INFORMED CONSENT AND PRACTICE POLICIES
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 to reach a clear understanding and set expectations about how the relationship between you and your clinician will work. This consent will provide a framework for your experience in therapy and outline administrative policies. Please read each section carefully, as you will be asked to consent to all of the information in this document.
The Therapeutic Process
The outcome of your treatment depends largely on your willingness to engage in therapy, which may at times result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings can elicit experiences of anger, depression, anxiety, or fear. There are no miracle cures, and your clinician cannot promise that your experiences or circumstances will change. We at Alexandria Art Therapy can promise to support you and do our very best to understand you and patterns that have emerged in your life. You and your clinician will work together to help 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 of individual therapy consist of an assessment period to establish treatment goals and determine if you and your therapist are a good fit for continuing to work together. 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, you and your therapist 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 request 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:
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.
A client threatens grave bodily harm or death to another person.
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.
Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
Suspected neglect of the parties named in items #3 and #4.
A court of law or credentialing board issues a legitimate subpoena for information stated on the subpoena.
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.
A client is using insurance benefits to access services and the insurance company requests treatment summaries, treatment plans, progress notes, diagnosis, and / or treatment information to determine eligibility of payment.
A client is undergoing a security clearance investigation and client session notes, diagnosis, or additional treatment documentation is requested.
If you are using insurance benefits to access services, the insurance company may request treatment summaries and additional treatment information to determine eligibility of payment. Insurance companies require a mental health diagnosis to determine that services are medically necessary and this diagnosis will appear on all insurance claims.
Occasionally clinicians may consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about your treatment and artwork made in therapy may be discussed in this context without using identifying details.
Pre-licensed or pre-credentialed clinicians are required to participate in clinical supervision in which case information may be discussed with identifying information protected.
In the event you see your therapist outside the office setting, your therapist will not acknowledge you unless you acknowledge them first. Your right to privacy and confidentiality is of the utmost importance, and your clinician is dedicated to act in a way that will not jeopardize your privacy. If you choose to approach your therapist in public, they will say hello and keep the conversation brief. All conversations about treatment will occur in session only.
Confidentiality for Minors
If you are a minor, your parent(s) / legal guardian(s) may be legally entitled to some general information about your therapy. Your clinician will discuss with you and your caregivers what information is appropriate for them to receive and which issues are more appropriately kept confidential.
Confidentiality and Expectations in Art Therapy Groups
Privacy is important when participating in a group therapy experience. Group expectations establish important boundaries for your therapeutic experience. While group facilitators (therapists) are required by law to maintain confidentiality, group members are not; therefore, conversations in group therapy are not protected by confidentiality. It is important that all members commit to the privacy of all participants to create an environment of mutual trust and respect.
To maintain respectful boundaries in the group, the following expectations have been established:
Be respectful of excess noise including loud conversations.
Time will be allotted to share artwork with the group.
Refrain from making judgmental statements about artwork, including praise. When comments are made about the aesthetics of artwork, it shifts focus to how it looks rather than what it means.
When others share, create space by listening with empathy and compassion. You are providing support without attempting to solve or fix that individual’s experiences.
Photographing members and their artwork is not permitted.
Creative Arts Workshops + Support Groups
Alexandria Art Therapy may host creative arts workshops and support groups at the office, in the community, and virtually. These workshops are open to the public and offer an opportunity to learn new creative skills, practice self care, and connect with others. You are welcome to attend workshops with the understanding that the clinician cannot guarantee protection of your confidentiality. Your clinician will never identify the nature of your relationship; however, therapy facilitates a close, intimate connection and others may sense that you know each other.
Therapy Appointments, Electronic Appointment Reminders, and Cancellations
The standard meeting time for individual therapy is 50 minutes. In the event that a longer session is required, options and fees may be discussed in advance.
