Informed Consent for Therapy Agreement

Please read through the following informed consent agreement. What follows is a basic understanding
between client and therapist. In general, what are listed below are the responsibilities and obligations of your
therapist, and also some expectations of you as the client. This document also contains important information
about our professional services and business policies. Do not sign the informed consent unless you completely
understand and agree to all aspects. If you have any questions, please bring this form back to your next session,
so you and your therapist can go through this document in as much detail as is needed. When you sign this
document, it will represent an agreement between us.
Psychotherapy
• Voluntary Participation: All clients voluntarily agree to treatment, and accordingly may terminate any time
without penalty. Counseling involves a large commitment of time, money, and energy, so you should be
thoughtful about the therapist you select. In the first couple of sessions, you should be deciding whether your
therapist is right for you. If you feel it is not a good match, then your therapist will be happy to assist you in
finding a new therapist.
• Client Involvement: All clients are expected to show up to appointments on time, prepared to focus on and
discuss therapy goals and issues, and will not attend while under the influence of mood altering chemicals. All
clients are expected to be open and honest so your therapist can assist you with your goals. Counseling is not like
a medical doctor visit. Instead, it calls for a very active effort on your part. In order for therapy to be most
successful, you are encouraged to work on things we talk about both during our sessions and at home.
Inconsistent attendance can negatively affect your therapy progress.
• Therapist Involvement: Your therapist will be prepared at the designated time, (barring emergencies), and will be
attentive and supportive in meeting the therapy goals and do everything possible to assist you in achieving a
greater sense of self-awareness and work toward helping you resolve problem areas.
• Guarantees: Although the majority of people do get better in therapy, some do get worse. Accordingly, your
therapist makes no guarantee of results. It is not possible to guarantee results such as: becoming happier, saving
marriages, stopping drug abuse, becoming less depressed, and so forth.
• Risks of Therapy: Just as medications sometimes causes unexpected side effects, counseling can stimulate painful
memories, unanticipated changes in your life, and uncomfortable feelings like sadness, guilt, anger, frustration,
loneliness, and helplessness. In some cases client’s symptoms become worse during the course of therapy,
occasionally necessitating hospitalization. Another risk of therapy is that throughout the process of therapeutic
change it is not uncommon for clients to reach a point of change where they may feel they are different and no
longer able to be the same person they were upon entering therapy. At times these feelings can be unsettling.
• Benefits of Therapy: The benefits of therapy can include: a higher level of functional coping, solutions to specific
problems, new insights into self, more effective means of communicating in relationships, symptomatic relief, and
improved self-esteem.
• Alternatives to Traditional Therapy: can include: stress management, twelve step programs, peer self-help
groups, bibliotherapy, and support groups.
• Credentials and Qualifications: Counselors at Innovative Psychological Consultants hold a variety of degrees in
the field of psychology such as: Masters or Doctoral Degrees in Psychology, Licensed Marriage and Family
Therapist, Psychiatry, or Licensed Independent Clinical Social Worker. In each case your counselor or physician
is licensed by the state of Minnesota to provide psychotherapy or the practice of medicine, based on their training
and education.
• Counseling Approach & Theory: Your therapist generally uses a therapy approach that includes a Cognitive-
Behavioral and Humanistic orientation to counseling. Your counselor focuses largely upon client responsibility in
therapy, building a relationship with clients, creating a nurturing environment conducive to change, exploration of
 past events and how they continue to affect you today, analysis of underlying belief systems and their relation to
inadequate functioning or hindrance to change, and implementation of specific emotional, cognitive, and
behavioral techniques designed to aid in change toward specified goals.
• Colleague Consultation: In keeping with standards of practice, your therapist may consult with other mental
health professionals regarding care and management of cases. The purpose of this consultation is to ensure quality
of care. Your therapist will maintain complete confidentiality and protect your identity by not using real names or
any identifying information.
• Meetings and Length of Therapy: Once we have agreed to work together, we will usually schedule one
appointment every 1-2 weeks at a time we can agree upon. Session length most insurance plans cover is 45
minutes. Occasionally sessions may run as long as 55-60 minutes. Because our meetings are your time, you are
expected to come to each session with a sense of what it is you would like to discuss or work on during that
particular session. Length of therapy is quite variable based on client motivation, number and severity of issues to
resolve, and work efforts outside of therapy sessions. On average, many people feel they have obtained what they
were looking for in 10-25 sessions. For some it is fewer and for others it may go longer.
• Young Children in the Waiting Area: We are not able to assume responsibility for the care of young children
during therapy sessions. Having young children is generally disruptive to the counseling process, and we ask that
you arrange for their care so you may come alone. If you have difficulty arranging child care elsewhere, please
talk with your therapist. Children old enough to be responsible for themselves may wait in the reception area.
• Confidentiality and Privilege: The information and content shared in therapy will remain confidential, except as
noted in the next section: Exceptions to Confidentiality and Privilege. Your information will not be shared with
anyone without your written consent. Your information is also privileged, which means that your therapist is free
from the duty to speak in court about your counseling unless you waive that right, or a judge orders it.
• Exceptions to Confidentiality and Privilege: As a mandated reporter in the state of Minnesota your therapist is
legally obligated to violate confidentiality under the following circumstances:
 When the therapist has reason to suspect that the client has been, or is currently, involved in the
