Informed Consent for Psychotherapy
The purpose of this document is to begin the conversation defining our professional relationship, including the limits of confidentiality. Each person attending therapy is required to read and understand this entire informed consent form, and to raise any questions or concerns before signing it. This form also provides you with information additional to that detailed in the HIPAA Notice of Privacy Practices and it is subject to HIPAA preemptive analysis. A printable version of this form can be found here. Please keep a copy for your records.
WHO WE ARE: “We” (or “us,” etc.) in this document are David Gordon Langford and Meshel Lewinski Langford. We are Licensed Marriage and Family Therapists (LMFTs), which means we have the training for and experience of working with couples and families, as well as individuals, that professionals without their LMFT do not have.
WHO THE CLIENT IS: In individual therapy, the client is the individual. For couples and families seeking therapy for their relationship, the client is the relationship — not any one person. Throughout this document, “client” in relationship therapy refers to the relationship itself, and matters of the relationship (the “client”) pertain to everyone in the relationship.
During the course of relationship therapy, sometimes one person might also benefit by coming for individual therapy as well, or we might alternate seeing one person and then the other in a balanced way. Should that occur, we will discuss how to go about it for the best fit for everyone at that time.
Sometimes a client benefits from having additional people come to therapy, whether to witness, provide support, or consult. The confidentiality of such sessions would apply to all persons present; the therapists would seek the authorization of the other individuals present for therapy before releasing confidential information to a third party.
WHERE ROOMS ARE: The waiting room is where to go before your appointment. We will invite you in as soon as we are available. The couples therapy office is entered through the waiting room. Outside the waiting room is our other door, where Meshel sees individuals. The restroom is the very next door on the same side of the hallway as Meshel’s office. If the restroom is locked, please do not hesitate to ask one of us to open it.
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law, and for clinical or administrative records requests, such as may be requested by your health plan.
DISCLOSURE BY LAW: Some of the circumstances where disclosure is or may be required by law are: Where there is a reasonable suspicion of child, dependent, or elder abuse or neglect; where a client presents a danger to self, to others, to property, or is gravely disabled; or when a client’s family members communicate to us that the client presents a danger to others. Disclosure may also be required pursuant to a legal proceeding by or against you. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain psychotherapy records and/or testimony by us.
OUR NO-SECRETS POLICY: Our obligation is generally to the client first, not to the individuals in relationship therapy. This means that we may need to share information with everyone in the relationship, whether that information was learned in session or during any other point of contact, even if you do not want us to. We will use our best judgment as to whether, when, and to what extent we will make disclosures to the others in relationship therapy, and will also, if appropriate, first give the individual(s) who communicated this information the opportunity to make the disclosure. Thus, if you feel it necessary to talk about matters that you absolutely want to be shared with no one, you might want to consult with an individual therapist outside of our office.
Our no-secrets policy is intended to allow us to continue relationship therapy by preventing, to the extent possible, a conflict of interest to arise where an individual’s interests may not be consistent with the interests of the relationship. For example, information learned in the course of a session with one individual may be relevant or even essential to relationship therapy. If we are not free to exercise our clinical judgment regarding the need to bring this information to relationship therapy, we might be placed in a situation where we will have to terminate treatment of the couple or the family. This policy is intended to prevent the need for such a termination.
CONSULTATION: We consult regularly with each other and other professionals regarding our clients; however, each client’s identity remains completely anonymous and confidentiality is fully maintained.
E–MAILS, TEXT MESSAGES, TELEPHONES, COMPUTERS, VIDEO COMMUNICATION & FAXES: All forms of electronic communication are inherently insecure, and can be accessed by unauthorized people, compromising the privacy and confidentiality of such communication. Additionally, our emails, texts, and phone calls are not encrypted. Our computers are equipped with a firewall, virus protection, and high-level encryption and security protocols which also protect periodic backups of all confidential information. Also, all electronic communication, including but not limited to emails, faxes, and texts, are part of the medical records. Please notify us if you decide to avoid or limit in any way the use of any or all communication devices, such as email, phone, text messages, or faxes. If you communicate confidential or private information electronically, such as via email, text messaging or fax, we will assume you have made an informed decision, and will view it as your agreement to take the risk that such communication may be intercepted, but our usual and customary policy is to only respond by scheduling an appointment to address your concerns privately and confidentially. Please do not use email, text messages, or faxes for emergencies.
