Informed Consent for Psychotherapy & Practice Policies

General Information

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

The Therapeutic Process

You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

My Approach to Therapy

  • My therapeutic style is trauma-informed and draws from the following: narrative therapy, systems therapy, relational therapy, polyvagal theory, mindfulness, motivational interviewing, solution focused brief therapy, and is emotionally focused and client-centered .

  • I am an autistic cisgender woman who brings my full self to all client interactions and invite you to bring your full self to session as well.

  • I am an LGBQIA+ ally, sex-positive, kink-friendly, and neurodiversity affirming in my practice. I have experience with open relationships, strive to be sex-worker friendly, and desire to show up without judgement to any human seeking support.

  • If you experience otherwise, please tell me so I can improve.

  • I have worked with nonprofits, child welfare systems, schools, churches with private individuals, and groups to provide social work services, therapy, and yoga/embodied movement instruction, case management, and consultation.

  • My goal is for you to feel confident in your ability to navigate the waves of life and use our time to check in, vent and receive support, and strategize how to help you continue living a life you desire without your mental health interfering beyond your ability to cope.

Neurodivergence Notes:

  • You may see me using fidget tools during session. These allow me to maintain mindful presence during our time together as my mind often needs physical micro movements to focus.

  • You may see me have my Emotional Support Dog Tailz in session from time to time.

  • You are welcome to bring your pet, stuffed animals, and other comfort items as desired

PRACTICE POLICIES: CONFIDENTIALITY

The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons.

Limitations of such client held privilege of confidentiality exist and are itemized below:

  1. If a client threatens or attempts suicide or otherwise conducts themselves in a manner in which there is a substantial risk of incurring serious bodily harm to themself or someone else.

  2. If a client threatens grave bodily harm or death to another person.

  3. If 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.

  4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

  5. Suspected neglect of the parties named in items #3 and # 4.

  6. If a court of law issues a legitimate subpoena for information stated on the subpoena.

  7. If 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.

Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

PRACTICE POLICIES: COMMUNITY CONNECTIONS

  • If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy.

  • That said, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

PRACTICE POLICIES: APPOINTMENTS AND CANCELLATIONS

  • Please remember to cancel or reschedule 36-48 hours in advance. You may be responsible for the cancellation fee if cancellation is less than 24 hours and/or if you fail to communicate to the therapist about rescheduling in a reasonable length of time if an emergency arises.

  • Cancellation fees are $100/session and may be waived at the therapist’s discretion.

  • We are all human and I do not desire to charge cancellation fees, however, cancellation fees will be charged in the event of a no-show, no-call after 48 hours have passed from the time of appointment.

  • Cancellations and re-scheduled session may be subject to a full charge if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time.

  • The standard meeting time for psychotherapy is 60 minutes at the standard rate of $250 per session (or the negotiated rate if you are accessing services through my Pay What You Can Model). I offer therapy in 30, 45, 60, 75, and 90 minute sessions. Each of these sessions carries a unique standard rate which is discussed in session.

  • It is up to you, however, to determine the length of time of your sessions and a standard session length and rate will be established during the initial intake appointment and evaluation. Requests to change the 60-minute session needs to be discussed with the therapist in order for time to be scheduled in advance.

  • Generally, I schedule up to 6 sessions at a time in the length selected during our initial appointment. Clients may request changes to the session length or meeting time in communication with the therapist.

  • Clients will be scheduled for 6 sessions after the initial intake to ensure that time is reserved in the clinicians calendar. After 4 sessions, the client will be offered the opportunity to continue booking sessions in increments of 4-6 sessions depending upon frequency.

  • If the client declines to book additional appointments through the clinician after the initial treatment time period (generally 2 months/6 sessions), the client waives the opportunity to have their regular appointment time held. Clients may request appointments via the client portal.

PRACTICE POLICIES: PAYMENT & INSURANCE UTILIZATION

  • All payment must be made at the time of services unless otherwise arranged with Kimberly Louvin, LCSW.

  • Clients utilizing Oregon Health Plan for services will NOT be charged for any services at any time.

  • Clients utilizing Commercial Health Insurance are billed via Headway - a third party company and clients complete independent Consent Documents via Headway.

  • Clients utilizing health insurance as a form of payment agree to update Kimberly Louvin LLC with any changes regarding their health insurance benefits that may affect access to therapy services.

