CLIENT INFORMATION AND CONSENT

Welcome to my practice. This document contains important information about my professional services. Please read it carefully and discuss any questions you have with me.

THERAPIST

I, Priya Loess, have a Master's in Clinical Psychology from the University of Montana and am currently a Doctoral Candidate at the University of Montana. I am an unlicensed professional, currently serving as an extern with Sweetgrass Psychological Services. I work exclusively under the supervision of Sara Boilen, Psy.D. (MT #1196) and am in training to become a psychologist. 

PSYCHOLOGICAL SERVICES

1. Psychotherapy.

Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and client, and the particular problems you bring forward. There are many different methods I may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.

Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have significant benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience. For example, one risk of marital therapy is the possibility of choosing to divorce.

Our first few sessions will involve an evaluation of your needs. By the end of our initial meeting, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select.

If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional.

2. Assessment.

My professional services also include a number of different types of assessments. These include evaluations for learning disabilities and Attention Deficit/Hyperactivity Disorder, cognitive functioning, familial functioning, couples testing, and psychological/emotional functioning.

Evaluations also have both benefits and risks. Risks can include experiencing uncomfortable and difficult feelings, as you may be asked to answer questions that are very difficult or to remember unpleasant episodes or aspects of your life. Like psychotherapy, evaluations require active participation on your part. The benefit of these evaluations is that they often lead to a more complete understanding of the nature of one’s functioning, including strengths and weaknesses, and areas that would benefit from interventions. The primary goals are to help you gain a better understanding of yourself, to provide you with immediate feedback to your questions to help you move toward healthier, happier living, and to help those with whom you are also working understand your needs and according recommendations.

Usually, an assessment begins with an interview (of the client or the client’s parents) which lasts 1 to 1 1/2 hours. At this time, background data is gathered and the issues to be addressed in the evaluation are identified. Additional appointments for the actual testing are set up, usually lasting 2-4 hours. Appointment times are also set up for feedback sessions to the client and/or his/her parents. A written report or letter (depending on the needs of the client) of the evaluation, including results and recommendations, is also provided as part of the evaluation. Fees for assessment approximate my hourly fee and are usually given as a sum figure prior to beginning the process that is agreed upon by both parties.

YOUR RIGHTS

As a client seeking mental health services, you have certain rights. These include your right to seek a second opinion from another therapist or your right to terminate this therapy at any time. You are also entitled to receive information regarding the methods of therapy, techniques used, the duration of therapy, if known, and the fee structure. Please ask if I do not fully provide you with this information or if you have any questions

The practice of psychology in Montana is regulated by the Montana Department of Labor and Industry. The agency within the Department that has responsibility for licensed and unlicensed psychotherapists is the Board of Psychologists. Any questions or concerns regarding your mental health treatment may be directed to:

Montana Board of Psychologists

Business Standards Division

301 South Park

4th floor

PO Box 200513

Helena, MT 59620-0513

THERAPEUTIC RELATIONSHIP

Your relationship with me is a professional and therapeutic relationship. In order to preserve this relationship, it is imperative that I not have any other type of relationship with you. Social and/or business relationships undermine the effectiveness of the therapeutic relationship. Gifts, bartering, and trading services are not appropriate and should not be shared between us. Additionally, sexual intimacy is never appropriate in a therapeutic relationship. Any circumstances of sexual intimacy within a therapeutic relationship should be reported to the grievance board listed above.

MEETINGS

If desired, I can provide a free 30 minute consultation appointment. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If psychotherapy is begun, I will usually schedule one 50-minute session per week at a time we agree on, although some sessions may be longer or more frequent. There is no charge for appointments cancelled 24 hours in advance of the scheduled time.

Appointments cancelled less than 24 hours ahead of time are charged full fee unless in case of an emergency.

PROFESSIONAL FEES

Psychotherapy: Your fee per 50-minute session is $50. This fee should be paid on the day of your session. Psychotherapy is being provided at a reduced fee due to the nature of my clinical training. 

Assessment: Your fee for the complete evaluation will be agreed upon at the completion of our initial session. One half of the payment for an assessment is expected initially, with one half due at the end of the evaluation.

INSURANCE REIMBURSEMENT

I am not an in network provider for any insurance company. Because of the status of my clinical training, our services are not eligible for reimbursement from your insurance company. Should you require a reduced rate for any reason, please discuss this with me in our initial meeting or whenever the need arises. 

In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. 

 

CONTACTING ME

I am often not immediately available by telephone. While I am often in my office, I do not answer the phone when I am with a client. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and feel that you can’t wait for me to return your call, you can call your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary.

It is important that you determine the level of emergency care that you would like to have in a therapist. My practice is not designed around 24-hour care. In the event of an emergency, it may be necessary for you to contact another health care provider. If this does not seem to meet your needs, please let me know and I will provide you with the names of therapists who provide 24-hour care.

In addition to being available to you by phone, I can also be reached via email. I routinely check email during business hours but if you are seeking a more immediate response, please leave try me by phone first. Scheduling can be done over email or phone but please note that unless you receive a response, your appointment request is not confirmed.

PROFESSIONAL RECORDS

The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of your records, or I can prepare a summary for you instead.

Because these are professional records, they may be misinterpreted by untrained readers. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents. Clients will be charged an appropriate fee for any professional time spent in responding to information requests. 

In the spirit of my training, I will be supervised by Sara Boilen, Psy.D. The supervision methods will include verbal accounts, review of written materials, and video taping. Should you wish to refuse video taping, please check the box below.  Please continue below for additional stipulations and signature. 

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CONFIDENTIALITY

In general, law protects the privacy of all communications between a client and a psychologist, and I can only release information about our work to others with your written permission. But there are a few exceptions.

In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it.

There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a client’s treatment. For example, if I believe that a child, elderly person, or disabled person is being abused, I must file a report with the appropriate state agency.

If I believe that a client is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client. If the client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. If such a situation occurs in your treatment, I will make every effort to fully discuss it with you before taking any action.

Additionally, I may occasionally find it helpful to consult other professionals about a case. During a consultation, I always maintain the confidentiality of the client’s identity. Please note that cellular phone and e-mail communications are vulnerable to breeches of confidentiality due to their modes of information transmission.

Given the nature of our community and its size and closeness, there are certain limitations to confidentiality that it is important to be aware of. First, should you elect to pay by check, Sweetgrass Psychological Services cannot ensure the confidentiality of your identity and your status as a client with regards to bank employees and other individuals who may have access to your personal banking information. Further, while all members who practice at 50 West Second Street have agreed to protect the confidentiality of any and all clients therein, we cannot ensure your confidentiality within our waiting room, parking area, or other common areas. 

Please feel free to voice any questions or concerns that you might have, either in response to this form or at any time during our work together. I look forward to working with you. 

Please note: Email is not a secure method of communication. Should you desire to communicate confidentiality through email, please inform me of your intentions and I will provide you with a secure and encrypted method. 

AGREEMENT

Your electron signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.

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