Hoffman Psychiatric Services

Informed Consent for Therapy and Practice Policy Agreement

For the purposes of this document, “the patient” refers to the person(s) receiving services at
Hoffman Psychiatric Services and “Dr. Hoffman” refers to Dr. Sigalit Hoffman providing said services.

General Information

The therapeutic relationship is unique in that it is a highly personal but also contractual agreement. Given this, it is important for both Dr. Hoffman and patient to reach a clear understanding about how the relationship will work and ongoing expectations. This consent will provide a clear framework for the work together. Feel free to discuss any of this with Dr. Hoffman.

Benefits/Outcomes

The therapeutic process seeks to meet goals established by all persons involved, usually revolving around specific challenges. Participating in therapy may include benefits such as the resolution of presenting problems as well as improved intrapersonal and interpersonal relationships. The therapeutic process may reduce distress, enhance stress management, and increase one’s ability to cope with problems related to work, family, personal, relational, etc. Participating in therapy can lead to greater understanding of personal and relational goals and values. This can increase relational harmony and lead to greater happiness. Progress will be assessed on a regular basis and feedback from patients will be elicited to ensure the most effective therapeutic services are provided. There can be no guarantees made regarding the ultimate outcome of therapy.

Expectations

In order for patients to reach their therapeutic goals, it is essential they complete tasks assigned between appointments. Therapy is not a quick fix. It takes time and effort, and therefore, may move slower than expected. During the therapy process, we identify goals, review progress, and modify the treatment plan as needed. Risks. In working to achieve therapeutic benefits, patients must take action to achieve desired results. Although change is inevitable, it can be uncomfortable at times. Resolving unpleasant events and making changes in relationship patterns may raise unexpected emotional reactions. Seeking to resolve problems can similarly lead to discomfort as well as relational changes that may not be originally intended. The patient and provider will work collaboratively toward a desirable outcome; however, it is possible that the goals of therapy may not be reached.

Confidentiality

The appointment content and all relevant materials to the patient’s treatment

will be held confidential unless the patient gives written authorization. The patient is able to

authorize the release of portions or all content to a specifically named person(s). There are

limitations to privileged patient confidentiality, which are itemized below:

1. If the patient threatens or attempts to complete suicide or engage in any behavior where there is substantial risk of serious bodily harm to the patient.

2. If the patient threatens serious bodily harm or death to someone else.
3. Reasonable suspicion that a minor or elderly person is the victim of (but not limited to) neglect or physical, emotional, or sexual abuse.

4. If a court of law and judge issues a legitimate subpoena for information stated on subpoena. Occasionally Dr. Hoffman may need to consult with other professionals in their areas of expertise in order to provide the best treatment for the patient. Information about the patient may be shared in this context without using the patient’s name or identifying information.

Provider/Patient Expectations

Dr. Hoffman/patient relationship is strictly professional. In order to preserve this relationship, it is imperative that there is no relationship outside of the counseling relationship (i.e., social, business, or friendship). If the patient and provider run into each other in a public setting, Dr. Hoffman will not acknowledge the patient unless the patient acknowledges her first. This is to ensure that the patient’s privacy will not be jeopardized. Dr. Hoffman will not to engage in any lengthy discussions including written correspondences in public or outside of the therapy office.

Records

Communications in the context of a provider/patient relationship are generally confidential and records will be maintained in accordance with the strictest level of confidentiality applicable under federal or state law. This means that Dr. Hoffman generally cannot be required to disclose information about the patient or the patient’s care without the patient’s consent. It may be necessary to share information or records with other providers as part of the patient’s treatment or if the patient transfers their care. The patient’s insurance company does not have access to a patient’s full medical record. However, the patient’s insurance company can request information about your records for the purpose of coverage eligibility and payment authorization at any given time. If you deny insurance access to the records requested, the insurance agency can decline authorization of payments and the patient will then be responsible for payment of all services rendered by Hoffman Psychiatric Services. Records of the patient’s sessions, communications, and other documentation regarding the patient’s relationship with the treating provider will be maintained during treatment and after for the time period required by law. Should the patient request a copy of their medical records, the cost is $1.50 per page. Payment for the medical records will be due prior or upon receipt and can be picked up at the specified office location. Please allow at least two weeks to prepare medical records.

Cancellation Policy

We see the therapeutic relationship as the most important aspect of treatment. If a patient has multiple late cancellations or no shows, Dr. Hoffman will discuss the impact, the barriers, and the purpose of treatment. In fairness to both our clinical providers and other patients, Dr. Hoffman kindly asks the patient to cancel and/or reschedule the appointment no less than 2 business days in advance. For example, if the patient has an appointment Tuesday at 4:00 PM, appropriate notice would be to cancel the appointment by Friday at 4:00 PM. If the patient has an appointment Monday at 9:00 AM, appropriate notice would be to cancel the appointment by Thursday at 9:00 AM. Should the appointment be canceled without sufficient notice or the patient does not show for the appointment, the patient will be required to pay the cost of the entire appointment, which includes the copay and the cost that insurance would have reimbursed for the session had the patient been present.

Late Appointments / No Shows

If the patient is late for the appointment or does not show, please be aware that the patient will lose that amount of time. The appointment will still need to end at the scheduled time, even if the patient is late to the appointment, out of respect for the time of other scheduled patients.

