Carolyn Settle, M.S.W., L.C.S.W
The cost of this service is your responsibility. Payment is expected at the time of service. I will provide a superbill for submission to your insurance company.
24 Hour Cancellation Notice: A charge will be made for appointments missed or canceled less than 24 hours in advance without good cause. Insurance does not cover missed appointments.
Telephone Calls: Telephone calls to your therapist which exceed 5 minutes will be charged directly to you. Insurance companies do not pay for phone calls.
ADMINISTRATIVE CHARGES will be applied when you request information to be sent or reviewed. It is your responsibility to verify these charges at the time of your request.
A FEE OF $35.00 WILL BE CHARGED FOR RETURNED CHECKS.
I understand that by signing below I waive my right to confidentiality in the collection of any fees in dispute for services rendered.
I have read and understand the above.
Carolyn Settle, M.S.W., L.C.S.W
Is there any family history of treatment for psychological/psychiatric conditions? Yes No
Have you ever had previous counseling or psychotherapy? Yes No
Have you ever felt suicidal? Yes No
Did a specific event lead to this session? Yes No
Have you ever been victim to physical or sexual abuse/assault? Yes No
This form provides you (patient) with information that is additional to that detailed in the Notice of Privacy Practices. Please sign on the last page in the space provided indicating that you have read and understand the contents of this form.
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (patient’s) written permission, except where disclosure is required by law. Most of the provisions explaining when the law requires disclosure were described to you in the Notice of Privacy Practices that you received with this form including methods for the patient to obtain information about their records.
When disclosure is required by law: Some of the circumstances where disclosure is required by law are: when there is a reasonable suspicion of child, dependent, or elder abuse or neglect, and where a patient presents a danger to self, to others, or is gravely disabled (see also Notice of Privacy Practices form).
When disclosure may be required: Disclosure may be required pursuant to a legal proceeding. 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 your therapist. In couple and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. Your therapist will not release records to any outside party unless they are authorized to do so by all adult family members who were part of the treatment.
Health insurance & Confidentiality of records: Disclosure of confidential information may be required by your health insurance carrier, HMO/PPO/MCO/EAP, or other third party payer in order to process the claims. Only the minimum necessary information will be communicated to the carrier. Unless authorized by you explicitly, the Psychotherapy Notes will not be disclosed to your insurance carrier. Your therapist has no control or knowledge over what insurance companies do with the information they submit or who has access to the information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy, or to future eligibility to obtain health or life insurance. The risk stems from the fact that mental health information, including a diagnosis, is entered into insurance companies’ computers and will also be reported to the Congress-approved National Medical Data Bank. Accessibility to companies’ computers or to the National Medical Data Bank database is always in question, as computers are inherently vulnerable to break-ins and unauthorized access. Medical data has been reported to have been sold, stolen, or accessed by enforcement agencies; therefore, you are in a vulnerable position.
Confidentiality of E-mail, cell phone, and fax communications: It is very important to be aware that e-mail and cell phone communication can be relatively easily accessed by unauthorized people and hence, the privacy and confidentiality of such communication can be compromised. E-mails, in particular, are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e-mails that go through them. Faxes can easily be sent erroneously to the wrong address. Please notify your therapist at the beginning of treatment if you decide to avoid or limit in any way the use of any or all of the above-mentioned communication devices or methods. Please do not use e-mail or faxes for emergencies.
Consultation: Your therapist may consult with other professionals regarding their patients; however, the patient’s name or other identifying information is never mentioned. The patient’s identity remains completely anonymous, and confidentiality is fully maintained. This is done to provide you with the best care possible.
THE PURPOSE AND PROCESS OF THERAPY: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Psychotherapy requires your very active involvement, honesty, and openness in order to change. Your therapist will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. During therapy, remembering or talking about painful memories, unpleasant events, feelings, or thoughts can result in your experiencing considerable discomfort or strong feelings. This may include anger, sadness, worry, fear, shame, anxiety, depression, insomnia, etc. Your therapist may challenge some of your assumptions and/or perceptions and propose different ways of looking at, thinking about, or handling situations that can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing perceptions, beliefs, behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, your therapist is likely to draw on various psychological approaches according, in part, to the problem that is being treated and their assessment of what will best benefit you. Sometimes more than one approach can be helpful in dealing with a certain situation. These approaches may include, but are not limited to: cognitive-behavioral, psychodynamic, EMDR, behavioral, existential, systems/family of origin, development (adult/child/family), biblio-therapy, or psycho-educational.
Discussion of treatment plan: The patient has the right to participate in treatment decisions and in the development and periodic review and revisions of the patient’s treatment plan. Within a reasonable period of time after the initiation of treatment, your therapist will discuss with you their working understanding of the problem, treatment plan, therapeutic objectives, and view of the possible outcomes of treatment. If you have any unanswered questions about the course of your therapy, the possible risks, your therapist’s ability, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits. If you could benefit from any treatment that your therapist does not provide, they have an ethical obligation to assist you in obtaining those treatments.
Termination: You have the right to terminate therapy at any time. Ideally, this happens when the goals of therapy have been met. If at any point during psychotherapy, your therapist believes they are not effective in helping you reach the therapeutic goals, they are obliged to discuss it with you and, if appropriate, to terminate treatment. In such a case, they would give you a number of referrals that may be of help to you. If you request it and authorize it in writing, your therapist will talk to the new psychotherapist of your choice in order to help with the transition. If at any time you want another professionals’ opinion or wish to consult with another therapist, your therapist will assist you in finding someone qualified, and with your written consent, will provide him or her with the essential information needed. You have the right to refuse any recommended treatment or withdraw consent to treatment and to be advised of the consequences of withdrawal or refusal.
Dual relationships: A dual relationship exists when you have some type of relationship with your therapist outside the clinical setting. This may include civic and philanthropic groups, religious communities, sports leagues, etc. Appropriate dual relationships are not unethical. Therapy never involves sexual or any other dual relationship that can be exploitative in nature, or impairs your therapist’s objectivity, clinical judgment, and/or therapeutic effectiveness. Appropriate non-sexual dual relationships can be clinically beneficial and may, in fact, be the reason you chose your therapist. Your therapist will discuss with you the potential benefits and difficulties that may be involved in dual relationships and will discontinue the dual relationship if it interferes with the effectiveness of the therapeutic process.