Laurie Pryor, MA, LPCC
INFORMED CONSENT FOR TREATMENT (updated 05.01.2019)
I realize that starting counseling is a major decision and you may have many questions. This document is intended to inform you of my credentials, policies, State and Federal Laws, and your rights. I have a Master’s Degree in Counseling, and am licensed by the State of New Mexico as a Licensed Professional Clinical Mental Health Counselor (LPCC). I use an integrative approach that blends techniques from cognitive behavioral, psychodynamic, transpersonal, EMDR, Brainspotting, mindfulness, and solution-focused modalities. My approach is tailored to meet the individual needs of each of my clients in a safe and supportive environment.
1) Counseling is a collaborative process in order to work on areas of dissatisfaction in your life and assist you with life goals. For counseling to be most effective, it is important that you take an active role in the process.
2) Risks: In counseling, major life decisions are sometimes made, including decisions involving separation with families, development of other types of relationships, changing employment settings, and changing lifestyles. Clients are urged to consider the risks that major psychological transformation may have on current relationships and the possible need for psychiatric consultation during periods of extreme depression or agitation. Not all people experience improvement from psychotherapy, and therapy may be painful at times. Alternate forms of treatment may be beneficial in addition to, or in lieu of traditional therapy. I will be available to discuss your options, assumptions, and any possible negative side effects of our work together.
3) Confidentiality: Your verbal communication and clinical records are strictly confidential except for: a) specific information you have signed a release for me to share; b) information that you are in danger of harming yourself or others; c) information you and/or your child report about physical or sexual abuse, neglect or abandonment, in which case New Mexico State Law mandates that I report this to the New Mexico Children, Youth, and Families Department; d) information necessary for case consultation; e) information necessary to defend myself against a formal complaint or legal action; f) information shared with your health insurance company and my billing agency to process your claims; and g) when required by law.
4) Social Networking: I do not accept friend requests from current or former clients on social networking sites, such as Facebook or LinkedIn. I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.
5) Internet Searches: While my present or potential clients might conduct online searches about my practice and/or me, I do not search my clients with Google or other search engines unless there is a clinical need to do so, as in the case of a crisis or to assure your physical wellbeing. If clients ask me to conduct such searches or review their websites or profiles and I deem that it might be helpful, I will consider it on a case by case basis and only after discussing possible impacts to our professional relationship and your privacy.
6) Electronic Communications: I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. You are also advised that any email sent to me via a computer in a work-place environment is legally accessible by an employer. If you prefer to communicate via text messaging or email for issues regarding scheduling, I will do so. I try to return messages in a timely manner however I cannot guarantee an immediate response and request that you do not use email or text communication to discuss therapeutic content and/or request assistance for emergencies.
7) Records: I am ethically and legally obligated to maintain records of each time we meet, talk on the phone, or correspond via electronic communication such as email or text messaging. These records include a brief synopsis of the conversation along with any observations or plans for the next meeting. A judge can subpoena your records for a variety of reasons, and if this happens, I must comply.
8) Consultation: Information about you may be discussed in confidence, without revealing your identity, with other qualified professionals so that I can provide you with the best possible service.
9) Independent Practice: My professional practice is independent. I am not partners with, nor do I have any legal association with any other services or mental health professionals.
10) Time Parameters: Sessions are scheduled for 50 minute segments, unless otherwise arranged. Being late for an appointment by 15 minutes will be considered a missed appointment and will require you to reschedule.
11) Fees and Payment: Payment is due at the time of service. If you have in-network insurance, I will bill your insurance as a courtesy and accept your copayment. If your insurance company denies payment or does not cover a service provided, you are responsible for the balance due. If I discontinue accepting your insurance you have the option of paying for sessions yourself or I will make the appropriate referrals for you to continue therapy. Fee increases may occur periodically, and you will be notified in advance if such occur. I accept cash and debit/credit cards. Debit/credit card payments will incur a nominal service fee per transaction (currently 2.8%. Subject to change.)
12) Cancellations and Missed Appointments: If you find it necessary to cancel an appointment, please contact me at (505) 695-8223 at least 24 hours in advance. Cancellations with less than 24 hours notice will incur a $60.00 missed-appointment fee. No shows will incur the full session fee. This fee will automatically be charged to your credit card on file. Health insurance does not cover missed appointments or no shows.
