Below is my coaching contract, which you'll be asked to sign at your first session. There will be time at our first session to address any questions you may have.
Judith B. Taylor LCSW
INFORMATION DISCLOSURE STATEMENT
The Therapy/Life Coaching relationship works in part because of clearly defined rights and responsibilities held by each person. This frame helps to create the safety to take risks and the support to become empowered to change. As a client in my practice, you have certain rights that are important for you to know about because this is your therapy or life coaching, whose goal is your well-being. There are also certain limitations to those rights that you should be aware of. As your life coach or therapist, I have corresponding responsibilities to you.
My Responsibilities to You as Your Therapist/Life Coach
With the exception of specific scenarios outlined below, you have the absolute right to the confidentiality of your life coaching/therapy. I cannot and will not tell anyone else what you have told me, or even that you come to see me, without your prior written permission. Under the provisions of the Health Care Information Act of 1992, I may legally speak to another health care provider or a member of your family about you without your prior consent, but I will not do so unless the situation is an emergency. I will always act so as to protect your privacy even if you do release me in writing to share information about you. You may direct me to share information with whomever you choose, and you can change your mind and revoke that permission at any time. You may request anyone you wish to attend a coaching/therapy session with you.
You are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA). This law ensures the confidentiality of all electronic transmission of information about you. Whenever I transmit information about you electronically (for example, sending bills or faxing information), it will be done with with special safeguards to insure confidentiality.
If you elect to communicate with me by email at some point in our work together, please be aware that email is not completely confidential. All emails are retained in the logs of your and/or my internet service provider. While under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrator(s) of the
internet service provider.
The following are legal exceptions to your right to confidentiality. I would inform you of any time when I think I will have to put these into effect.
1. If I have good reason to believe that you will harm another person, I must attempt to inform that person and warn them of your intentions. I must also contact the police and ask them to protect your intended victim.
2. If I have good reason to believe that you are abusing or neglecting a child or vulnerable adult, or if you give me information about someone else who is doing this, I must inform Child Protective Services within 48 hours and Adult Protective Services immediately.
3. If I believe that you are in imminent danger of harming yourself, I may legally break confidentiality and call the police or the county crisis team. I am not obligated to do this, and would explore all other options with you before I took this step. If at that point you were unwilling to take steps to guarantee your safety, I would call the crisis team.
4. If you tell me of the behavior of another named health care provider that leads me to believe he or she has a) engaged in sexual contact with a patient, including yourself, or b) is impaired from practice in some manner by cognitive, emotional, behavioral, or health problems, then I will be obligated to report this to the Maine Licensing Board. I would inform you before taking this step. If you are my client and a health care provider, however, your confidentiality remains protected under the law from this kind of reporting.
5. The following is not a legal exception to your confidentiality. However, it is a policy of which you should be aware
before beginning sessions. If you invite another person into your sessions it is possible that things you have said in the past during your individual sessions with me may come up or be repeated for the purpose of the work we are doing together. I use my best discretion in these matters, with all the best intent for improving your relationships.
I keep very brief records, noting only that you have been here, what interventions happened in session, and the topics we discussed. If you prefer that I keep no records, you must give me a written request to this effect for your file, and I will only note that you attended in the record. Under the provisions of the Health Care Information Act of 1992, you have the right to a copy of your file at any time. You have the right to request that I correct any errors in your file. You have the right to request that I make a copy of your file available to any provider at your written request. I maintain your records in a secure location that cannot be accessed by anyone else.
If you are requesting insurance reimbursement for your sessions with me I will most likely be required to give you a mental health diagnosis. Diagnoses are technical terms that describe the nature of your problems and whether they are short-term or long-term problems. If I do use a diagnosis, I will discuss it with you. All of the diagnoses come from a book titled the DSM-V; I have a copy in my office and will be glad to let you borrow it and learn more about what it says about your diagnosis.
IV. Other Rights
You have the right to ask questions about anything that happens in therapy/life coaching. I'm always willing to discuss how and why I've decided to do what I'm doing, and to look at alternatives that might work better. You can feel free to ask me to try something you think will be helpful. You can ask me about my training for working with your concerns, and can request that I refer you to someone else if you decide I'm not the right therapist for you. You are free to leave therapy at any time.
V. Managed Mental Health Care
If you are being reimbursed in full or in part by a managed care firm, there are usually further limitations to your rights as a client imposed by the contract of the managed care firm. These may include their decision to limit the number of sessions
available to you, decide the time period within which you must complete your therapy with me, or require you to use medication if their reviewing professional deems it appropriate. They may also decide that you must see another therapist in their network rather than me, if I am not on their list. Such firms also usually require some sort of detailed reports of your progress in therapy, and on occasion, copies of your case file, on a regular basis. I do not have control over any aspect of their rules. However, I will do all that I can to maximize the benefits you receive by filing necessary forms and gaining
required authorizations for treatment, and assist you in advocating with the MC company as needed.
You normally will be the one who decides when therapy/life coaching will end, with three exceptions. If we have contracted for a specific short-term piece of work, we will finish therapy at the end of that contract. If I am not in my judgment able to help you because of the kind of problem you have or because my training and skills are in my judgement not appropriate, I will inform you of this fact and refer you to another therapist/life coach who may meet your needs. If you threaten or harass me, the office, or my family, physically or emotionally, I reserve the right to terminate you unilaterally and immediately from treatment. If I terminate you from therapy/life coaching, I will offer you referrals to other sources of care, but cannot guarantee they will accept you for therapy/life coaching.
I am away from the office several times in the year for extended vacations or to attend professional meetings. I will let you know in advance of those times. I may be available during regular business hours for brief phone calls.
If you are experiencing an emergency when I am out of town, or outside of my regular, office hours (after 5 pm weekdays or over the weekend), please call the Crisis Help Line at 207-774-4357. If you believe that you cannot keep yourself safe, please call 911, or go to the nearest hospital emergency room for assistance.
VI. Your Responsibilities as a Coaching/Therapy Client
You are responsible for coming to your session on time and at the time we have scheduled. Sessions last for approximately one hour. If you are late, we will end on time and not run over into the next person's session. If you miss a session without canceling, or cancel with less than twenty-four hours notice, you must pay twenty dollars for that missed session at our next regularly scheduled meeting. The answering machine texting or email has a time and date stamp which will keep track of the time that you called me to cancel. I cannot bill these sessions to your insurance. The only exception to this rule is if you would endanger yourself by attempting to come (for instance, driving on icy roads without proper tires), or if you or
someone whose caregiver you are has fallen ill suddenly.
You are responsible for paying for your session weekly unless we have made other firm arrangements in advance. My fee for a session is $65.00 for sixty minutes, unless a different fee is negotiated between you and me at your first session.
If we decide to meet for a longer session, I will charge you prorated on the hourly fee.
Emergency phone calls of less than ten minutes are normally free.
I am not willing to have clients run a bill with me. I cannot accept barter for therapy, I do accept Paypal payments prior to a session, otherwise please pay with cash, a personal check, or a debit/credit card at the time of our session.
If you're unhappy with what's happening in therapy/life coaching, I hope you'll talk about it with me so that I can respond to your concerns. I will take suriticism seriously, and with care and respect. If you believe that I've been unwilling to listen and respond, or that I have behaved unethically, you can complain about my behavior to the Socal Work Board
located through the State of Maine Home page.