| Christian Wolff, MA/ Licensed Psychologist Associate/ Consultant 820 NW 21st Ave., Suite B/ Portland, Oregon 97209 / 503.284.4501 / www.ChristianWolff.com TREATMENT CONTRACT / INFORMED CONSENT TO TREATMENT |
I. Rights
You may discontinue treatment at any time. There is nothing in this contract which requires you to start
or to continue in therapy.
Confidentiality. You may review my "Notice of Privacy Practices" for additional information about
the uses and disclosures of information. The information you share with me in treatment is
confidential. This means I am legally and ethically bound to maintain your privacy and confidentiality.
The following are legal exceptions to your legal rights to confidentiality. If, at any time, I believe I will
have to put one of these into effect, I will inform you first if at all possible without jeopardizing the
purpose of the disclosure.
Risks and benefits. You have the right to know the potential risks and benefits of the treatment you
are receiving. Treatment has both benefits and risks. It requires an investment of your time and energy
in order to make the process of treatment most successful. We will begin with a discussion or your
needs and concerns and what it is you would like to accomplish by coming for treatment. Next, we will
discuss a treatment plan in accordance with your goals and aims. Frequently, individuals go through
periods in treatment which result in emotional discomfort, changes in their relationships, or temporary
worsening of their symptoms. This should subside as the work progresses. Remember, you always
retain the right to request changes in treatment or refuse/decline treatment at anytime.
Treatment works best if you are knowledgeable about your problems and diagnosis. You have
the right to ask me questions about anything that happens in treatment. I am always willing to discuss
how and why I have made my decisions as well as my diagnosis and understanding of your problems.
Treatment works best if we can work as a team. We will work together to establish the goals and
duration of therapy, and you will have the right to discuss and change these at any time. Most
insurance plans will provide payment for services which are determined to be “medically necessary,”
and I will inform you of the medical necessity of your treatment. You have a right to participate in the
discussion regarding the ending of our work together.
Emergencies. I am available by phone for emergencies by calling my regular number which is 503-
284-4501. I will return the phone call as soon as possible. However, at times I cannot be reached for
an emergency, you may call the Mental Health Crisis Line at 503-291-9111. If the emergency is life
threatening, call 911.
Right to a referral. If I am not able to help you with my services, you have the right to a referral to
another treatment provider who may be better able to meet your needs.
II. Responsibilities
Attendance:
You are responsible for coming to your sessions at your scheduled time. If you are unable to keep an
appointment, please notify me immediately. If an appointment is missed with less than a twenty-four
hour notice, you will be billed for the session. Exceptions to this rule will be extremely rare. If you are
billed for a missed session, it is unlikely that your insurance carrier will pay for this charge and you may
have to pay this on your own.
You are responsible for telling me when you wish to conclude treatment.
Payment Method:
By signing this treatment contract, the client and/or other responsible parties agree to allow
me to provide to their insurance carrier (if insurance is being used), any information
necessary for the collection of fees from the insurance carrier.
By signing this treatment contract, the client and/or other responsible party agree that they
have read it carefully, have understood its content, have been offered a copy, and agree to
its terms.
The client also agrees that he or she has read and understands my “Notice of Privacy
Practices” and agrees to participate in treatment under the terms set forth.
_____________________________________________________________________________
Client signature and date
_____________________________________________________________________________
Other responsible party signature, relationship to client, and date
_____________________________________________________________________________
Witness signature and date
You may discontinue treatment at any time. There is nothing in this contract which requires you to start
or to continue in therapy.
Confidentiality. You may review my "Notice of Privacy Practices" for additional information about
the uses and disclosures of information. The information you share with me in treatment is
confidential. This means I am legally and ethically bound to maintain your privacy and confidentiality.
The following are legal exceptions to your legal rights to confidentiality. If, at any time, I believe I will
have to put one of these into effect, I will inform you first if at all possible without jeopardizing the
purpose of the disclosure.
- If I have good reason to believe that you are planning to imminently harm another person, I may
be required by law to a) inform the intended victim, and b) contact the police so that they may
protect the intended victim.
- If I believe you are in imminent danger of harming yourself, I may legally break confidentiality
and contact the police. I would explore all other options with you before I took this step.
- If I have good reason to believe that you have, even in the past, abused a child or vulnerable
adult (such as an elderly person or a mentally impaired person), I may be required by law to
report this to Child and/or Adult Protective Services. The same is true I have reason to believe
that a child in treatment is being abused or if I have good reason to believe that any vulnerable
person in your charge is being neglected to the point of causing them harm.