abuse or neglect of child
 When the therapist has reason to suspect that the client has been, or is currently, involved, in the
abuse or neglect of vulnerable adults
 If a client is pregnant and taking street drugs
 If the client reports sexual misconduct by another counselor
 If a client is a serious danger to themselves, i.e., if suicidal
 If a client is a serious danger to someone else, i.e., if homicidal
 If the courts order copies of records
o Another time when confidentiality has limitations is for minor clients. Parents and guardians have legal
right to access a minor client’s records
o Minor clients do have the rights to complete confidentiality in obtaining counseling for pregnancies and
associated conditions, sexually transmitted diseases, and information about alcohol or drug abuse
• Custody Issues & Therapy for Minors: It is the policy of IPC that for minor children, where legal custody is split
(joint) between parents or guardians who are no longer married or cohabiting, we need authorization and signature
from both parents on our Informed Consent and Confidentiality Notice prior to the child being seen. These forms
can be downloaded from our website and completed prior to arrival.
• Ethical Guidelines: Your counselor follows the American Psychological Association (APA) ethical guidelines, as
well as those rules dictated in the MN Board of Psychology Practice Act. Copies of these materials can be
obtained from: American Psychological Association 750 First Street NE Washington, DC 20002 1-800-374-2721
// MN Board of Psychology 2829 University Ave. SE #320 St. Paul, MN 55414 612-617-2230
• Medical Records: The laws and standards of our profession require that we keep treatment records. You are
entitled to receive a copy of the records unless we believe that seeing them would be emotionally damaging, in
which case we will send them to a mental health professional of your choosing. Because these are professional
records, they can be misinterpreted and/or upsetting to untrained readers. We recommend you review them in
your therapist’s presence so we can discuss the contents. All client records include: a data sheet filled out prior to
therapy, a chronological listing of appointments and fees, a copy of signed releases, copies of any correspondence
regarding your case, a copy of the signed informed consent packet materials, and a copy of all therapist notes. All
records will be maintained by your therapist in a secured area for a period of seven years from the time of service
 termination. As a client you have a right to access your records. You also have a right to contest material in your
records and it will be duly noted in your record. You do not have a right to alter your records or dictate
information be removed. You have the right to access and view your record, but you do not own the records, they
are property of Innovative Psychological Consultants, LLC.
• Counseling and Records for Minors: If you are under 18 years of age, please be aware that the law provides your
parents the right to review your treatment records as well as obtain information from us about your diagnosis,
progress, and treatment. It is our policy to request an agreement from parents that they agree to avoid unnecessary
review of records and involvement in your treatment with us. If they agree, we will only provide them general
information about our work together, unless we feel there is a high risk that you will seriously harm yourself or
someone else. In this case, we will notify them of our concern.
• Supporting Vendors: In the course of operating our mental health clinic we contract with various external
vendors such as an accountant, information technology (IT), claims clearinghouse, and an electronic health record
(EHR) vendor. In all these cases we have a HIPAA business associate contract in place with our vendors. This
means they understand the federal HIPAA guidelines for confidentiality and agree to abide by those regulations
set forth and maintain the same level of confidentiality that healthcare professionals are bound to in the event they
should encounter patient information. Careful steps are taken with our accountant and IT vendor to ensure they
rarely encounter any client information. Our claims clearinghouse and Electronic Health Record (EHR) is used to
submit medical claims electronically and maintain patient records. In both cases, bank level security and
encryption is used to protect client information. Their systems are also electronically automated and vendor
support rep’s are only accessed if a data input error occurred. Support staff of the claims clearinghouse and EHR
vendor have restricted access and are not able to access patient narrative notes. Our EHR vendor, like most EHR
vendors, does have authority to use de-identified patient information. They do this in compliance with HIPAA
guidelines to ensure any data extracted for research purposes can in no way be identified to a client. If you have
any concerns or further questions, please talk to our HIPAA officer, Chris Anderson, Psy.D., LP at 763-416-4167.
• Psychiatry: If you are receiving psychiatric medication management at IPC, the following information pertains to
you. Your psychiatrist will review with you the risks and benefits of psychotropic medications and you can speak
with your pharmacist about risks and side effects as well. Psychiatrists are not available after hours or on
weekends. In the event of an emergency, you should go to the emergency room at North Memorial, Mercy,
Abbott, or Fairview Riverside. An after hours nurse triage line is available to assist with medication reactions. It is
the client’s responsibility to monitor when their prescription is running out. When you need a refill on medication,
please contact your pharmacy a week prior to your medication running out and they will send us a refill request
form. Your refill will only be provided if you are returning for follow up medication management visits on the
time intervals your psychiatrist has specified. Your psychiatrist may not refill your prescription if you have not
returned for a follow up visit. It is your responsibility to schedule these in a timely manner. It is not uncommon
for psychiatrists to be booked out 1-2 months. Psychiatrists are monitored by the MN Board of Medical Practice
and complaints can be directed to 612-617-2130.
• Disputes and Complaints: Any disputes or complaints that can not be resolved between the client, therapist, and
Innovative Psychological Consultants can be directed to the MN Board of Psychology 2829 University Ave. SE
#320 St. Paul, MN 55414 612-617-2230 or the respective Board coinciding with your clinician’s licensure: Board
of Social Work, Board of Board of Marriage and Family Therapy, MN Board of Medical Practice.
• Professional Fees: All clinicians will perform an initial diagnostic session which is more expensive. Follow up
