Office Policies & General Information Agreement for Psychotherapy Services or Informed Consent for Psychotherapy
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.
WHEN DISCLOSURE IS REQUIRED OR MAY BE REQUIRED BY LAW: Some of the circumstances where disclosure is required 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 Dr. Bonaventura 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 the psychotherapy records and/or testimony by Dr. Bonaventura. In family therapy, or when different family members are seen individually, even over a period of time, confidentiality and privilege do not apply among family members, unless otherwise agreed upon. Dr. Bonaventura will not release records to any outside party unless she is authorized to do so by all adult parties who were part of the family therapy, or other treatment that involved more than one adult client.
EMERGENCY: If there is an emergency during therapy where Dr. Bonaventura becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, she will do whatever she 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.
HEALTH INSURANCE & CONFIDENTIALITY OF RECORDS: Disclosure of confidential information, such as diagnosis, may be required by your health insurance carrier or HMO/PPO/ MCO/EAP in order to process the claims. If you so instruct Dr. Bonaventura, only the minimum necessary information will be communicated to the carrier. Dr. Bonaventura has no control over, or knowledge of, what insurance companies do with the information she submits or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy or to future capacity to obtain health or life insurance or even a job. The risk stems from the fact that mental health
information is likely to be entered into big insurance companies' computers and is likely to be reported to the National Medical Data Bank. Accessibility to companies' computers or to the National Medical Data Bank database is always in question as computers are inherently vulnerable to hacking and unauthorized access. Medical data has also been reported to have been legally accessed by law enforcement and other agencies, which also puts you in a vulnerable position.
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 Dr. Bonaventura to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested unless otherwise agreed upon. Should Dr. Bonaventura be subpoenaed to court, her fee for time in court (including drive time and preparation) will increase to $400.00 per 50 minutes.
CONSULTATION: Dr. Bonaventura consults regularly with other professionals regarding her clients; however, each client's identity remains completely anonymous and confidentiality is fully maintained.
E–MAILS, CELL PHONES, COMPUTERS, AND FAXES: It is very important to be aware that computers and e-mail communication as well as texts by phone can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. E-mails, in particular, are vulnerable to unauthorized access due to the fact that internet servers have unlimited and direct access to all e-mails that go through them. It is important that you be aware that e-mails, and important texts are part of the medical records. Dr. Bonaventura does use HIPPAtizer, so that her e-mails through HIPPAtizer are encrypted. She uses HIPPAtizer for transmission of confidential information, including superbills, and encourages her clients to email through HIPPAtizer to ensure confidentiality. Additionally, Dr. Bonaventura’s computers are equipped with a firewall, a virus protection, and a password and she also backs up all confidential information from her computers on a regular basis. Please notify Dr. Bonaventura if you decide to avoid or limit the use of any or all communication devices, such as e-mail, cell phone, texts. If you communicate confidential or private information via e-mail outside of HIPPAtizer, Dr. Bonaventura will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via e-mail. Please do not use e-mail for emergencies.
RECORDS AND YOUR RIGHT TO REVIEW THEM: Both the law and the standards of Dr. Bonaventura’s profession require that she keep treatment records for at least seven years. Unless otherwise agreed to be necessary, Dr. Bonaventura retains clinical records only as long as is mandated by Texas law. If you have concerns regarding the treatment records, please discuss them with Dr. Bonaventura. 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 Dr. Bonaventura assesses that releasing such information might be harmful in any way. In such a case, Dr. Bonaventura 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, Dr. Bonaventura will release information to any agency/person you specify unless Dr. Bonaventura assesses that releasing such information might be harmful in any way. When more than one client is involved in treatment, such as in cases of family therapy, Dr. Bonaventura will release records only with signed authorizations from all the adults (or all those who legally can authorize such a release) involved in the treatment.
TELEPHONE & EMERGENCY PROCEDURES: If you need to contact Dr. Bonaventura between sessions, please leave a message at (323) 835-3661 and your call will be returned as soon as possible. Dr. Bonaventura checks her messages several times daily. If an emergency
situation arises, indicate it clearly in your message and if you need to talk to someone right away in an emergency, call 911. Please do not use e-mail for emergencies. Dr. Bonaventura does check her e-mail and texts daily during normal business hours.