Payment

By signing this form and placing a credit card on file the patient is agreeing to be charged through DrChrono payments, which processes credit card payments. The patient has the option of paying via check, cash, or through web applications like Venmo or Zelle. Please see Hoffman Psychiatric Services Financial Policy for additional information regarding patient financial responsibility.

Electronic Communication

Services by electronic means, including, but not limited to, telephone communication, the Internet, fax machines, and email are generally considered telemedicine by state law. Dr. Hoffman cannot ensure the confidentiality of communication through electronic media, including text messages and email. Dr. Hoffman can ensure patient confidentiality only by correspondence through the Onpatient portal, to which every patient can create an account. If the patient prefers to communicate via text message or email for issues regarding scheduling or cancellations, Dr. Hoffman will do so. While Dr. Hoffman may try to return messages in a timely manner, she cannot guarantee immediate response and requests that the patient does not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

Telephone Accessibility and Emergencies

If the patient needs to contact Dr. Hoffman between appointments, please leave a voicemail or send an email to Dr. Hoffman through the patient portal. She may not be immediately available; however, Dr. Hoffman will attempt to return the patient’s call within 24 hours. Dr.Hoffman will text, call, or email in between appointments only for scheduling, administrative issues, or medication refill requests. If the patient prefers to communicate via text message or email for issues regarding scheduling or cancellations, the provider will do so. Please note that we cannot ensure the confidentiality of any form of communication through electronic media, including text messages and email. While the provider may try to return messages in a timely manner, Dr. Hoffman cannot guarantee immediate response and requests that the patient does not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

The patient can access emergency assistance by calling the National Suicide Prevention Lifeline at 1-800-273-8255. If an immediate emergency situation arises, including if either the patient or someone else is in danger of being harmed, dial 911 or go to the local emergency room (at the patient’s cost).

Social Media and Telecommunication

Due to the importance of the patient’s confidentiality and minimizing dual relationships, Dr. Hoffman does not accept friend or contact requests from current or former patients on any social networking site (Facebook, Instagram, LinkedIn, etc.). Hoffman Psychiatric Services believes that adding patients as friends or contacts on these sites can compromise the patient’s confidentiality and respective privacy. It may also blur the boundaries of the therapeutic relationship. If the patient has questions about this, please bring them up with Dr. Hoffman at the next session to discuss further. If the patient chooses to comment on our professional social media pages or posts, the patient does so at the patient’s own risk and may breach confidentiality. Hoffman Psychiatric Services and Dr. Hoffman cannot be held liable if someone identifies the patient. Posts and information on social media are meant to be educational and should not replace therapy.

Minors

All parent(s) or guardian(s) with legal custody must consent to treatment before services can be provided to a minor or an adult with a guardian. If one parent or guardian has sole legal custody, a copy of the custody agreement must be provided in advance of the intake appointment. If there is joint legal custody, both guardians must consent to treatment. If the patient is a minor, the parents may be legally entitled to some information about the therapy. Dr. Hoffman will discuss with the patient and patient’s guardian what information is appropriate for them to receive and which issues are more appropriately kept confidential. There is a risk of disagreement between parent(s) and Dr. Hoffman regarding treatment. Dr. Hoffman will work to resolve these differences in the interest of the child or adolescent’s therapeutic progress. However, parents and guardians ultimately decide whether services will continue.

Couples/Family Therapy

If the patient is participating in couples/family outpatient therapy, the patient understands that couples/family therapy may include experiencing negative emotions such as anger, frustration, anxiety, sadness, fear, or guilt because coming to therapy often requires discussion of unpleasant or traumatic aspects of the patient’s life or relationships. The patient understands that it is possible that the relationship may seem to get worse before it gets better as each person experiences personal change. Additional referrals to better address the presenting challenges may be warranted and could include referral to individual therapy. Records for couples/families seeking counseling together will be maintained in a single record under the name of the financially responsible member. In the event that the financially responsible member is also, separately, a patient receiving treatment as an individual, the record will be segregated, and the other member(s) will only be able to access the records from joint sessions. If one party requests a copy of couples/family therapy records in which they participated, an authorization from each consenting participant (or their representatives and/or guardians) must be obtained before the records can be released.

Termination

Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. Dr. Hoffman may terminate treatment after appropriate discussion with the patient and initiate the termination process if she feels that she cannot meet the patient’s needs, feels that she is a poor “fit” for the patient, if she determines that the therapy is not being effectively used, or if the patient is in default on payment. She will not terminate the therapeutic relationship without first discussing and exploring the reasons for and purpose of terminating. If therapy is terminated for any reason or the patient requests another provider, they are encouraged to contact their health insurance provider for a list of in network providers.

Trial, Court Ordered Appearances, Litigation

Rarely, but on occasion, a court will order a provider to testify, be deposed, or appear in court for a matter relating to the patient’s treatment or case. In order to protect the patient’s confidentiality, Dr. Hoffman strongly suggests not being involved in the court. If the Hoffman Psychiatric Services provider gets called into court by the patient or patient’s attorney, the patient will be charged a fee of $400.00 per hour to include travel time, court time, preparing documents, etc.

COVID-19 and In-Person Services

The patient understands that by coming to the office, the patient is assuming the risk of exposure to COVID-19 (or other public health risk). This risk may increase if the patient travels by public transportation, cab, or ridesharing service. Hoffman Psychiatric Services has taken steps to reduce the risk of spreading the virus within the office; however, she cannot guarantee exposures unknown to Dr. Hoffman or Hoffman Psychiatric Services

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