INFORMED CONSENT AND PRACTICE POLICIES
FOR ART THERAPY & COUNSELING

General Information

The therapeutic relationship is unique in that it is both a highly personal connection and a contractual agreement. Given this, it is important for us to reach a clear understanding and set expectations about how our relationship will work. This consent will provide a framework for our work together in therapy.

The Therapeutic Process

You have already begun a process to alleviate symptoms and foster a greater sense of well being by seeking out therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings can bring on strong feelings of anger, depression, anxiety, or fear. There are no miracle cures and I cannot promise that your experiences or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself. With focused attention and commitment to your therapeutic goals, relief and growth is possible.

The first several sessions consist of an assessment period that will help determine if we are a good fit for working together and tailor treatment to best meet your needs. In order to get the most out of the process, it is recommended that you attend weekly for 4-6 weeks. By the end of this period, we will address the frequency for sessions that is appropriate for you.

Confidentiality

The session content and all relevant materials will be held confidential unless a requests in writing is submitted to have all or portions of such content released to a specifically named person/persons. Limitations to confidentiality are itemized below:

1.    A client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.

2.    A client threatens grave bodily harm or death to another person.

3.    The therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.

4.    Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

5.    Suspected neglect of the parties named in items #3 and #4.

6.    A court of law issues a legitimate subpoena for information stated on the subpoena.

7.    A client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.

Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using identifying details.

Northern Virginia is a small community and we may see each other outside of the therapy office. If we see each other outside the office setting, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not want to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you.

Termination

Ending relationships can be difficult. Therefore, it is important to have a termination process for closure of our work together. The appropriate length of the termination depends on the length and intensity of the treatment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. Upon request, I will provide you with a list of qualified art therapists or psychotherapists to continue therapy. You may also choose someone on your own.

Should you fail to schedule an appointment or cancel three sessions in four consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I may consider the professional relationship discontinued. You will receive written notification of this termination.

At the end of therapy artwork from sessions will be compiled for you to take. Should you choose not to take artwork, it will securely stored for 6 months and confidentially destroyed at the end of this period.

Appointments and Cancellations

The standard meeting time for therapy is 50 minutes. In the event that a longer session is required, we will discuss options and fees in advance.

Please cancel or reschedule with at least 24 hours notice. You will be responsible for the full session fee if cancellation is less than 24 hours. Insurance companies do not reimburse for cancelled sessions, so you will be responsible for the full fee when using in-network benefits. If you are late for a session, you may lose some of that session time.

Professional Fees

Payment is due at the time of the session. All forms of payment are accepted and a credit card is required on file in the event of cancellation fees.

In addition to session fees, charges will incur for any other professional services requested, including report writing, professional consultation (with your permission), telephone conversations lasting longer than 15 minutes, preparation of treatment summaries.

If you anticipate becoming involved in a court case, please discuss fully before waiving your right to confidentiality.  If you become involved in legal proceedings that require my participation, you will be expected to pay for all the professional time required, including preparation and transportation costs, even if I am called to testify by another party. Because of the difficulty of court involvement, I charge $350 per hour for preparation and any involvement in legal proceedings.

If you refuse payment for any session fees, I reserve the right to use an attorney or collection agency to secure payment.

A $25.00 service charge will be charged for any returned checks. If a returned check is received on an account, an alternative form of payment is required. This may include a cashier’s check for service fees. 

Insurance

I am an in-network provider with CareFirst BlueCross BlueShield. Prior to your first session, please check with your insurance provider to ensure that I am considered an in-network provider and services are covered. Some plans require that a deductible is met before sessions are covered. In the event that you have not met your deductible you will be responsible for the full session fee. Clients with in-network benefits are responsible for a co-pay at the time of service and I will bill your company for the remainder of the fee.

Insurance companies require a mental health diagnosis in order to reimburse for services. We will discuss the potential risks and benefits of such service requirements in the first session.

I am considered out of network for all other insurance companies. At your request, I will provide a “superbill” for services that you may submit to your insurance company for reimbursement. Prior to beginning therapy it is important to contact your company to determine reimbursement eligibility. I cannot guarantee reimbursement.

Phone Accessibility and Electronic Communication

If you need to contact me between sessions, you are welcome to email or leave a message on my voicemail. I am often not immediately available; however, I will attempt to return your call or email within 24 hours business hours. I may also be reached via text message on the business day of your appointment, should you need to cancel or are arriving late. If an emergency situation arises, please call 911 or visit your local emergency room.

I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

Social Media

Due to the importance of your confidentiality and the practice of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and may also blur the boundaries of our therapeutic relationship.

I do maintain a professional Facebook and Instagram account to connect with professionals and community members. Following these accounts does increase the likelihood of compromised confidentiality as someone may see that you have “liked” or “followed” the account. Messaging and commenting on these sites is not recommended. I will not respond to messages or comments if we have already begun a therapeutic relationship and I reserve the right to delete public comments to protect your confidentiality.

Alexandria Art Therapy, LLC and Adele Stuckey, LPC, ATR-BC may be listed on business review sites such as Google, Yelp, Healthgrades, Yahoo Local, and Angie’s List. Many of these sites are auto-populated and the existence of such listings is not a request for review, ratings, or testimonials.

Minors
If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.