Alexandria Art Therapy, LLC uses an Electronic Health Record (EHR) system, Simple Practice, that automatically sends appointment reminders to the phone number and email address on file. This setting is set to “ON” for all new clients. A reminder email is sent 72 hours in advance and a text 24 hours before the session.
Email reminders provide the opportunity to cancel or reschedule without incurring the late cancellation fee. You may opt out of either reminder at any time.
Please cancel or reschedule with notice of at least 48 business hours. Please call, text, or email your clinician to communicate scheduling changes. If you miss your appointment without notice, this will be considered a late cancellation.
Refer to the following to determine the day upon which you must cancel or reschedule to avoid the fee.
Appointment on Monday: cancel by time of appointment on Friday
Appointment on Tuesday: cancel by time of appointment on Friday
Appointment on Wednesday: cancel by time of appointment on Monday
Appointment on Thursday: cancel by time of appointment on Tuesday
Appointment on Friday: cancel by time of appointment on Wednesday
Appointment on Saturday: cancel by time of appointment on Thursday
Appointment on Sunday: cancel by time of appointment on Friday
Insurance companies do not reimburse for canceled sessions; the full contracted insurance rate will be charged for cancellations within 48 business hours of the appointment time or missing your appointment without notice. This includes your copay and the amount insurance reimburses AAT for services.
Charging the cancellation fee allows AAT to continue providing high quality, individualized care. Without 48 hours notice, it can be difficult to fill canceled session times and clinicians are not paid for their time.
Payment for Cancellation Charges
Cancellation fees must be paid in full in order to schedule the next session. Your card on file will be charged the day of your scheduled session. If you prefer to use an alternative card instead of your card on file, please notify your clinician at the time of cancellation.
Professional Fees and Payment
A credit card is required on file for all clients.
This card will be charged for session fees on the day of your session. If you prefer an alternative card is utilized for payment, please notify your clinician or our Practice Manager.
Payment is due on the day of the session.
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, and preparation of treatment summaries.
Please note that insurance does not cover these services.
If you refuse payment for any session fees, the practice reserves the right to use an attorney or collection agency to secure payment.
A $100.00 service charge will be charged for any disputed credit card charges. If a disputed charge is received on an account, an alternative form of payment may be required.
In the event that payment is not completed on the day of services, your balance must be paid by the next session. If the balance is not paid during your next session, you will be unable to schedule again until your balance is paid. This ensures that clients do not accrue a balance on their account.
Legal Issues
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 clinical participation, you will be expected to pay for all the professional time required, including preparation and transportation costs, even if the therapist is called to testify by another party. Because of the difficulty of court involvement, the rate is $350 per hour for preparation and any involvement in legal proceedings, including travel time.
Alexandria Art Therapy does not provide court ordered services.
Insurance and Out of Network Insurance Benefits
All services are out of network for all insurance companies. If you have an insurance plan that covers out-of-network services or a FSA / HAS account that requires documentation of services, the practice will send a “superbill” (receipt of services) each month.
This superbill will include information including a diagnosis code and service code. Insurance companies require a diagnosis in order to consider therapy services medically necessary and reimburseable.
Reimbursement is not guaranteed. Please check with your insurance company, noting the credentials of the therapist you are choosing to work with. Non-licensed art therapist’s services are often not continued reimbursable due to requirements set by insurance companies.
Contacting Your Therapist Between Sessions
To contact your therapist between sessions, please email or call. Our policy is to respond to messages within 24 business hours. If an emergency mental health situation arises, please call 911 or 988 or visit your local emergency room and request emergency mental health services.
The following methods of communication are HIPAA compliant and offer a higher level of privacy when communicating electronically:
HIPPA Compliant G-Suite email (info@AlexandriaArtTherapy.com)
Standard phone calls and voicemail, hosted by RingRX (703-596-9557)
Your privacy is extremely important. If you reach out via non-secure methods (e.g. text messaging) your clinician will respond with the understanding that by using this form of communication, you accept the risks involved with transmitting private information in a non-encrypted form.