RECORDS AND YOUR RIGHT TO REVIEW THEM: Both the law and the standards of our profession require that we keep treatment records for at least seven years after the last service provided. Unless otherwise agreed to be necessary, we retain clinical records only as long as is mandated by Wisconsin law. If you have concerns regarding the treatment records, please discuss them with us. Your records may be released upon request of your health plan as part of a routine audit, even if you are seeing us as an out-of-network provider. As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when we assess that releasing such information might be harmful in any way. In such a case, we will provide the records to an appropriate and legitimate mental health professional of your choice. Considering all of the above exclusions, if it is still appropriate, and upon your request, we will release information either 1) regarding individual therapy, to any agency/person you specify unless we assess that releasing such information might be harmful in any way, or 2) regarding relationship therapy, we would first seek the authorization of all the people defined as the client in therapy, and release records only with signed authorizations from all the adults (or all those who legally can authorize such a release) involved in therapy, and only after receipt of authorization will we release information to any agency/person you specify unless we assess that releasing such information might be harmful in any way. If treatment records were subpoenaed, we would assert the psychotherapist-patient privilege on behalf of the client, including everyone who, taken together, constituted the relationship in cases of relationship therapy.
EMERGENCY: If there is an emergency during therapy, or in the future after termination of therapy, where we become concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, we will do whatever we can, within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, we may also contact the persons whose names you have provided on the Intake Form.
CONTACT & EMERGENCY PROCEDURES: If you need to contact us between sessions, please leave a voice or text message at (608) 729-8611, or write us at our email. We generally check our messages daily. If you call, email, or text and do not receive a response from us for 24 hours, please presume that your message did not get through, and please attempt to contact us again. Please do not use email, text messages or faxes for emergencies.
If a crisis arises, indicate it clearly in your message, and if you need to talk to someone right away call 988, send a text to 988, or use the online chat function on suicidepreventionlifeline.org to connect with a counselor at the Wisconsin Lifeline. In a life-threatening emergency, call 911.
PAYMENTS & INSURANCE: The usual and customary fee is $380 per 45-60 minute session, due at the end of each session. Sessions that run 90-120 minutes are possible, but will be billed as two sessions at the same rate. If a session that is scheduled for 45-60 minutes might take up the time of a second session, we will ask if a second hour is preferred. Time for services beyond regular sessions as described above, such as telephone conversations, site visits, writing and reading of reports, writing homework letters, consultation with other professionals, release of information, reading records, travel time, etc. will be charged at the rate of $380 per hour, unless indicated and agreed upon otherwise. Please notify us if any problems arise during the course of therapy regarding your ability to make timely payments. If you do not pay for two sessions, the next session cannot begin until it and the previous two sessions are paid for. With in Sight, LLC accepts cash, checks, and credit, debit, and HSA cards, and some insurance. You are responsible for making payment in full for what your insurance does not pay, including deductibles and changes of your insurance coverage, such as changes incurred when you change your insurance provider, including a change to a provider we cannot bill, when a new fiscal year incurs a new deductible, etc.
THE PROCESS OF THERAPY, EVALUATION & SCOPE OF PRACTICE: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. We will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. We may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. You may wish you had never come to therapy. During the course of therapy, we are likely to draw on various psychological approaches according, in part, to the problem that is being treated and our assessment of what will best benefit you. These therapies include, but are not limited to: Behavioral, cognitive, psychodynamic, existential, experiential, symbolic-experiential, emotionally focused, narrative, systems and family approaches, developmental, humanistic, and psycho-educational. We do not provide custody evaluation recommendation, or medication or prescription recommendation, or legal advice, as these activities do not fall within our scope of practice.
RISK OF COVID-19: If you choose to attend sessions at our place of business, you assume the risks inherent to doing so, including the risk of contracting COVID-19. While we attempt to keep a clean and sanitary environment, such as by purifying the air via HEPA filtration, sterilizing surfaces frequently, and requiring the wearing of masks as per CDC guidelines, there is still a risk introduced simply by leaving home. If you wish to avoid that risk, please note that we do also offer telemedicine, which is therapy conducted over live video or telephone, subject to the discussion of electronic devices, above. Please also see our Informed Consent for Telemedicine form for more.
CANCELLATION: Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 48 hours (2 days) notice is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, the usual and customary fee will be charged for sessions missed without such notification.
TREATMENT PLANS: Within a reasonable period of time after the initiation of treatment, we will discuss with you our working understanding of the problem, treatment plan, therapeutic objectives, and our view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, our expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments and their risks and benefits.
