CONSENT FOR COUNSELING SERVICES PROVIDED BY THOMAS A MERZ, LPC
THE THERAPEUTIC PROCESS
Participation in counseling can lead to many benefits, including improving interpersonal relationships and resolution of the specific concerns that led you to seek counseling. Productive counseling means ongoing effort, active involvement, and an openness to change your thoughts, feelings and/or behavior. At times, I will ask you to assess your progress and goals, and other aspects of the therapy, and it is important to provide honest feedback.
During counseling, remembering, or talking about unpleasant events, feelings, or thoughts can result in a degree of discomfort, feelings of anger, sadness, worry, fear, etc. or heightened anxiety, depression, insomnia, etc. I may challenge assumptions or perceptions or propose different ways of looking at situations. Resolving issues that brought you to therapy in the first place, eg personal relationships, may result in changes that were not originally intended.
Counseling may lead to decisions about changing behaviors, employment, substance use, schooling, housing, relationships, and more. Sometimes a decision that is positive for one family member is viewed negatively by another family member. Change will sometimes happen quickly, but more often, it will take time and patience on your part. There is no guarantee that counseling will yield positive or intended results, but it can at least lay some of the groundwork.
During therapy, depending on the situation and issues, I will utilize various psychological and motivational approaches designed to facilitate progress and provide positive outcomes for you. These approaches include but are not limited to behavioral, cognitive-behavioral, existential, psychodynamic, system/family, developmental (adult, child, family), psycho-educational, or coaching techniques. In the process, we will gain a sense for what works best for you.
DISCUSSION OF A TREATMENT PLAN
During the first session and throughout this process, I will touch on your understanding of the therapeutic objectives, and perception of the possible outcomes of treatment. If you have unanswered questions about therapy, the possible risks, my expertise in helping you, or the process and goals, please do not hesitate to ask. You also have the right to inquire about other potential treatments and their risks and benefits. If you could benefit from approaches that I do not provide, I have an ethical obligation to assist you in exploring or obtaining that treatment.
DUAL RELATIONSHIPS
Not all dual relationships are unethical or avoidable. However, any dual relationship that might impair therapist objectivity, clinical judgment, or effectiveness or that could be exploitative in nature must be avoided. In addition, I will never acknowledge working therapeutically with anyone without his/her/their written permission. In some instances, even with permission, I will avoid acknowledgement to preserve the integrity of our working relationship, for example, social networking invitations on sites such as Facebook, Pinterest, LinkedIn, Twitter, etc. I will not respond to blogs written by clients or accept comments on my blog from clients.
TERMINATION AND REFERRAL
During the intake process and first couple of sessions, I will assess whether I can be of benefit to you. My assessment will include your suitability to psychotherapy delivered via technology. I do not accept clients who, in my opinion, I cannot help. In such a case, I will provide referrals you may contact. If at any point during counseling, I determine I am ineffective in helping you reach your therapeutic goals, I will discuss options with you, up to and including termination of services. In that event, I would provide appropriate referrals that you could contact.
If you request and authorize in writing, I will talk to the psychotherapist of your choice to help with the transition. If at any time you want another professional’s opinion or wish to consult with another therapist, I will assist you in finding someone qualified, and if I have your written consent, I will provide her/him with relevant or requested information. You have the right to terminate therapy at any time. If you choose to do so, I can offer potential referrals for you.
PRIVACY AND CONFIDENTIALITY
All information disclosed within sessions and the records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law. Likewise, you are expected to keep our communications confidential and you understand that records of communication between client and therapist remain the property of Thomas A Merz, LPC. Verbatim material from therapy sessions remain in the client record and should not be revealed publicly unless both client and therapist agree.
When Disclosure Is Required by Law
Circumstances in which disclosure is required by the law include: a reasonable suspicion of child, dependent or elder abuse or neglect; the client presents a danger to self or others or is gravely disabled; a valid court order. For further detail, refer to the Notice of Privacy Practices.
When Disclosure May be Required
Disclosure may be required pursuant to a legal proceeding. If you are involved in a custody dispute or if you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by me. In couples and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. I will use my clinical judgment when revealing such information. I will not release records to any outside party unless I am authorized to do so by all adult family members who were part of the treatment.
Harm to Self or Others
If there is an emergency during our work together, or following termination, in which I become concerned about your personal safety, the possibility of you injuring someone else, or you receiving proper psychiatric care, I will do whatever I can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive proper care. For this purpose, I may also contact the police, hospital or an emergency contact you have provided.
