that you agree to prior to sessions.
• 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 therapy wherever is convenient for you.
• Ease of Access. You can attend telehealth sessions without worrying about traveling, meaning you can schedule less time per session and can attend therapy during inclement weather or illness.
• Recommendations
• Make sure that other people cannot hear your conversation or see your screen during sessions.
• Therapy sessions will not be audio- or video-recorded by the Practice without your informed consent and any consent otherwise required by law. You may not record a session without discussing it with your Provider and obtaining permission in advance. Third-party observation of a therapy session will occur only with appropriate informed consent.
• At the beginning of each telehealth session, you may be asked to confirm your current physical location and a way to contact you if the connection is interrupted or an emergency occurs. You should inform your Provider if your location changes during a session.
Confidentiality
Your Provider will protect the privacy of information you share in therapy in accordance with applicable federal and Iowa law. Your Provider generally will not disclose information about your treatment without your authorization except when disclosure is permitted or required by law.
Your Notice of Privacy Practices provides additional information about how your health information may be used and disclosed. However, there are a few exceptions.
• Your Provider may speak to other healthcare providers involved in your care.
• Your Provider may speak to emergency personnel.
• If you report that another healthcare provider is engaging in inappropriate behavior, your Provider may be required to report this information to the appropriate licensing board. Your Provider will discuss making this report with you first, and will only share the minimum information needed while making a report. If your Provider must share your personal information without getting your permission first, they will only share the minimum information needed. There are a few times that your Provider may not keep your personal information confidential.
• If your Provider believes there is a specific, credible threat of harm to someone else, they may be required by law or may make their own decision about whether to warn the other person and notify law enforcement. The term specific, credible threat is defined by state law. Your Provider can explain more if you have questions.
• If your Provider has reasonable cause to believe that a child or dependent adult has been abused or neglected, your Provider may be required by Iowa law to make a report to the appropriate authorities.
• If your Provider believes that you present a serious or 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 other appropriate persons or professionals, consistent with applicable law. Whenever reasonably possible, your Provider will discuss these steps with you first.
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 treatment records are maintained electronically using TherapyNotes, an electronic health-record platform used by the Practice. The Practice uses reasonable administrative, physical, and technical safeguards to protect the privacy and security of your information. No electronic system can be guaranteed to be completely free from security risks.
Communication
You decide how to communicate with your Provider outside of your sessions. You have several options:
• Texting/Email
• Ordinary email and text messaging may not be secure methods of communication. The Practice may use these methods for limited administrative communications, such as appointment reminders, when permitted by law. You should not use ordinary email or text messaging to send sensitive clinical information unless you have discussed the risks with your Provider and have agreed to communicate in that manner.
• Secure Communication
• The Practice's preferred method for communicating sensitive or confidential information is the secure TherapyNotes patient portal or another secure communication method designated by the Practice. Secure communications are the best 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.
• Social Media/Review Websites
• If you try to communicate with your Provider via these methods, they will not respond. 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. The Provider will not acknowledge a therapeutic relationship with you through social media, review websites, or other public platforms.
• 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. You should also know about the following:
• No-Show and Late Cancellation Fees
• If you are unable to attend therapy, you must contact your Provider at least 24 hours before your session. Otherwise, you may be subject to fees outlined in your fee agreement. Insurance does not cover these fees.
• Balance Accrual
• Payment is due at the time of service unless other arrangements have been made. When insurance is being billed, you are responsible for applicable copayments, coinsurance, deductibles, non-covered services, and other amounts for which you are responsible under your insurance plan or agreement with the Practice. If you are unable to pay, tell your Provider. Your Provider may offer payment plans or a sliding scale. If not, your Provider may refer you to other low- or no-cost services. Any balance due will continue to be due until paid in full. If necessary, your balance may be sent to a collections service.
• 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 are listed in the fee agreement. Payment is due 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.
• Sharing Information with Insurance Companies
• If you choose to use insurance benefits to pay for services, you will be required to share personal information with your insurance company. Insurance companies keep personal information confidential unless they must share to act on your behalf, comply with federal or state law, or complete administrative work.
• 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. Your Provider will tell you if they can help you file for reimbursement from your insurance company. If your insurance company decides that they will not reimburse you, you are still responsible for the full amount.
• Payment Methods
• The practice requires that you keep a valid credit or debit card on file. This card will be charged for the amount due at the time of service and for any fees you may accrue unless other arrangements have been made with the practice ahead of time. It is your responsibility to keep this information up to date, including providing new information if the card information changes or the account has insufficient funds to cover these charges.
Complaints
If you feel your Provider has engaged in improper or unethical behavior, you can talk to them, or you may contact the licensing board that issued your Provider's license, your insurance company (if applicable), or the US Department of Health and Human Services.