therapy sessions or medication management visits are less expensive. Fees vary for other services provided such
as testing or psychiatry. A fee schedule for services can be provided at your request. If you are utilizing health
insurance benefits, your health plan may have a contracted rate with your therapist or doctor that differs from the
usual and customary fees listed in our fee schedule.
• Health Insurance: You should be aware that most insurance companies require you to authorize us to provide
them with a clinical diagnosis for benefits to pay for services. Sometimes we are required to provide additional
clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This
information will become part of the insurance company files and will probably be stored in a computer. Although
all insurance companies claim to keep such information confidential, we have no control over what they do with it
once it is in their hands. In some cases, they can share the information with national medical information
databanks. It is important to remember that you always have the right to pay for services yourself to avoid the
potential problems described above. Please keep us informed of changes in your financial status and insurance or
 medical assistance eligibility. You may be responsible for charges incurred if your coverage has changed or
lapsed and you do not inform us in advance.
• Phone Availability: We are often not immediately available by phone. Because of other obligations, we are
currently only returning phone calls in the evening. We will also not answer the phone when we are with a client.
When we are unavailable, you are able to leave us a voice message and we will make every effort to return your
call the same day you have called, with the exception of weekends and holidays. If you are difficult to reach, we
encourage you to leave us times when you will be available. We also encourage the use of an after hours crisis
counseling agency where a counselor is able to assist you with any problems. That agency is Crisis Connection
and their number is:
612-379-6363.
• Emergency & Interruption of Therapy: In the event of any mental health or substance abuse emergency, we
encourage you to contact the after hours crisis service (crisis Connection: 612-379-6363) or call 911. When we
are on vacation or plan to be unavailable for a brief period of time, we will provide you with the name and
number of another therapist you can contact with questions or come in to see as needed. In the event of a longer
interruption of therapy we will make appropriate referrals as needed.
• Termination: Either the client or the therapist may end therapy at any time. Your voluntary involvement allows
you to discontinue at any time. If your therapist feels you are no longer benefiting from therapy or your therapist
feels there is a conflict in values they may discuss termination. If you desire additional counseling your therapist
will provide you with a referral competent to address your issues.
• Client Satisfaction Survey: We welcome feedback about the services you receive. We are dedicated to improving
the delivery of services to clients. Attached is a client satisfaction survey that you may fill out at anytime during
or after the completion of counseling. Return it to: Innovative Psychological Consultants 7236 Forestview Lane
N., Maple Grove, MN 55369 Alternatively, you may fill out the survey online at: WWW.IPC-MN.COM
Financial Agreement and Terms
• Billing and Payments: You will be expected to pay for each session at the beginning of our meetings, unless we
have agreed on other arrangements. In the case of health insurance, you will be expected to provide any
deductible or co-payments prior to our session meetings. Keep in mind that it is you (not your insurance
company) that is responsible for full payment of fees. Therefore, it is very important that you find out exactly
what mental health services your insurance policy covers.
• Copays & Co-insurance: My signature below indicates that I understand and agree to pay for any copays at the
beginning of my session on the date it is provided. If I am utilizing health plan benefits, I understand that I am
responsible for any amount my insurance does not cover. Deviation from this agreement must be arranged with
Innovative Psychological Consultants, LLC directly.
• Cancellation, No Show or Late Arrival: In general, all clients must provide the therapist a minimum of 24 hours
notice in the event of a cancellation, which does not include weekends. This means if you have an appointment at
1:00pm on Monday, you will need to have cancelled by 1:00pm on the Friday prior. Clients will be charged for
appointments that are not canceled at least 24 hours in advance and for all no shows. Insurance companies do not
pay for missed appointments, therefore, you will be responsible for the full amount charged. Clients arriving late
will not be provided an extension of time beyond what they were scheduled so as not to disrupt other client
appointments. No reduction in fees will result from shortened sessions due to a client’s late arrival. Additionally,
if a client misses two appointments, your therapist has the option to terminate services and refer you to another
clinic for services. These terms may not be applicable to you if are receiving coverage through the MN Health
Care Programs (MHCP).
• Account Balance Maximum: Whenever a client’s account reaches an outstanding balance of $500 and no
payments have been made or received toward the account, additional counseling services will be suspended.
Services will remain suspended until client begins making payment toward their account. If no payments are
made, services will remain suspended and/or clients may be referred to alternate providers for services.
• Collections: If your account has not been paid for more than 60 days and arrangements for payment have not been
agreed upon, we have the option of using legal means to secure payment. This may involve hiring a collection
agency or going through small claims court. In most collection situations, the only information released regarding
a client’s treatment is his/her name, the nature of the services provided, and the amount due. Accounts turned over
to collections may be subject to future requirements such as providing a retainer for future services.
 Innovative Psychological Consultants:
Client Satisfaction Survey
At Innovative Psychological Consultants we are committed to growth and the improvement of service
delivery. Your feedback is welcome and appreciated. Thank you for taking the time to fill out this survey.
The information you provide will help guide us in making changes for future clients who will receive
counseling with us. You are welcome to remain anonymous. You may also Complete the survey online at:
WWW.IPC-MN.COM