PAYMENTS & INSURANCE REIMBURSEMENT: All billing arrangements will be discussed and agreed upon before any psychological services are rendered. Clients are expected to pay the standard fee of $200.00 per 50 minute session. Dr. Bonaventura will charge credit cards on file on the day of the scheduled session unless other arrangements have been made. Please notify Dr. Bonaventura if any problems arise during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance companies. Unless agreed upon differently, Dr. Bonaventura will provide you with a copy of your receipt (“superbill”) on a monthly basis, which you can then submit to your insurance company for reimbursement, if you so choose. As was indicated in the section, Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems, which are dealt with in psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage.
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 Dr. Bonaventura 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 Texas in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed. 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.
THE PROCESS OF THERAPY/EVALUATION AND 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. Dr. Bonaventura 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. Dr. Bonaventura 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. During the course of therapy, Dr. Bonaventura is likely to draw on various psychological approaches according, in part, to the problems that are being treated and her assessment of what will best benefit you. These approaches include, but are not limited to, psychodynamic, family systems, cognitive-behavioral, ACT, existential, developmental (adult, child, family), humanistic or psycho-educational. Dr. Bonaventura provides neither custody evaluation recommendation nor medication or prescription recommendation nor legal advice, as these activities do not fall within her scope of practice.
TREATMENT PLANS: Following the initial evaluation, Dr. Bonaventura will discuss with each client her working understanding of the issues presented, and will create a treatment plan including therapeutic objectives, initial diagnosis, techniques to be used in treatment, and a tentative timeframe for treatment. This treatment plan will be discussed and consent will be obtained by the client before treatment commences. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, Dr. Bonaventura's 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 for your condition and their risks and benefits.
TERMINATION: As set forth above, after the first meeting, Dr. Bonaventura will assess if she can be of benefit to you. Dr. Bonaventura does not accept clients who, in her opinion, she cannot help. In such a case, she will give you a number of referrals whom you can contact. If at any point during psychotherapy, Dr. Bonaventura assesses that she is not effective in helping you reach the therapeutic goals or that you are non-compliant, she is obligated to discuss it with you and, if appropriate, to terminate treatment. In such a case, she would give you referrals that may
be of help to you. If you request it and authorize it in writing, Dr. Bonaventura 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, Dr. Bonaventura will assist you with referrals, and, if she has your written consent, she will provide her or him with the essential information needed. You have the right to terminate therapy at any time. If you choose to do so, and if appropriate, Dr. Bonaventura will offer to provide you with names of other qualified professionals.
DUAL RELATIONSHIPS: Despite a popular perception, not all dual or multiple relationships are unethical or avoidable. Therapy never involves sexual or any other dual relationship that impairs Dr. Bonaventura's objectivity, clinical judgment or can be exploitative in nature. Dr. Bonaventura will assess carefully before entering into non-sexual and non-exploitative dual relationships with clients. It is important to realize that in some communities, particularly small towns, military bases, university campus, etc., multiple relationships are either unavoidable or expected. Dr. Bonaventura will never acknowledge working with anyone without his/her written permission. Nevertheless, Dr. Bonaventura will discuss with you the often-existing complexities, potential benefits and difficulties that may be involved in dual or multiple relationships. Dual or multiple relationships 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 Dr. Bonaventura if the dual or multiple relationship becomes uncomfortable for you in any way. Dr. Bonaventura will always listen carefully and respond to your feedback and will discontinue the dual relationship if she finds it interfering with the effectiveness of the therapy or your welfare and, of course, you can do the same at any time.
SOCIAL NETWORKING AND INTERNET SEARCHES: I do not accept friend requests from current or former clients on social networking sites, such as Facebook. I believe that adding clients as friends on these sites and/or communicating via such sites is likely to compromise their privacy and confidentiality. For this same reason, I request that clients not communicate with me via any interactive or social networking web sites.
CANCELLATION: Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours notice is required for rescheduling or canceling an appointment. Unless we reach a different agreement, the full fee of $200.00 will be charged for sessions missed without such notification. Insurance companies do not reimburse for missed sessions.
I have read the above Office Policies and General Information, Agreement for Psychotherapy Services or Informed Consent for Psychotherapy carefully (a total of 6 pages), including Dr. Bonaventura’s 24 hour cancellation policy.