3. Informed Consent

Informed Consent for AMR Mental Health Therapy

Welcome to AMR Mental Health Therapy


This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you agree on the referral form it will represent an agreement between us. We can discuss any questions you have when at any time in the future.

Psychological Services

Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in psychotherapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But there are no guarantees about what will happen. Psychotherapy requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions. The first session will involve a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some initial impressions of what our work might include. At that point, we will discuss your treatment goals. You should evaluate this information and make your own assessment about whether you feel comfortable working with me. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I can refer you to another therapist.


Appointments will ordinarily be 50 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If it is possible, I will try to find another time to reschedule the appointment. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.

Cancellation Policy

The cancellation policy for services is 24-hour notice through either email or phone contact, otherwise the will be billed at a $40 rate for missed or cancelled sessions. Voicemail and email are available 24 hours a day, 7 days a week if you need to cancel your appointment. If we do not have a credit card on file, a bill will be emailed directly to you and must be paid in full to continue services. Upcoming appointments will need to be rescheduled. Previous appointment times cannot be guaranteed. After three cancellations, services may be terminated, and a referral will be given.

Professional Fees

AMR Mental Health Therapy is a private pay office. We do not take insurance. The cost of services will be discussed prior to first session. AMR Mental Health Therapy offers a sliding scale to those who qualify. Your session rates will be discussed during intake. AMR Mental Health Therapy accepts debit and all major credit cards. There is a $2 processing fee for credit cards. In addition to weekly appointments, it is my practice to charge $100 per hour on a prorated basis for other professional services that you may require such as report writing, telephone conversations that last longer than 15 minutes, attendance at meetings or consultations which you have requested, or the time required to perform any other service which you may request of me. If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required even if another party compels me to testify. I also provide assessments for emotional support animals. If you are interested in such an assessment it is a $175 fee, which includes the letter, if you meet criteria.

Professional Records

I am required to keep appropriate records of the psychological services that I provide. Your records are maintained in a secure location. I keep brief records noting that you were here, your reasons for seeking therapy, the goals and progress we set for treatment, topics we discussed, your medical, social, and treatment history, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file (outside of progress notes). Because these are professional records, they may be misinterpreted and / or upsetting to untrained readers. For this reason, I recommend that you initially review them with me, or have them forwarded to another mental health professional to discuss the contents. If I refuse your request for access to your records, you have a right to have my decision reviewed by another mental health professional, which I will discuss with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request.


My policies about confidentiality, as well as other information about your privacy rights, are fully described in the Notice of Privacy Practices. You have been provided with a copy of that document and we have discussed those issues. Please remember that you may reopen the conversation at any time during our work together.

Use of Technology

It is part of AMR Mental Health Therapy to utilize Thera Nest to update clients about records and to send and receive HIPPA information. AMR Mental Health Therapy utilizes encrypted e-mail certified by G Suite as HIPAA compliant if necessary, to communicate and send documents. However, this does not guarantee security on the client’s end, unless the client e-mail is through a secure server. Email is to only be used to request sessions or send necessary paperwork. AMR Mental Health Therapy will not respond to e-mails if they discuss treatment. If you are experiencing a crisis please call 911 or go to the nearest emergency room, email is not an appropriate form of communication. AMR Mental Health Therapy may send autogenerated text message reminders of appointment only. However, due to the lack of security via text message, AMR Mental Health Therapy cannot receive text messages. If you need to schedule to change an appointment, please contact AMR Mental Health Therapy.

Contacting Me

I am often not immediately available by telephone and E-Mail. At these times, you may leave a message on my confidential voice mail and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters. If you are experiencing a crisis or emergency, please go to the nearest emergency room, or contact 911. AMR Mental Health Therapy cannot guarantee a timely response in a crisis.

Teletherapy Consent

Teletherapy services are used when mental health staff is not physically present with you to evaluate your mental health needs. Mental health staff will be present at another location and available to serve you through newly available technology. Instead of talking to someone on the phone at another location, Teletherapy health services use a video camera and computer to send both voice and personal images (pictures) between you and mental health staff so not only can you talk to each other, but you can also see each other. This allows mental health staff to make a better evaluation of your needs.How is it different than a regular session with mental health staff?Other than you and mental health staff not being in a room together, there is very little difference in the session. Mental health staff will ask and document clinical information that you share, document the service that is provided, and ensure that documentation is included in your clinical record for future reference.

Teletherapy Services

Teletherapy does NOT provide emergency services. Nevada and California residents only may participate in teletherapy. It is the client’s responsibility to ensure they are considered a Nevada or California resident prior to participating in teletherapy. Teletherapy may be utilized for client’s only if teletherapy is determined to be appropriate for the client by the therapist. Teletherapy is through https://doxyme. or Thernaest both HIPAA compliant sites. Teletherapy exchange is confidential. Therapists are required to notify authorities if we suspect a client is about to physically harm someone; or if they are abusing, or about to abuse, children, the elderly, or the disabled. Teletherapy session are by appointments only. Clients initiate the contact for Teletherapy by going to the link https://doxy.me/amrtherapy. Please enter session five minutes prior to session. AMR Mental Health Therapy has the right to discontinue teletherapy if it proves to be ineffective for the client. AMR Mental Health Therapy will work with the client to suggest alternative options better suited to the client’s needs. The client must have a credit card on file to participate in teletherapy. The client understands that they will be charged $100 per 50-minute session. If the client is disconnected during session, they will be charged for the length of the time prior to disconnection. Client is responsible for information security on their computer. The cancellation policy for Teletherapy services is 24-hour notice through either email or phone contact, otherwise the will be billed at a $40 rate for missed or cancelled sessions.

Credit Card Authorization

AMR Mental Health Therapy uses the Square credit card processing system through TheraNest Data Security Standard (PCI- DSS) to ensure customer protection that stores sensitive credit card data. If you do not want to permit your credit card for payment, Venmo as payment can be You authorize AMR Mental Health Therapy to charge my credit card for services rendered. uses enhanced security PCI accepted. You authorize AMR Mental Health Therapy to charge my credit card for teletherapy sessions within 24 hours of services rendered. You authorize AMR Mental Health Therapy to charge my card for cancellations and missed sessions without a 24-hour notice. Missed sessions will be charged at $40 rate within 48 hours of missed appointment. You understand that I will be charged $2.00 service fee per transaction.Other RightsIf you are unhappy with what is happening in therapy, I hope you will talk with me so that I can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist and are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect that I will not have social or sexual relationships with clients or with former clients.

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