Informed Consent for Treatment

Penllyn Counseling Associates LLC
589 Skippack Pike, Suite 303, Blue Bell, PA 19422
NPI #1952047987

Informed Consent Form

Penllyn Counseling Associates (PCA) welcomes you!

Introduction

This document outlines the important details regarding the psychological services we offer in our private practice. Please read this information carefully and ask any questions you may have before signing below. By signing this form, you acknowledge that you have read and understood this information and that you have had all your questions answered. If you elect to use your insurance benefits, as described in the section below called Insurance Reimbursement, then by signing this form you are also giving me and PCA permission to share your information with your insurance company.

The Pennsylvania and New Jersey license numbers of the providers within Penllyn Counseling Associates:

• Judith Kurtis LCSW - PA CW018543, NJ 44SC05555400

• Rachael Rosenfeld LCSW - PA CW019016, NJ 44SC06242700

Services Offered

• PCA provides individual therapy for adults (ages 18+) and children (under 18) experiencing a variety of challenges, including anxiety, depression, relationship issues, communication breakdown.

• PCA utilizes cognitive-behavioral therapy, mindfulness-based therapies, solution- oriented therapy, and psychodynamic therapy.

• PCA does not offer, e.g., medication management, court-ordered evaluations, return to work letters, animal support letters.

Evaluation

• The first few sessions will involve an evaluation of your needs. This evaluation typically lasts 1-2 sessions.

• Following initial evaluation, we will discuss if the therapist is the right therapist for you and will offer a treatment plan.

• The therapist will refer you to another therapist if someone else is better suited.

Psychotherapy

• Psychotherapy is a collaborative effort that requires active participation from you.

• The approach used will vary depending on your needs and it may involve discussing uncomfortable topics.

• There are no guarantees about the outcome of therapy, but studies have shown psychotherapy to be helpful to those who undergo it.

Benefits and Risks of Therapy

• Therapy requires a significant investment of time, money, and energy. Therapy can be a helpful and effective way to address emotional and behavioral difficulties.

• Potential benefits of therapy include improved mood, reduced stress, better coping skills, and enhanced relationships.

• However, therapy can also involve some emotional discomfort as you explore challenging issues.

• Throughout any therapy sessions, you are encouraged to ask questions. Also, feel free to seek a second opinion at any time.

Confidentiality

• All information discussed in therapy sessions will be kept confidential, unless you give us written permission to share such information, with some exceptions as outlined below:

• The therapist may be required by law to report suspected abuse or neglect, for example regarding children, elders, or disabled adults. PCA may also be required to disclose information if compelled by a court order.

• If the therapist believes you may harm yourself or others, the therapist may need to take steps to ensure your safety or the safety of others.

• The therapist may consult with other professionals about your case to help provide you with appropriate care. If a consultation occurs, every effort will be taken to avoid revealing information that could identify you to maintain your privacy.

• If you use your insurance benefits, PCA must share clinical information about you as described in the Insurance Reimbursement section below at the request of your insurance company.

If you are concerned about confidentiality in any situation, please bring it to our attention.

Fees

• All billing, copays, deductibles are managed by Philadelphia Medical Billing - https://www.pmbill.com/.

• Sessions are typically [30, 45 or 50] minutes long.

• There is a cancellation fee of $60 for cancellations with less than 48 hours' notice.

Additional Fees

• Additional services, including the list below, will be billed at rate per hour.

• Report writing

• Telephone conversations at your request

• Attendance at meetings with other professionals per your request

• Preparation of records or treatment summaries

• Time spent performing any other service you may request of PCA and to which PCA agrees

Legal Matters

• You are responsible for professional time if legal matters require PCA participation, even if the therapist or records are subpoenaed.

• PCA’s fee for legal preparation and attendance at proceedings is $120.00 per hour and is adjusted based on time and codes.

Insurance Reimbursement

• Understanding your insurance coverage is important for setting realistic treatment goals.

• Your insurer may require authorization before providing reimbursement and may limit the number of sessions that are covered by insurance. Should you request more
  sessions beyond your insurance coverage, you would be responsible for the total amount of those sessions.

• PCA recommends contacting your insurance company directly and in advance of our first session to understand your specific mental health coverage benefits and any
  limitations or pre-authorization requirements.

• If you are using EAP benefits, please contact your Benefits Administrator for this information:

• The EAP authorization code

• How many sessions are authorized

• The starting and ending date

• Your insurance information will still be needed to be able to continue therapy seamlessly beyond the number of authorized sessions.

Most insurance companies, including Medicare, require a diagnosis to provide coverage and may request additional clinical information (treatment plans, progress
notes, etc.). When you sign this form, you are giving us permission to share your information with your insurance company to seek payment for your covered services.

Choosing not to use your insurance for some or all your care. You have the right to pay for services yourself to avoid these limitations and potential privacy concerns associated with using your insurance.

Your Rights

• You have the right to participate actively in your treatment and make informed decisions about your care.

• You have the right to ask questions and request clarification at any time.

• You have the right to terminate therapy at any time.

• You have the right to seek a second opinion.

• You have the right to access your treatment records, with some exceptions. Please let us know if you would like to discuss.

Contacting Us

• When you contact PCA, you are welcome to leave a message or text or email, and PCA will return your call, text or email promptly.

• If you require immediate help and you have not connected with PCA, call 911 or call 988.

• In case of an extended absence on our part, your therapist will provide you with contact information of a colleague who may be able to provide you with services.

Our Responsibilities

• PCA is committed to providing you with competent and ethical psychological care.

• PCA will respect your privacy and confidentiality.

• Your therapist will discuss the limitations of their expertise and refer you to another provider if necessary.

Agreement
I agree and consent to participate in behavioral health care services offered and provided at/ by Penllyn Counseling Associates LLC, a behavioral healthcare provider.

By signing below, you acknowledge that you have read and understood this Informed Consent for Treatment document, that you have had all your questions answered to your satisfaction, and you consent to the release of information described above. You agree to participate in therapy voluntarily.