- If we have some individual sessions as part of family or couples therapy, what is said in those
individual sessions can and probably will be discussed in the following family or couples
sessions. Do not tell me anything you wish kept secret from other family members who are in
treatment with me.
- I may have to speak about you or release your records if ordered to do so by a judge. This is
very rare, and if subpoenaed, I will remind the attorney or judge of your right to confidentiality.
In most cases, they withdraw the subpoena. Only once in my career have I ever been order to
speak.
- I may have to release certain clinical information about you to insurance carriers as required for
payment or review of your claim. It is my personal policy to provide as little information as
possible to insurance carriers. You should consult your carrier or review your policy in order to
make informed decisions about the use of your insurance.
Risks and benefits. You have the right to know the potential risks and benefits of the treatment you
are receiving. Treatment has both benefits and risks. It requires an investment of your time and energy
in order to make the process of treatment most successful. We will begin with a discussion or your
needs and concerns and what it is you would like to accomplish by coming for treatment. Next, we will
discuss a treatment plan in accordance with your goals and aims. Frequently, individuals go through
periods in treatment which result in emotional discomfort, changes in their relationships, or temporary
worsening of their symptoms. This should subside as the work progresses. Remember, you always
retain the right to request changes in treatment or refuse/decline treatment at anytime.
Treatment works best if you are knowledgeable about your problems and diagnosis. You have
the right to ask me questions about anything that happens in treatment. I am always willing to discuss
how and why I have made my decisions as well as my diagnosis and understanding of your problems.
Treatment works best if we can work as a team. We will work together to establish the goals and
duration of therapy, and you will have the right to discuss and change these at any time. Most
insurance plans will provide payment for services which are determined to be “medically necessary,”
and I will inform you of the medical necessity of your treatment. You have a right to participate in the
discussion regarding the ending of our work together.
Emergencies. I am available by phone for emergencies by calling my regular number which is 503-
284-4501. I will return the phone call as soon as possible. However, at times I cannot be reached for
an emergency, you may call the Mental Health Crisis Line at 503-291-9111. If the emergency is life
threatening, call 911.
Right to a referral. If I am not able to help you with my services, you have the right to a referral to
another treatment provider who may be better able to meet your needs.
II. Responsibilities
Attendance:
You are responsible for coming to your sessions at your scheduled time. If you are unable to keep an
appointment, please notify me immediately. If an appointment is missed with less than a twenty-four
hour notice, you will be billed for the session. Exceptions to this rule will be extremely rare. If you are
billed for a missed session, it is unlikely that your insurance carrier will pay for this charge and you may
have to pay this on your own.
You are responsible for telling me when you wish to conclude treatment.
Payment Method:
- The client, or his or her guardian, is considered responsible for payment of professional fees. If
we agree to bill a third party and that third party fails to make payments, I will notify you and
arrange a payment schedule.
- Payment of all required co-payments, deductible, and non-allowable charges will be made at
the time of service. Presently, I am unable to accept credit cards or debit cards. Payment will
need to be in the form of cash or check.
- Specific fees are outlined on the Fee Agreement Form which you will need to sign.
- Defaulted accounts may be sent to collection, and you may be responsible for payment of the
cost of collection.
- Insurance and third party payments. If you would like me to bill your insurance carrier
directly, I will. This depends, however, on the reputation of, and my experience with, the
particular insurance carrier. With some insurance carriers, I will only provide you with the
information you need to file the claim yourself. In such a case, you will need to be prepared to
pay my full fee at the time of service and to expect your reimbursement to come from your
insurance carrier at a later date. Generally Oregon law requires that they pay within 30 days.
In any case, you are responsible for payment of all co-payment, deductible, and non-allowable
charges for medically necessary treatment. Some insurance companies require pre-
authorization of services.
By signing this treatment contract, the client and/or other responsible parties agree to allow
me to provide to their insurance carrier (if insurance is being used), any information
necessary for the collection of fees from the insurance carrier.
By signing this treatment contract, the client and/or other responsible party agree that they
have read it carefully, have understood its content, have been offered a copy, and agree to
its terms.
The client also agrees that he or she has read and understands my “Notice of Privacy
Practices” and agrees to participate in treatment under the terms set forth.
_____________________________________________________________________________
Client signature and date
_____________________________________________________________________________
Other responsible party signature, relationship to client, and date
_____________________________________________________________________________
Witness signature and date
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