TERMINATION: As set forth above, after the first couple of meetings, we will assess if we can be of benefit to you. We do not accept or continue working with clients who, in our opinion, we cannot help. In such a case, we may give you referrals you can contact. If at any point during psychotherapy, we assess that we are not effective in helping you reach the therapeutic goals, or that you are not making a genuine effort, we are obligated to discuss it with you and, if appropriate, to terminate treatment. In such a case, we may give you referrals that may be of help to you. If you request it and authorize it in writing, we will talk to the psychotherapist of your choice in order to help with the transition. If, at any time, you want another professional’s opinion or wish to consult with another therapist, we will assist you with referrals, and, if we have your written consent, we will provide her or him with the essential information needed. You have the right to terminate therapy at any time. If at any time you are dissatisfied with the session you have just had we will refund your money for that session. If you choose to do so, and if appropriate, we will offer to provide you with names of other qualified professionals. Not making a genuine effort sufficient for termination of therapy includes, but is not limited to: ongoing absence of a concerted effort; failure to notify us that an appointment must be rescheduled with 48 hours notice on three or more occasions; and any kind of threatening, destructive, or injurious behavior.
THERAPIST-CLIENT RELATIONSHIP: If you do not already know us in another capacity, such as in private or professional life, we will not create a relationship outside of therapy if possible. For example, if you and David Langford or Meshel Langford see each other in a public place, we will not recognize you, and will treat you no differently than any other anonymous member of the public. This policy is to avoid compromising clients’ confidentiality and privacy. If you decide to openly recognize us outside of the office, we will view it as your agreement to take the risk that such communication may compromise your confidentiality and privacy, and will honor your desire to be recognized outside of the office.
DUAL RELATIONSHIPS: If you do already know David Langford or Meshel Langford in another capacity, the initiation of therapy creates a dual (or multiple) relationship. Therapy never involves sexual or any other dual relationship that impairs our objectivity, clinical judgment, or that can be exploitative in nature. We will assess carefully before entering into non-sexual and non-exploitative dual relationships with clients. It is important to realize that, despite a popular perception, in some circumstances, multiple relationships are not unethical, unavoidable or unexpected. We will never acknowledge working with anyone without their permission. Some clients have chosen us as their therapists because they knew us before they entered therapy with us, and/or are personally aware of our professional work and achievements. Nevertheless, if appropriate we will discuss with you the often-existing complexities, potential benefits and difficulties that may be involved in dual or multiple relationships, which can enhance trust and therapeutic effectiveness but can also detract from it, and often it is impossible to know which ahead of time. It is your responsibility to advise us if the dual or multiple relationship becomes uncomfortable for you in any way. We will always listen carefully and respond to your feedback and will discontinue the dual relationship if we finds it interfering with the effectiveness of the therapy or your welfare, and you can, and we would trust that you would, do the same at any time.
SOCIAL NETWORKING: With in Sight, LLC, David Langford and Meshel Langford cannot accept friend or fan requests from current or former clients on social networking sites, such as Facebook, due to the fact that these sites can compromise clients’ confidentiality and privacy. For the same reason, we request that clients do not communicate with us via any interactive or social networking websites.
MEDIATION & ARBITRATION: All disputes arising out of, or in relation to, this agreement to provide psychotherapy services shall first be referred to mediation before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of David Langford and Meshel Langford and the client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed upon. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Dane County, Wisconsin in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, David Langford or Meshel Langford can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum as and for attorney’s fees. In the case of arbitration, the arbitrator will determine that sum.
LITIGATION LIMITATION: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that, should there be legal proceedings (such as, but not limited to, divorce and custody disputes, injuries, lawsuits, etc.), neither you nor your attorney(s), nor anyone else acting on your behalf will call on David Langford or Meshel Langford to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested unless otherwise agreed upon.
MINORS IN THERAPY (may skip if no one in therapy is under eighteen): If you are under eighteen years of age, please be aware that the law may give your parents or guardians the right to obtain information about your treatment and/or examine your treatment records. It is our policy to request a written agreement from your parents or guardians indicating that they consent to give up access to such information and/or to your records. If they agree, we will provide them only with general information about our work together subject to your approval, or, if we feel it is important for them to know in order to make sure that you and people around you are safe. If we think it is appropriate, we will involve them if we feel that there is a high risk that you will seriously harm yourself or another/others. Before giving them any verbal or written information, we will discuss the matter with you, if possible. We will do the best we can to resolve any differences that you and we may have about what we are prepared to discuss.