Confidentiality & Privacy Policy
The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without written permission.
Exceptions include:
- Suspected child abuse or dependent adult or elder abuse, for which I am required by law to report this to the appropriate authorities immediately.
- If a client is threatening serious bodily harm to another person/s, I must notify the police and inform the intended victim.
- If a client intends to harm himself or herself, I will make every effort to enlist their cooperation in ensuring their safety. If they do not cooperate, I will take further measures without their permission that are provided to me by law in order to ensure their safety.
Amee Dassani, Psy.D.
Confidentiality Form
I am so excited that you have allowed me the privilege of joining you on this healing journey! Please review this document in order to understand the process of therapy from a legal and ethical perspective. I want to let you know that our sessions are completely confidential. However there are some limits to confidentiality. It is important for you to review this document and agree to it. If you have any questions about anything written here, I would be happy to answer these questions.
PSYCHOLOGICAL SERVICES
Psychotherapy will be based on the individual needs of the client. The term “psychotherapy” is not easily described in general terms, as there are many theoretical orientations and many doctors treat clients in different ways. There are many different methods I may use to deal with the problems that you hope to address. Psychotherapy calls for an active approach on your part and you will have to work on things we talk about both during our sessions and at home.
Psychotherapy can have benefits and risks. Since we will discuss some difficult topics and issues in our sessions this may bring up uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness usually this is temporary. There are also benefits such a better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience as everyone is unique and will react differently.
How Therapy Works with Dr. Amee Dassani
In our first few sessions, we will gather information in regards to your family relationships and background. We will work together to understand your life problems and what factors of your life contribute to these issues, which seem ongoing. This information will guide the process of therapy and I will offer strategies to give you some relief. Initially, I will be getting to know you and understand your problems and difficulties. I am very open and non-judgmental. I strive to make you as comfortable as possible during this process. We will examine your family relationships and patterns. What are areas that you feel stuck in? In addition, we will examine some of your core beliefs and how these have impacted you. My intention is for you to live to your highest potential. Uncovering the blocks to this will help me find strategies to help you live in more joy and less distress. Some of these core beliefs may bring you some more pain and sadness initially, but we will work through them to resolve these emotions as they come up.
In some cases, therapy involves recommendations to other professionals such as physicians, psychiatrists, etc.. While these recommendations are not requirements, they may be necessary for you to fully recover and avoid serious difficulties. In addition, I require that you provide me with two names as emergency contacts.
It is important for you to work with a therapist who you feel completely comfortable with, if you have any concerns, I am happy to offer referrals to a therapist better suited to your needs.
ONLINE THERAPY SESSIONS
Most of my sessions are conducted online through a HIPAA compliant (very confidential) therapy site called ITherapy. Research has shown Videosessions to be just as effective as in person sessions. In addition there are many benefits to this type of session. You do not have to travel or pay for parking and therapy is conducted in the leisure of your free time at home. With the busy lives we all live, this type of session offers the convenience of being comfortable in your own home and many clients report feeling more comfortable discussing difficult issues in their own home rather than in an office. All you need is to have internet access or a cell phone. Sessions are conducted using the Zoom application, which can be easily downloaded.
Limitations of Online Psychotherapy
Telephone, chat, and video sessions have limitations compared to in-person sessions. It is important to consider if those limitations may impact your therapeutic progress and select an in-person provider if so. In some clinical situations, such as crises or suicidal or homicidal thoughts, in-person treatment may be the most appropriate treatment choice.
Online psychotherapy providers, like many in-person providers, do not provide 24-hour crisis services. If a life-threatening crisis should occur, contact a crisis hotline, call 911, or go to a hospital emergency room. Should your clinician determine that you are at risk, he/she may call local police to assess your safety in person.
Technology is not always consistent and we may lose contact through our session. If this occurs please know that I will make every attempt to make contact. As a lost resort, I will call you in order to complete our session.
Consultation:
I consult regularly with other professionals regarding my clients; however the client’s name or other identifying information is never disclosed. The clients’ identity remains completely anonymous and confidentiality is fully maintained.
Dual Relationships
Not all dual relationships are unethical or avoidable. However in order to respect the integrity of therapy, the therapeutic relationship will remain professional.
In addition, your clinician will never acknowledge working therapeutically with anyone without his or her written permission. In some instances, even with permission, the clinician may choose to preserve the integrity of the therapy relationship. For this reason, your clinician will not accept any invitations via social networking sites nor will he/she respond to blogs written by clients. Your clinician will not build a relationship with you outside of sessions, which means that outside of session communications will be limited to scheduling purposes.
LIMITS ON CONFIDENTIALITY
The law protects the privacy of all communications between a patient and a psychologist. In most situations, we can only release information about your treatment to others if you sign a written Authorization form. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make sure that the other professional is aware of confidentiality. We will note all consultations in your Clinical Record, which is kept confidential.