Confidentiality of Online, Phone, and Fax Communication
Therapeutic email is delivered via HushMail. You agree to utilize HushMail or another encrypted email/chat service determined to be suitable by Thomas A Merz, LPC. Additionally,
It is not a regular part of my practice to search client information through search engines such as Google or social media sites like Facebook. Extremely rare exceptions may be made during times of crisis. If I have a reason to suspect that you are in danger and you have not been in touch, I might utilize a search engine to find you and attempt to make contact as part of ensuring your welfare. If that event, I will document and discuss that with you when possible.
Litigation Limitation
Due to the nature of the therapeutic process and the frequent full disclosure of confidential issues, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you nor your attorney, nor anyone else acting on your behalf, will request that I testify in court or at any other proceeding, nor will a disclosure of the therapy records be requested for use in these types of situations.
Consultation and Peer Supervision
I periodically consult with other professionals regarding my clients; however, the client’s name and any other identifying information is never disclosed. Confidentiality is fully maintained.
TELEPHONE & EMERGENCY PROCEDURES
If an emergency arises that requires immediate attention, you can use the appropriate hotline (check my website for resources), eg the National Suicide Hotline at 800-784-2433 or dial 911. If a life-threatening crisis should occur, you agree to contact a crisis hotline, call 911, or go to a hospital emergency room.
FEE FOR SERVICE AND CANCELLATION POLICY
Current rates for therapeutic services are posted on my website. My practice is “fee for service” meaning that fees are due at the time of your appointment. I do not participate in insurance panels as either a preferred or out-of-network provider. Due to unreasonable administrative costs and the time involved, and in order to keep fees as low as possible, I do not communicate with insurance companies at any time for any reason; therefore I do not issue receipts with diagnostic criteria and other information necessary in order for my services to be reimbursable.
Session and email payments can be processed through my website. Phone and video sessions are generally purchased in 50-minute increments and/or as a package. Therapeutic mail exchanges can be purchased one at a time or as a package.
Since scheduling of an appointment involves the reservation of time specifically for you, a minimum 24-hour notice is required for rescheduling or canceling. If you are running late and we agree to move forward with the session, that time is part of the session. Unless we reach a different agreement, the full fee will be charged for sessions missed without notification.
If we are scheduled for a phone or video session and are unable to connect or are disconnected during a session due to a technological breakdown, please try to reconnect within ten minutes. If reconnection is not possible, we will schedule a new session time.
DISPUTES, COMPLAINTS AND RATINGS
You may find my psychotherapy practice on websites, eg Yelp, Healthgrades, Yahoo Local, etc, that include forums in which users rate their providers and add reviews. Many of these sites comb search engines for business listings and automatically generate listings regardless of whether the business has consented to be added. If you should find my listing on any of these sites, please know that my listing is not a request for a testimonial, rating, or endorsement from you as my client. Asking for a testimonial from you would be unethical practice on my part.
If you choose to write something on a business review site, please keep in mind that you may be sharing personally revealing information in a public forum. It is best to create a pseudonym that is not linked to your regular email address or friend networks for your own privacy and protection. If you ever have a complaint or problem that you want me to know about, I may not see your post on a review site. Always feel free to discuss any concerns with me personally.
All disputes arising out of or in relation to this agreement to provide therapy services shall be referred to mediation, before and as a precondition to the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of Thomas A Merz, LPC and the client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved matter related to this agreement should be submitted to and settled by binding arbitration in accordance with the rules of the American Arbitration Association that are in effect at the time the arbitration demand is filed.
Notwithstanding the foregoing, if your account is overdue (unpaid) and there is no agreement on a payment plan, I can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitrator will determine that sum.
LIMITATIONS REGARDING ONLINE THERAPY
As a client, you understand that distance or online therapy is a different experience than in-person sessions. You understand that phone/online counseling is not a substitute for medication under the care of a psychiatrist or doctor and is not appropriate if you are experiencing a crisis or having suicidal or homicidal thoughts. As previously stated, if a life-threatening crisis should occur, you agree to contact a crisis hotline, call 911, or go to the ER.
You also understand that I follow the laws and professional regulations of the State of Georgia (USA) and that the sessions or email exchanges will be considered to have taken place within the state of Georgia (or other states in which I may be licensed). Typically, I do not conduct online therapy with clients whose permanent domicile is located outside my license jurisdiction.
THE THERAPEUTIC PROCESS
Participation in counseling can lead to many benefits, including improving interpersonal relationships and resolution of the specific concerns that led you to seek counseling. Productive counseling means ongoing effort, active involvement, and an openness to change your thoughts, feelings and/or behavior. At times, I will ask you to assess your progress and goals, and other aspects of the therapy, and it is important to provide honest feedback.
