Benna Z. Sherman,
Ph.D.
Licensed
Psychologist
479 Jumpers Hole Rd, Suite 304B
Severna Park, MD 21146
Phone:
410.544.9564 Fax: 410.647.9174
bzsherman@comcast.net
DrBennaSherman.com
Informed Consent to Psychotherapy
Risks and Alternatives
The
primary risk of therapy, albeit small, is that it can lead to unpredicted
personal changes and temporary destabilizations. Career paths can change, relationships can be
terminated, memories can resurface, etc.
There is no sure way to guarantee results or the qualitative nature of
the process. However, patient welfare is
always the guiding principle. You will
always be actively involved in making decisions about therapeutic goals and
methods.
Please
be aware that there are many different therapies and therapists available. If this therapy does not meet your needs, you
are encouraged to consider alternatives.
Emergencies
This practice is NOT an emergency service. I am not predictably accessible outside my
normal business hours, although voicemail is available 24 hours a day, 7 days a
week. I will make every effort to return
phone messages in a timely way. However,
if you have an emergency and I am not
available, please go to the nearest emergency room.
Confidentiality
Please read the provided “Policies and Procedures”
concerning federal HIPAA regulations pertaining to handling of patients’
Protected Health Information.
In
general, the confidentiality of all communications between a patient and a
psychologist is protected by law, as well as by the American Psychological
Association Code of Ethics. In general,
I can only release information about our work with your written
permission. There are a few exceptions,
however, and you should be aware of them from the outset.
In most judicial proceedings you have the right to
prevent me from testifying. However, in
child custody proceedings, adoption proceedings, and proceedings in which your
emotional condition is an important element, a judge may require my testimony
if it is determined that resolution of the issues before the court requires
it. If you are involved in litigation,
or are anticipating litigation, and you choose to include your mental or
emotional state as part of the litigation, I may have to reveal part of all of
your treatment or evaluation records.
If you are called as a witness in criminal proceedings,
opposing counsel may have some limited access to your treatment records. Testimony may also be ordered in a) legal
proceedings relating to psychiatric hospitalization; b) malpractice and
disciplinary proceedings brought against a psychologist; c) court-ordered
psychological evaluations; and d) certain legal cases where the client has
died.
In addition, there are some circumstances in which I am
required to breach confidentiality without a patient’s permission. This occurs if I suspect the neglect or abuse
of a minor, in which case I must file a report with the appropriate state
agency. In addition, if, in my
professional judgment, I believe that a patient is threatening serious harm to
self or another, I am required to take protective action, which may include
notifying the police, warning the intended victim, or seeking the client’s
hospitalization. The intent of these
requirements is that a psychologist has both a legal and ethical responsibility
to protect endangered individuals from harm when professional judgment
indicates that such danger exists.
I may occasionally find it helpful or necessary to
consult about a case with another professional.
In these consultations, I make every effort to avoid revealing the
identity of the client. The consultant
is, of course, also legally bound to maintain confidentiality.
I am required to maintain complete treatment
records. Patients are entitled to
receive a copy of these records, unless I believe that the information would be
emotionally damaging and, in such cases, the records must be made available to
the patient’s designee. Patients will be
charged an appropriate fee for records preparation.
If you submit claims to an insurance company or other
third party, you will need to provide the payor with a clinical diagnosis,
record of treatment dates and services, and, sometimes, a treatment plan or
summary. This obviously compromises confidentiality
as well. You must understand that once
this kind of information leaves my hands I cannot warrant its continued
confidentiality.
If you are under 18 years of age, please be aware that
your parents or guardians have a right to receive general information on the
progress of the treatment and may have the right to access your chart in its
entirety.
Under current Maryland
law, in group, family, and marital therapy, all participants are required to
consent to the release of information before any information can be released.
One marital partner may not waive privilege for another. In cases of marital therapy, therefore, the
record may be released only if both parties waive privilege or if
release of the record is court ordered.
The law governing these issues is complex. If you need more specific advice, formal
legal consultation may be advisable.
Note: email is not
a secure method of communication. Please
be aware that I cannot guarantee the confidentiality of email communication.
Parents/Guardians
If you are consenting to treatment for a minor, by signing the
consent for services the parent/guardian is affirming that there is no other
parent/guardian that has the legal right to override your consent or deny such
services.
I have read the above and understand and consent to it.
I have received and
had an opportunity to ask questions about the Maryland Notice Form, which
details HIPAA Policies and Procedures to Protect the Privacy of Patient’s
Health Information as implemented by Dr. Sherman.
_____________________________ _______________
Signature Date
______________________________ ________________
Signature Date
IF THIS IS CONJOINT THERAPY
(involving more than one person, such as in marriage counseling) ALL NON-MINOR
PARTIES TO THE THERAPY MUST SIGN THIS FORM
(9/09)