Due to the nature of outpatient services, responses to messages will occur within 24 business hours. Please do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.
Holidays
The administrative office is closed on all federal holidays unless otherwise noted. Your clinician may choose to provide services on federal holidays; please consult with them regarding their availability.
Inclement Weather
The physical office will close for inclement weather if the Federal Government is closed or roads are unsafe.
If the physical office is closed or you find the weather too unsafe for travel, your clinician may offer telehealth sessions.
If the road conditions are clear and safe at the time of your appointment, and you are not able to make your appointment or participate in a telehealth session, your missed session will be treated as a late cancellation and the full session fee will be charged.
As always, use your best judgment for taking the best care of yourself.
An email will be sent out the morning of your session if the office will be closed or the schedule altered. If you do not receive an email, then the office is open as scheduled. Please check your email prior to coming to your appointment and email, call, or text to check in.
Artwork
Artwork created in session provides a tangible representation of your experiences in session and progress in treatment. Your clinician will create a portfolio of your artwork. In the event that you choose to take artwork home, your clinician will photograph the piece to add to your portfolio.
Artwork is treated like a part of a medical file and stored in a confidential manner. At the time of termination, your artwork will be compiled for you to take. Should you choose not to take artwork, it will be securely stored for 6 months and confidentially destroyed at the end of this period.
By signing this form, you authorize your clinician at Alexandria Art Therapy, LLC to photograph and use your original artwork for consultation and documentation purposes only. Artwork will be shared in a respectful, professional manner and all identifying information will be removed or covered to protect your confidentiality. You may revoke this authorization, in writing, at any time unless action based on it has already taken place.
Telehealth
Most clinicians at the practice provide services via a secure telehealth platform. Clinicians may only provide telehealth to clients located in specific locations. All clinicians at Alexandria Art Therapy may provide telehealth to clinicians located in Virginia. For clients located in Maryland, DC, or other states, please consult with your clinician or the Practice Manager to determine eligibility.
The client must be physically located in the state covered by the clinician’s credential. This is not based on your mailing address or state of residency.
Telehealth can make therapy more accessible and convenient, but may increase the risk of confidentiality breaches due to overheard conversations or data interception. We encourage telehealth clients to make sure that you have a quiet, private space for scheduled telehealth sessions. Clinicians utilizing telehealth attempt to minimize risks as much as possible by hosting sessions in a secure space using non-public internet service.
Telehealth services may feel different from in-person services since you are not sharing the room with your provider. Nonverbal information can be lost through the computer screen and technology issues can be problematic. You or your clinician can discontinue the telehealth session if it is felt that the video conferencing connections are not adequate for the situation and in-person services are available.
While research has generally been supportive of telehealth for the treatment of a variety of individual diagnoses, there is little research to date on the effectiveness of telehealth for couple- or family-based services, and as such, these services are best categorized as experimental in nature.
Telehealth by SimplePractice is the technology service we will use to conduct telehealth video conferencing appointments. It is simple to use, and there are no passwords required to log in. By signing this document, you acknowledge:
Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will call 911.
Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.
I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service.
To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.
COVID-19 Vaccination
Full vaccination for COVID-19 (per CDC guidelines) is required to participate in in-person sessions. Clients must provide a copy of your vaccination card and sign a COVID-19 informed consent prior to participating at the office.
Clients who are not fully vaccinated may participate in therapy virtually.
Social Media
Alexandria Art Therapy’s clinicians do not accept “friend” requests or similar connections with current or former clients, or their family members or friends, on social media. This is to protect your confidentiality and privacy and avoid blurring the boundaries of the therapeutic relationship.
If you would like to like Alexandria Art Therapy’s professional Facebook page or follow us on Instagram, you may do so at your own risk. 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. We will NOT respond to messages or comments if we have already begun a therapeutic relationship and we reserve the right to delete public comments to protect your confidentiality. We will not follow you back on any social media platform should you choose to follow any of our professional accounts.