During counseling, remembering, or talking about unpleasant events, feelings, or thoughts can result in a degree of discomfort, feelings of anger, sadness, worry, fear, etc. or heightened anxiety, depression, insomnia, etc. I may challenge assumptions or perceptions or propose different ways of looking at situations. Resolving issues that brought you to therapy in the first place, eg personal relationships, may result in changes that were not originally intended.
Counseling may lead to decisions about changing behaviors, employment, substance use, schooling, housing, relationships, and more. Sometimes a decision that is positive for one family member is viewed negatively by another family member. Change will sometimes happen quickly, but more often, it will take time and patience on your part. There is no guarantee that counseling will yield positive or intended results, but it can at least lay some of the groundwork.
During therapy, depending on the situation and issues, I will utilize various psychological and motivational approaches designed to facilitate progress and provide positive outcomes for you. These approaches include but are not limited to behavioral, cognitive-behavioral, existential, psychodynamic, system/family, developmental (adult, child, family), psycho-educational, or coaching techniques. In the process, we will gain a sense for what works best for you.
DISCUSSION OF A TREATMENT PLAN
During the first session and throughout this process, I will touch on your understanding of the therapeutic objectives, and perception of the possible outcomes of treatment. If you have unanswered questions about therapy, the possible risks, my expertise in helping you, or the process and goals, please do not hesitate to ask. You also have the right to inquire about other potential treatments and their risks and benefits. If you could benefit from approaches that I do not provide, I have an ethical obligation to assist you in exploring or obtaining that treatment.
DUAL RELATIONSHIPS
Not all dual relationships are unethical or avoidable. However, any dual relationship that might impair therapist objectivity, clinical judgment, or effectiveness or that could be exploitative in nature must be avoided. In addition, I will never acknowledge working therapeutically with anyone without his/her/their written permission. In some instances, even with permission, I will avoid acknowledgement to preserve the integrity of our working relationship, for example, social networking invitations on sites such as Facebook, Pinterest, LinkedIn, Twitter, etc. I will not respond to blogs written by clients or accept comments on my blog from clients.
TERMINATION AND REFERRAL
During the intake process and first couple of sessions, I will assess whether I can be of benefit to you. My assessment will include your suitability to psychotherapy delivered via technology. I do not accept clients who, in my opinion, I cannot help. In such a case, I will provide referrals you may contact. If at any point during counseling, I determine I am ineffective in helping you reach your therapeutic goals, I will discuss options with you, up to and including termination of services. In that event, I would provide appropriate referrals that you could contact.
If you request and authorize in writing, I will talk to the psychotherapist of your choice to help with the transition. If at any time you want another professional’s opinion or wish to consult with another therapist, I will assist you in finding someone qualified, and if I have your written consent, I will provide her/him with relevant or requested information. You have the right to terminate therapy at any time. If you choose to do so, I can offer potential referrals for you.
PRIVACY AND CONFIDENTIALITY
All information disclosed within sessions and the records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law. Likewise, you are expected to keep our communications confidential and you understand that records of communication between client and therapist remain the property of Thomas A Merz, LPC. Verbatim material from therapy sessions remain in the client record and should not be revealed publicly unless both client and therapist agree.
When Disclosure Is Required by Law
Circumstances in which disclosure is required by the law include: a reasonable suspicion of child, dependent or elder abuse or neglect; the client presents a danger to self or others or is gravely disabled; a valid court order. For further detail, refer to the Notice of Privacy Practices.
When Disclosure May be Required
Disclosure may be required pursuant to a legal proceeding. If you are involved in a custody dispute or if you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by me. In couples and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. I will use my clinical judgment when revealing such information. I will not release records to any outside party unless I am authorized to do so by all adult family members who were part of the treatment.
Harm to Self or Others
If there is an emergency during our work together, or following termination, in which I become concerned about your personal safety, the possibility of you injuring someone else, or you receiving proper psychiatric care, I will do whatever I can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive proper care. For this purpose, I may also contact the police, hospital or an emergency contact you have provided.
Confidentiality of Online, Phone, and Fax Communication
Therapeutic email is delivered via HushMail. You agree to utilize HushMail or another encrypted email/chat service determined to be suitable by Thomas A Merz, LPC. Additionally,
- Text messaging, if offered, is acceptable for appointments and housekeeping issues only.
- I do not store your name in my phone.