In the section below please rate your experience by selecting one of the following numbers: (1 = poor, 2 =
fair, 3 = average, 4 = good, 5 = excellent, NA = Not applicable). Choose the number that best describes
how you felt about each particular item.

____ 1. The counselor returned my initial call within 24 hours

____ 2. I was able to get an appointment that was convenient to my needs

____ 3. I was able to get an appointment in a timely manner

____ 4. I felt the location was convenient and easy to find

____ 5. I felt the office was professional and relaxing

____ 6. I was treated in a professional and courteous manner

____ 7. The therapist heard my concerns and answered my questions

____ 8. I felt that I could trust my therapist

____ 9. I felt my therapist cared about me and really wanted to help

____ 10. I felt that the counseling was helpful and worthwhile

____ 11. I would recommend Innovative Psychological Consultants to others

12. Counselor name: ________________________________________________

13. The thing that most helped me resolve my problems was: _______________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
14. Please provide any other feedback you have about your therapy experience:
__________________________________________________________________
__________________________________________________________________

Name (Optional) _________________________________________________________

Please return to: IPC 72736 Forestview Lane N., Maple Grove, MN 55369
 Innovative Psychological Consultants, LLC: Informed Consent Agreement

As the client, my signature below indicates that I have been provided a copy of the Informed Consent for
Therapy Agreement. My signature below confirms my understanding of all the rules and responsibilities of both
the client and the therapist, in addition to understanding the financial terms and agreements. My signature
constitutes my agreement and compliance to this document. I, as well as my clinician, will abide by the
stipulations listed herein.

_____________________________________ _______________________
Print Client Name Date of Birth

_____________________________________ ________________________
Signature Date

_____________________________________ ________________________
Signature of Parent/Guardian (If applicable) Date