Informed Consent

 


New Client Forms
Please feel free to read the following forms to learn more about me and my
services.  For new clients, please read these forms prior to your first appointment.Informed Consent and Treatment GuidelinesLaura Umfer, Psy. D., C-MI, C.C.H., SFN, LLC.
Licensed Clinical Psychologist  PY 7289
4511 North Himes Ave, Suite 200 Tampa, FL 33614
813-385-7974
umfer@umfer.orgProfessional StatementWelcome to my practice. This statement will provide you with information regarding my qualifications, my therapeutic philosophy and what you can expect while working with me. Being in therapy requires much time, energy, money and commitment on your part, and you may want to carefully choose your psychologist. During our first meeting, we can discuss your concerns and decide if we can effectively work together. Should you have any concerns, at any time during our work together, please voice them.Qualifications

I am a licensed clinical psychologist and a forensic psychologist, with a doctoral degree from the Florida School of Professional Psychology at Argosy University, an American Psychological Association (APA) accredited program. I completed my pre-doctoral internship at Coastal Behavioral Health Care Inc., which is accredited by the APA. My post-doctoral training was through Psychological Management Group, which was a forensic residency. I am a member of NBCCH, AIHCP, and ICBCH. I am also a certified meditation instructor and certified clinical hypnotherapist.

My specialty focuses on, but is not limited to the following: anxiety, PTSD, military psychology, women’s issues, weight loss, eating disorders, substance abuse evaluations, chronic pain, mind-body conflicts, depression, anger management issues, sex offender evaluation… I treat both adolescents and adults with those issues, in addition to adolescents with conduct and substance abuse problems. If I do not think I have the experience and competence to work with you, then I will help you find a clinician who does.


Therapeutic Philosophy

My theoretical orientation is eclectic, with a focus on cognitive-behavioral, solution focused and spiritualistic approaches (via meditation and hypnosis training). Basically I tend to focus on your thought patterns and emotions, and will help you to better identify and trust your instincts. I have an open, direct style of interacting with people, and I tend to be honest, and sometimes more honest than people would sometimes like. I use my reactions to therapeutic encounters as a tool to better understand you and help you meet your treatment goals. However; I am able to adapt to using empirically supported methods that are best suited for the problems that you are experiencing, that are within my realm of competence. Our work together involves your self-healing via my support, education, guidance and occasional reality checks. While therapy can be painful at times, it does not have to be. I believe that it is important to use humor to cope with painful emotions and experiences, and to enhance the strengths you already have, rather than solely focusing on what is not working for you. I abide by the APA’s code of ethics and I strive to exceed these guidelines. These guidelines can be found on the APA’s website: apa.org.


Goals of Therapy

We will work as a team to enable you to reach your fullest potential. My main goal is to aid you in self-discovery, symptom reduction and learning better means of coping and living. Specific goals are a joint effort between us, and goals will be defined once we assess what issues to address in therapy. In and out of session tasks must be mutually agreed upon, and you can refuse to engage in any activity that you are not comfortable with. However, if you are seeking treatment for sex offender therapy or reunification services, then for the safety of the involved children and the community, there may be times when certain guidelines must be followed in order for treatment to proceed.


Termination

While discussing treatment goals, we will also target a termination date. Therapy should end when treatment goals are met, or if some situation warrants a referral to another clinician. We may determine that more time is needed to complete treatment goals. Ideally, therapy should end once you are able to apply the techniques learned in therapy to various problems that surface. We may elect to schedule a booster session several months after we end our work together to evaluate your progress. We will also discuss what circumstances would warrant you choosing to re-enter therapy.

 

Issues Related to Individual and Groups in Sessions

In most cases, I know initially if I will be working with an individual, a couple or a family. Sometimes, during the course of therapy, we may agree to allow other family members or significant others to attend a limited number of sessions. Confidentiality, as defined below will be maintained, however if engaged in couples or family therapy, there will be no secrets between a member and myself. If initially engaged in couples or family therapy, I will not generally see a couple or family member alone. If you are a minor, you, your parent(s)/guardian and I will contract a confidentiality agreement. Generally, parents have a right to information about their children. My stance is that the child has a right to privacy, unless they are engaging in harmful behavior the parent/s should know about. In those situations, the minor and I will discuss how to inform the parent/s/guardian/s to encourage the minor to trust and take accountability.


Confidentiality

Confidentiality is generally protected by law, and I can only release information about you with your written consent. However; there are exceptions, including you being a danger to yourself or others. If you are considering harming yourself, I may be required to seek hospitalization for you or contact a family member to help keep you safe. I may also have to seek hospitalization if your weight or health status makes you a danger to yourself. If you are threatening to harm another, I may have to contact the potential victim or the authorities or seek appropriate hospitalization. I am obligated by law to report all cases of children, elderly or disabled persons being abused.

There may also be instances where I am court ordered to provide information about our work together, although you have the right to prevent me from doing so. However, if you are involved in a court proceeding where your emotional condition is an important element (ex: insanity defense, custody proceedings, suing your psychologist) confidentiality can and likely will be broken.

Some insurance companies require treatment plans, clinical diagnosis, progress notes, or an entire record, which becomes part of your permanent record. You must sign a consent form before I can release such information.

There may be times when I consult with other professionals about your case, and confidentiality binds these consultations. Basically, I shield your identity when discussing your case with other professionals. Except for consultations, I will first discuss with you any intention to provide information to a third party about our work together.