Do not use public social media accounts as a channel to contact your therapist for therapy-related discussion, even in an emergency.
If you would like your therapist to review your (or your child’s) social media interactions as part of your therapeutic work, please print what you would like to review and bring it with you to the session. Even if your or your child’s social media accounts are public, your therapist will not examine them without your specific consent and direction.
Please note that any social media apps you use may seek to connect you with me or with other visitors to this office, through a “people you may know” or similar feature. Alexandria Art Therapy has no control over apps that may intrude on the privacy of your treatment in this way. If you would like to minimize the risk of others becoming aware of your connection to our practice, please make use of the privacy controls available on your phone. Turning off a social media app’s ability to know your location, and refusing it access to your email account and the contacts and history in your phone can protect your privacy and confidentiality.
Alexandria Art Therapy, LLC and your clinician 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.
If you wish to discuss content you have seen on any of our profiles, you are welcome to send an email response or discuss the content in the next session.
Search Engines
We do not search for clients on Google or other Social Media platforms. There are extreme exceptions, for instance in the event that you are in suspected danger, and we have not been in contact via our typical means (i.e. appointments, phone, or email). In the event that you are suspected to be in danger, your clinician may use a search engine to ensure your safety. This would be a very unusual circumstance, and if your clinician has to resort to such means, they will fully document this and discuss it with you in your next session.
Recording devices
The office has a variety of smart devices, including but not limited, to cell phones, laptops, and smart speakers. Most devices generally have voice control turned off, and so are not recording. However, for any device (such as a smart speaker) that is voice controlled, recorded snippets of conversation may be sent to the device manufacturer.
If you bring a smart device to session and haven’t turned voice control off, the microphone may be recording snippets of the conversation and sending it to the manufacturer.
Please feel free to take notes in session if you believe it will be helpful in remembering key points of discussion. However, audio or video recording of sessions is prohibited without discussing options with your therapist.
Animals
Clinicians at Alexandria Art Therapy do not write letters related to Emotional Support Animals. Animals other than officially trained service animals are not allowed in the office.
Therapist Emergency or Incapacitation
In the event that your clinician is absent unexpectedly, AAT administrative staff or the clinical director will reach out to you regarding coverage and / or future plans for treatment.
Staff at Alexandria Art Therapy, including clinical staff or administrative staff, may access your file in order to coordinate care.
Threats, Harassment, and Intimidation
If you engage in threats, harassment, or intimidation towards AAT staff, clinicians, or others in this office, this may be grounds for immediate termination of therapy. You also grant permission for me to share information about any threatening behavior with law enforcement and/or others as I believe necessary to protect my safety and that of others.
Termination
The appropriate length of the termination process depends on the length and intensity of the treatment. Your clinician will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. Upon request, your clinician will provide you with a list of qualified art therapists or psychotherapists to continue therapy. You may also choose someone on your own.
In order for you to benefit from the therapy process, it is important to participate consistently. Should you fail to schedule an appointment or cancel a set number of sessions consecutively, without specific plans with your therapist, for legal and ethical reasons, the practice may consider the professional relationship discontinued.
This policy applies to weekly clients after missing three consecutive weeks and bi-weekly (twice a month) after two consecutive sessions.
Your clinician will attempt to engage in a dialogue about cancellations and explore reasons for cancellations and appropriateness of continuing therapy. If you are unavailable to participate in sessions, your clinician will notify you in writing of attempts to reach out and process termination.
Products Sold by Alexandria Art Therapy
You may see products being sold on the website and posted on social media, such as self care cards. It can be unethical to sell products to existing clients; therefore, please let your clinician know if you are interested in any products created under the name Alexandria Art Therapy, LLC or clinicians at the practice. At times it can be helpful to give tangible objects, such as self care cards, to clients as a coping tool. Value of items will be considered and accommodations may be made (e.g. offering different packaging).
If you have questions about this form before signing, please contact Alexandria Art Therapy’s Practice Manager at info@alexandriaarttherapy.com.