  • For clients who are wishing to utilize Out of Network Benefits, I am able to provide what is called a SuperBill that clients may turn in to insurance company for possible reimbursement via Out of Network (OON) Benefits. Clients are encouraged to contact their insurance provider BEFORE beginning services to inquire about out of network benefits.

  • Superbills require a diagnostic code to be assigned, which can become a part of your medical record. Please let me know if you have concern about this and we can discuss this.

  • If a client wishes to use OON benefits and cannot pay up front, you are encouraged to connect with the provider ASAP and discuss alternative arrangements.

PAYMENT PROCESSING

  • Clients establish a method of payment via credit card that is kept on file PRIOR to the intake appointment.

  • Clients utilizing health insurance as a form of payment agree to provide updated insurance information to the therapist before sessions begin and as any changes take place to their insurance benefits.

  • Clients are billed within 24 hours after the start time of their appointment and agreement to this policy acknowledges that if any payment methods need to be adjusted, updated, or negotiated, that the client will notify the the therapist in writing or during session to avoid payment errors.

  • Clients are expected to pay balances before the start of the next session unless other arrangements are made with the clinician.

  • Clients who have a balance of more than 2-session fees will not be able to schedule future appointments until a payment has been made or an arrangement has been established.

PAYMENT RATES

  • The standard meeting time for psychotherapy is 60 minutes at the standard rate of $250 per session for clients paying Out of Pocket. I offer therapy in 30, 45, 60, 75, and 90 minute sessions. Each of these sessions carries a unique standard rate which is discussed in session.

  • Sliding scale rates are available through a Pay What You Can Fee model where a per-session rate is established during the Consultation or Intake appointment. This fee is reviewed every 6 sessions to ensure it is in alignment with client’s ability to access therapy as frequently as desired without compromising economic stability.

PRACTICE POLICIES: TELEPHONE AND EMAIL ACCESSIBILITY

  • I do not make myself available to clients between session, but if you would like to schedule an additional brief session, contact me and I will check my availability.

  • I do not offer crisis support to clients due to the model of practice I operate within and generally am not available to offer same-day appointments or communication.

  • If you need to contact me between sessions, please leave a message on my voice mail or contact me via email at kimberly@kimberlylouvin.com.

  • Communication outside of the client portal or these methods is not guaranteed to be as secure. Any identifiable information sent by the client outside of the client portal is done at the assumed risk of the client. I strive to maintain a high level privacy and confidentiality for clients.

  • Please note that Face- to-face sessions via video call are highly preferable to phone sessions. However, in the event that you are out of town, sick or need additional support, phone sessions may be available.

  • If an emergency situation arises, please call 911 or any local emergency room.

PRACTICE POLICIES: SOCIAL MEDIA AND TELECOMMUNICATION

  • Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, Instagram, LinkedIn, etc). I believe that connecting with clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship.

  • Your choice to follow, like, or share any public-facing social media, blog, or other publicly available material does not indicate my endorsement of you and I will not disclose our professional therapeutic relationship unless you have signed a Release of Information and given me explicit permission to do so.

  • If you have questions about this, please bring them up when we meet and we can talk more about it.

PRACTICE POLICIES: TREATMENT OF CLIENTS UNDER 18

  • If you are a minor, your parents may be legally entitled to some information about your therapy. I am happy to discuss this via email or in a free consult for prospective clients.

  • Minors over the age of 14 in the States of Oregon and Washington, 16 in Tennessee, and 16 in Florida are able to access mental health care services without the consent of their parents or guardian.

  • For more information on this https://www.hearthsidemedicine.com/post/child-teen-health-rights-in-oregon-what-you-should-know

  • My goal is for parents/guardians to be aware of services and willing to receive any updates the client would like them to have at a timeline and in a manner established through the therapeutic relationship.

  • As necessary, I will discuss with the client and their parent/legal guardians what information is appropriate for them to receive and which issues are more appropriately kept confidential.

PRACTICE POLICIES: TERMINATION OF SERVICES

  • Ending relationships can be difficult.

  • Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment.

  • I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.

  • Should you fail to schedule an appointment for four consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.

  • If a client does not schedule appointments and the professional relationship is discontinued, the client may reach out to the provider to request resuming the therapeutic relationship. At this time, its up to the discretion of the clinician and availability of appointments regarding the need for a new intake appointment, etc.