13) Professional Fees: In addition to session fees, there are other billable professional services that you may request, such as report writing, phone conversations exceeding 15 minutes, attendance at meetings or consultations, or the time required to perform any other service you may request. Such professional services are billed at the rate of $150.00 per hour.
14) Legal/Custody Disputes: I will not voluntarily participate in any custody dispute or litigation in which a client is involved. I will not make any recommendations as to visitation or custody regarding my clients. As a rule, I will not give testimony or records unless compelled to do so by a court having jurisdiction over my practice. If my records or I am subpoenaed, records compilation, depositions and court appearances are billed at $400.00 per hour with a minimum charge of eight (8) hours per day, plus travel and incidental expenses, payable at the time the records are delivered or seven (7) days prior to the time of deposition/appearance. Payment must be made by certified bank check or USPS money orders payable to Laurie Pryor, MA, LPCC. Cash or personal checks will not be accepted. If you anticipate becoming involved in a legal case, it is recommended that we discuss this before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for my professional time even if another party compels me to participate.
15) Insurance: Some insurance plans limit mental health benefits to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some clients feel that they need more services after insurance benefits end. If this situation arises you can either pay for sessions yourself or I will do my best to refer you to another provider for continued therapy. We will discuss what we can reasonably expect to accomplish with the benefits that are available and your options if coverage ends before you feel ready to end treatment.
Most insurance companies require a clinical mental health diagnosis for services to be covered by your plan. A mental health diagnosis may or may not be appropriate in your case. If no mental health condition exists, it is possible that insurance may not pay for counseling sessions. In addition to a clinical mental health diagnosis, some insurance companies may require additional clinical information such as treatment plans or summaries, or copies of the entire record. This information will become part of the insurance company files and will probably be stored on a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with the information once it is in their hands. In some cases they may share the information with a national medical information databank. By signing this consent, you agree that I can provide requested information to your insurance carrier if you plan to pay with insurance.
Some policies leave a percentage of the fee (coinsurance) or a flat dollar amount (copayment) to be paid by the client. Coinsurance and copayments are due at the beginning of each session, payable by cash or credit/debit card.
You always have the right to pay for services yourself to avoid the problems described above.
16) Emergencies: If an emergency situation arises for which you feel immediate attention is necessary, please contact emergency services (911) immediately or go to the hospital emergency room. The Santa Fe Mobile Crisis Response Team (505-820-6333) is also available 24 hours to support you in a crisis situation. I will follow-up with standard counseling at our next scheduled appointment.
17) Transfer Plan: In the event of my death, disability, retirement, or inability to provide counseling services, Carol Parker, PhD, LPCC (505) 235-1284 will provide those services or assist in referring you to another qualified provider, and will possess and maintain my clinical records for a period of 10 years. After 10 years all records will be destroyed in accordance with Federal HIPAA guidelines.
18) Concurrent Treatment: Clients must disclose any concurrent mental health treatment, including but not limited to couples therapy, family therapy, group therapy, individual therapy, and medication management, and sign an Authorization to Release/Secure Information permitting me to communicate with the providers regarding your treatment. If concurrent mental health treatment is initiated after you have begun regular sessions with me, you must notify me the next time we meet and sign the Authorization to Release/Secure Information.
19) Termination of Treatment: Clients often seek counseling in times of crisis and then stop abruptly when they experience some relief. The real work in counseling is done after the initial stabilization. If you feel concerned about how therapy is going, please talk with me about it. I can always refer you to another therapist if I am not a good fit. Clients have the right to refuse or discontinue services at any time, but are recommended to participate in planned termination. Ideally, termination occurs when treatment goals have been met or sufficient progress has been made and you no longer need clinical services. There are reasons I may terminate treatment before it is completed, these include: your mental health needs exceed my scope of practice or areas of expertise; conflict of interest; failure to progress or comply with treatment recommendations; non-payment of services; repeated cancellations or missed appointments; and lack of contact or communication. If I do not have contact or communication from you for a period of 30 days, I will assume that you no longer intend to remain active in this therapeutic relationship and your case will be closed. You can return to therapy in the future if you decide to continue treatment or I will provide referrals for you to continue treatment with another therapist.
I have read, understood, and consented to the above conditions of service stated. I have also received a copy of the HIPAA Notice of Privacy Practices. My signature indicates I understand my rights as a client and have had the opportunity to ask questions about these policies.