- If you call me, please be aware that unless we are both on land line phones, the conversation is not confidential.
- If you send a fax to me, my fax is secure.
- Any computer files referencing our communication are maintained using secure and encrypted measures.
- I will not respond to personal and clinical concerns via regular email.
- If you wish to use email to “journal” information between sessions, you understand that I may not have the opportunity to review your journal emails until our next scheduled session.
- You understand that emails between sessions that contain confidential information will be sent via encryption.
It is not a regular part of my practice to search client information through search engines such as Google or social media sites like Facebook. Extremely rare exceptions may be made during times of crisis. If I have a reason to suspect that you are in danger and you have not been in touch, I might utilize a search engine to find you and attempt to make contact as part of ensuring your welfare. If that event, I will document and discuss that with you when possible.
Litigation Limitation
Due to the nature of the therapeutic process and the frequent full disclosure of confidential issues, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you nor your attorney, nor anyone else acting on your behalf, will request that I testify in court or at any other proceeding, nor will a disclosure of the therapy records be requested for use in these types of situations.
Consultation and Peer Supervision
I periodically consult with other professionals regarding my clients; however, the client’s name and any other identifying information is never disclosed. Confidentiality is fully maintained.
TELEPHONE & EMERGENCY PROCEDURES
If an emergency arises that requires immediate attention, you can use the appropriate hotline (check my website for resources), eg the National Suicide Hotline at 800-784-2433 or dial 911. If a life-threatening crisis should occur, you agree to contact a crisis hotline, call 911, or go to a hospital emergency room.
FEE FOR SERVICE AND CANCELLATION POLICY
Current rates for therapeutic services are posted on my website. My practice is “fee for service” meaning that fees are due at the time of your appointment. I do not participate in insurance panels as either a preferred or out-of-network provider. Due to unreasonable administrative costs and the time involved, and in order to keep fees as low as possible, I do not communicate with insurance companies at any time for any reason; therefore I do not issue receipts with diagnostic criteria and other information necessary in order for my services to be reimbursable.
Session and email payments can be processed through my website. Phone and video sessions are generally purchased in 50-minute increments and/or as a package. Therapeutic mail exchanges can be purchased one at a time or as a package.
Since scheduling of an appointment involves the reservation of time specifically for you, a minimum 24-hour notice is required for rescheduling or canceling. If you are running late and we agree to move forward with the session, that time is part of the session. Unless we reach a different agreement, the full fee will be charged for sessions missed without notification.
If we are scheduled for a phone or video session and are unable to connect or are disconnected during a session due to a technological breakdown, please try to reconnect within ten minutes. If reconnection is not possible, we will schedule a new session time.
DISPUTES, COMPLAINTS AND RATINGS
You may find my psychotherapy practice on websites, eg Yelp, Healthgrades, Yahoo Local, etc, that include forums in which users rate their providers and add reviews. Many of these sites comb search engines for business listings and automatically generate listings regardless of whether the business has consented to be added. If you should find my listing on any of these sites, please know that my listing is not a request for a testimonial, rating, or endorsement from you as my client. Asking for a testimonial from you would be unethical practice on my part.
If you choose to write something on a business review site, please keep in mind that you may be sharing personally revealing information in a public forum. It is best to create a pseudonym that is not linked to your regular email address or friend networks for your own privacy and protection. If you ever have a complaint or problem that you want me to know about, I may not see your post on a review site. Always feel free to discuss any concerns with me personally.
All disputes arising out of or in relation to this agreement to provide therapy services shall be referred to mediation, before and as a precondition to the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of Thomas A Merz, LPC and the client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved matter related to this agreement should be submitted to and settled by binding arbitration in accordance with the rules of the American Arbitration Association that are in effect at the time the arbitration demand is filed.
Notwithstanding the foregoing, if your account is overdue (unpaid) and there is no agreement on a payment plan, I can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitrator will determine that sum.
LIMITATIONS REGARDING ONLINE THERAPY
As a client, you understand that distance or online therapy is a different experience than in-person sessions. You understand that phone/online counseling is not a substitute for medication under the care of a psychiatrist or doctor and is not appropriate if you are experiencing a crisis or having suicidal or homicidal thoughts. As previously stated, if a life-threatening crisis should occur, you agree to contact a crisis hotline, call 911, or go to the ER.
You also understand that I follow the laws and professional regulations of the State of Georgia (USA) and that the sessions or email exchanges will be considered to have taken place within the state of Georgia (or other states in which I may be licensed). Typically, I do not conduct online therapy with clients whose permanent domicile is located outside my license jurisdiction.