Paul F. Schmidt, PhD
mynewlife.com (502) 633-2860
INFORMED CONSENT FOR TREATMENT
PSYCHOLOGICAL SERVICES: I provide psychotherapy, psychological testing, and counseling (similar to life coaching). These services are described on my website above. The following pages can be accessed on drop-down menus under the main heading of “WORK WITH ME”, where you will see and can download a copy of this consent form.
MEETINGS: After you’ve returned this form to me, you can set up your first appointment with me over the phone. The first session will be 75 minutes long, and future sessions will usually be for one hour.
PROFESSIONAL FEES: The first session costs $255 if by Zoom or phone, $270 if it is in person. After the first session, in-person sessions cost $180 for one hour, always during 8:30 to 5:30 on weekdays. Zoom or telephone sessions cost $170 per hour during weekdays, $180 during weeknights 7:30 through 9:45. Costs of personality testing are listed on my website.
BILLING AND PAYMENTS: Sessions are paid at time of service by cash, check, or Venmo. Except for illness or unsafe roads, to avoid the late cancel charge of $90, cancellations need to be sent to me by text or voicemail by end of the day before your session.
INSURANCE REIMBURSEMENT: You are responsible for finding out what your coverage is for a state-licensed out-of-network provider, which I am and will always be. How you can discuss coverage and payment with your insurance company is also described under this tab. If you choose to file insurance, within two weekdays I will give you the digital or hard-copy statements you need, describing my services, procedure codes, charges, diagnosis, credentials, and my provider identification numbers. As YOU WILL BE FILING THE CLAIM, reimbursement will be made out to and sent directly to you. You understand that, by using your insurance, you authorize me to release such information to your insurance company. I will try to keep that information limited to the minimum necessary.
CONTACTING ME: Your fees pay for 15 minutes per week of my spontaneous (unscheduled) time with your phone calls, texting, and emailing while we are regularly working together. So text, email or call me whenever you like. I will respond at my first convenience, almost always within half a day, unless I’ve told you I’m on vacation. If you feel you are unable to wait for me to return your call, contact your family physician, the nearest emergency room, or the local mental health hotline.
CONFIDENTIALITY: In general,the privacy of all communications between a patient and a psychologist is protected by law, and I can only release information about our work to others with your written permission. But there are a few exceptions:
v If you sign a release directing me to do so, or if a judge or court order requires me to;
v If I am told that someone has been or may be abused or neglected without it being reported; v If you tell me that you or someone else poses a serious threat for physically harming someone, or v If you confess to me that you or someone else has committed an unreported crime.
Emergencies: If I feel that an emergency such as those in the four previous lines above may occur or may have occurred, I am required by law to report this. To help me do so, you agree to do all your telephone, Face-time, and Zoom sessions from your home or business addresses given below. Unless you request otherwise and take responsibility for the privacy of the call, we will communicate through a private telephone and video conferencing service (Zoom), where our messages and pictures are protected with encryption (scrambled at each end, so they cannot be recorded or intercepted). Social Media: I will not give or receivecontact with you on social media, as it isn’t private enough. Details of this policy are on my website above. My possible need to discuss transferring your case: If I ever believe you need to work with another therapist instead of me, you release me to discuss our sessions with a consulting licensed counselor of my choice, and we both agree to follow the directives of this counselor.
____________________
Now please open this form/document, read it, and call or text me if there’s anything that seems confusing, difficult, or unfair to you. Of course I won’t give or sell this info to anyone, but by digitally entering the five pieces of information below, you acknowledge that you’ve agreed to these as terms for our working together.
Your name: Cell phone(s) I can use:
Email(s) I can use to reach you: Today’s date:
Address(es) from where you might Zoom or call me (required by suicide prevention laws):
________________________________ ________________________________
________________________________ ________________________________
Once this information is entered, save this new document with your info on it, and email it back to me as an attachment, to [email protected]. Then we can set the time for our first appointment, and be ready to go when our first session begins. Thank you, and I look forward to working with you.
______________________________ ______________________________
Your Signature of agreement Your Signature of agreement
Thanks!