If a client seriously threatens to harm himself/herself or others, we may seek hospitalization for him/her, or to contact family members or others who can help provide protection. Illinois law provides that a professional may disclose confidential information only to medical or law enforcement personnel if the professional determines that there is a probability of imminent physical injury by the patient to the patient or others, or there is a probability of immediate mental or emotional injury to the patient. In the event that you are hospitalized by someone other than myself, a signature on this consent form allows me to speak to the medical doctor, and authorized employees in charge of your care.
As a mandated reporter, I am required to report any child abuse or elderly abuse that I am aware of.
A court order is the only way that clinical notes can be sent without your consent and I will only send the minimum required information with your consultation. However, I will discuss privilege of your rights with any second parties who request this information before anything is sent.
BILLING AND PAYMENTS
Our session fee is range from $120 to $150. I currently accept Blue Cross and Blue Shield of Illinois and Meridian Health Plan. Please email me a copy of your insurance card (front and back) and a copy of your driver’s license if you have insurance. This email will be deleted once I transfer this information into my secure database.
You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. Co-pays are due at each session.
Health insurance companies require that I provide them with information relevant to the services provided to you. I am are required to provide a clinical diagnosis and sometimes additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, we will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, we have no control over what they do with it once it is in their hands.
The Process of Termination
I recommend that therapy end through a few sessions and a process of termination. This will allow you to review therapeutic gains achieved during treatment; develop a plan of action to maintain those gains; identify what other services or activities may still be needed; and to process any emotions that may exist regarding the ending of the therapeutic relationship. If you decide to end therapy without engaging in the process of termination, I appreciate if you let me know through an email or voicemail communication. If I do not hear from you, once I leave two messages, not returned, I will assume you no longer wish to receive services and you will be discharged from care. However, you can call at any time to schedule an appointment if you wish to continue.
Both the therapist and the client have the right to end counseling at any time.
Mediation and 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 initial of arbitration. The mediator shall be a neutral third party chosen by agreement of iTherapy, your clinician and you (the client). The cost of such mediation, if any, shall be split equally, unless otherwise agreed. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorney’s fees. In the case or arbitration, the arbitrator will determine that sum.
Agreement
Your signature indicates that you have read this five-page contract; that you understand all that it contains; that you agree to abide by it’s terms; and that you voluntarily consent to treatment. Additionally, your signature below indicates that you understand that I, Amee Dassani,Psy.D., am an independent practitioner; therefore, iTherapy, and associated providers are not responsible for or involved in your (the client’s) care or treatment unless you directly contracted with that provider.
_________________________________________________ _________________
Signature Date
Please initial if you consent to the willingness to discuss scheduling via:
Email: ______
Preferred Email Address for Communication:_____________________________
Text: _______
Preferred Cell Phone Number for Communication:_______________________
Phone:_______
(Cell Phone Number above unless otherwise noted:_____________________
Voicemail: ______ (Cell Phone Number above unless otherwise noted)
Please sign and date to signify that you have read and understand the Privacy Statement Document:
_________________________________________________ _________________
Signature (Adult or Minor Aged 16 or older) Date
After reading the Privacy Agreement, please initial if you consent to the willingness to share your Protected Health Information via:
Email: ______
Preferred Email Address for Communication:_____________________________
Text: _______
Preferred Cell Phone Number for Communication:_______________________
Phone:_______
(Cell Phone Number above unless otherwise noted:_____________________
Voicemail: ______ (Cell Phone Number above unless otherwise noted)
Communication by Email, Text Message, and Other Non-Secure Means
It may become useful during the course of treatment to communicate by email, text message (e.g. “SMS”) or other electronic methods of communication. Be informed that these methods, in their typical form, are not confidential means of communication. If you use these methods to communicate with Dr. Amee Dassani, there is a reasonable chance that a third party may be able to intercept and eavesdrop on those messages. The kinds of parties that may intercept these messages include, but are not limited to:
- People in your home or other environments who can access your phone, computer, or other devices that you use to read and write messages
- Your employer, if you use your work email to communicate with Dr. Amee
- Third parties on the Internet such as server administrators and others who monitor Internet traffic
If there are people in your life that you don’t want accessing these communications, please talk with Dr. Amee about ways to keep your communications safe and confidential.
CONSENT FOR TRANSMISSION OF PROTECTED HEALTH INFORMATION BY NON-SECURE MEANS
Please initial next to each item you consent to. I consent to allow Dr. Amee Dassani to use unsecured email and mobile phone text messaging to transmit to me the following protected health information:
____Information related to the scheduling of meetings or other appointments
____Information related to billing and payment
____ Information that is clinical in nature (e.g. treatment summaries, diagnosis)
I have been informed of the risks, including but not limited to my confidentiality in treatment, of transmitting my protected health information by unsecured means. I understand that I am not required to sign this agreement in order to receive treatment. I also understand that I may terminate this consent at any time.
(Signature of client) Date
**Written communication of this consent form is based on a workshop conducted by Dr. Amber Lyda and some of the wording is copied from her consent form and from the consent form found on ITherapy.