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        Informed Consent for Psychotherapy Assessment Consultation
                       Click here to download the form (PDF)

The purpose of this Initial Assessment Consultation is to determine your needs and to offer you treatment recommendations.  This session is for assessment only.  Treatment is offered under a separate agreement.  

Confidentiality:  I am legally and ethically required to keep our sessions confidential.  As a result, I will only release information to another professional or other interested party with your written consent, except (1) when subpoenaed in certain legal proceedings in which you give up your right to confidentiality, (2) in cases of behavior that is actually or potentially a serious danger to yourself or others, and (3) specifically, suspected child abuse or abuse of elders or dependent adults.  In some cases I would be required to report to public agencies, and possibly to warn those who may be at risk.  I will tell you, if possible and prudent, before I make such a report.  If you are unclear about anything in this paragraph, please ask me about it as soon as possible.  

Appointments:  Time is reserved by agreement with you.  If you need to cancel or change an appointment time, please give 48 hours notice.  Cancellation without 48 hours notice will be charged to you at the regular fee.  

Length of sessions:  Regular sessions are 45-50 minutes in length.  One and 1/2 sessions are one hour and 5-15 minutes, and double sessions are 90-100 minutes in length.  These times include the time needed for business matters, such as making appointments and paying for the session.  Group psychotherapy is usually 90 minutes.  

Fees:  Payment is due at each appointment.  Payment for group psychotherapy is paid one month in advance.  Please make checks payable to “Lee Blackwell, Ph.D.”  In order to use MasterCard or Visa to pay your bill, you will need to fill out a separate form.  

Insurance:  Insurance will often cover part of the cost of psychotherapy.  If you filled out the insurance page, I will provide you with a completed insurance form at the end of each month, for you to sign and send to your insurer for processing.  I do not belong to any insurance panels.  

Collections:  As stated above, payment for services rendered is due and payable in full at the time the service is provided.  If any balance remains 30 days following the service date, I (we) agree to pay an additional charge of one and one-half per cent (1½%) per month on the unpaid balance, except where a written agreement exists to extend the payment period.  In the event the services of an attorney are required to pursue and/or collect any past due sums, I (we) agree to pay reasonable attorney's fees and collection costs. 


____________________________________________________________             Patient signature                                                            Date 

____________________________________________________________             Spouse/partner signature                                                 Date
                                 

                                                                                 Form date 9/2007