There may be times where we may have spontaneous contact in the community, such as the grocery store, or the mall. To protect your confidentiality and our therapeutic relationship, I will not initiate contact, and I will not be able to engage in any type of social activity with you. However, you may choose to initiate contact. My stance is once a client, always a client. Therefore, we will not be able to be friends, date, and work as co-workers, ever. This is to protect you, and I will be happy to discuss this in more detail with you.

Confidentiality cannot be guaranteed while using email, Skype or any online communication.

Contact Outside of Therapy

Our relationship is professional, and our contact will be limited to therapeutic sessions. In the event of an emergency, such as wanting to hurt yourself, call 911 or 1-(800)-799-7233, unless other arrangements have been made and contracted upon. I frequently check my messages and email, and I will return your calls as soon as possible. If I am away for an extended period of time, I will leave the number of a trusted colleague.


Expectations from Therapy

Therapy is often an intense, powerful and sometimes a disruptive life experience. You may feel uncomfortable as feelings surface, or when altering your (eating, addictive etc.) behaviors. You may have heard the expression ‘the cure is worse than the disease’. In other words, it usually feels worse before it gets better. You may make many changes, such as changing jobs, ending a relationship or seeking shelter. However; you have an opportunity to replace unhealthy habits, reduce negative symptoms and improve your well being and your relationship with yourself and with others.


Tasks of Therapy

Our beginning sessions will focus on evaluation of your needs and determining treatment goals. Our sessions will be 45 minutes for individual sessions, and usually take place once weekly. Therapy sessions generally include talking and processing, role- playing, relaxation exercises and completing thought/feeling exercises, as well as other techniques appropriate to your needs. Some tasks may also be out of session assignments that are meant to enhance your therapy experience, and prepare you for forthcoming sessions. You may be asked to practice relaxation techniques, read materials, attend AA, NA or OA, or complete a food diary, depending on your needs. You may also engage in an activity that our sessions prepared you for, such as asking for a raise, or setting a limit with a child or spouse.


Responsibilities

You and I are responsible for honoring our contract, including billing arrangements (See List of Fees and Terms of Engagement Contract for specifics regarding cancellation and no-show fees). I also expect you to attend scheduled sessions on time and to be prepared to discuss any issues you may want to focus on. You are also responsible for completing tasks you agreed to complete and to bring up any concerns you may have about our contract or our work together. It is ok to tell me something you may think I won’t want to hear. I can handle it. This is one of the times in your life where it really is about you and your needs. These guidelines also apply to situations, where you or your minor, engage in psychological testing or evaluation. However; there may be cases where the court and related parties will have access to those reports, which will be discussed prior to beginning any of these functions. If you are already in therapy with me, then I will not be able to provide psychological testing or evaluation, and you will have to be provided with referrals. There may be exceptions, such as intelligence testing to aid treatment or some other specific symptoms that need clarification. However; once therapy begins, I will not be able to testify as an expert witness, only a fact witness as your therapist, nor will I be able to provide a risk assessment evaluation (different from ongoing risk assessment), psychological testing or any testing regarding custody issues. Also, there are always situations that occur that are not covered in this form that may be complex, and will warrant discussion as to the best way to solve the problem while respecting your rights, boundaries and well being.

I do not visit my patients’ social media sites, such as facebook, twitter etc., so if you are reaching out for help, I won’t know about it. Please contact me, or call 911 if it is an emergency. You can also call 211 in Florida for help and for resources. If you follow me on twitter, (as it is only for blogging about articles to enhance wellness) please keep any comments related to the article and maintain your boundaries by not telling people you are a patient. I will not be able to follow you.

 

Terms of Engagement Contract

 

I appreciate your decision to retain me as your psychologist. The following summarizes my office’s billing practices and certain other terms that will apply to our relationship:1.  Payment is expected prior to each session. Initial appointments require payment via a credit card of $180.00, or more for hypnosis/evaluations, for your first session or more for evaluations. This can be achieved over the telephone or email, whatever you are more comfortable with. Exceptions can be made, but are not guaranteed. If we haven’t worked together long enough to have established trust, and you don’t have your fee, we will reschedule for another time. I refuse to get into situations where people owe money. It puts too much strain on you and our professional relationship. This helps avoid focusing time and energy on finances, and allows us to focus on the reasons you are seeking my services. No shows or not cancelling within a reasonable time frame (48 hours) will result in being charged a $180.00 (unless other set fee was arranged) cancellation fee (more if being seen for an evaluation). That will be expected to be paid along with your regular fee in your next session. If I have your credit card information stored, I will bill it at that time. I understand that life happens, but it is not fair to others who want to get into my schedule to no-show or cancel without adequate notice. For those with insurance, if insurance does not pay for services, your card will be charged. If payment by credit card or check is denied due to insufficient funds, you authorize Laura Umfer, Psy.D.,LLC to reveal my name and the type of services sought to a collection agency in order to collect the funds. This applies to all fees, including the cancellation policy. When establishing fees for services I render, I am guided primarily by the time endured in clinical and academic experiences, in addition to individual needs and financial situations based on each individual’s needs.  I invite my clients to discuss freely with me any questions that may arise concerning a fee charge for any matter. I want my clients to be satisfied with both the quality of my professional services and the reasonableness of the fees that I charge for these services. I will attempt to provide as much detailed billing information as may be required in any customary form desired. I am willing to discuss with my clients any of the billing formats my office uses and that may best suit the client’s needs.In determining a reasonable fee for the time and labor required for a particular project, I take into account the skills, time demands, and other factors influencing the professional responsibility required for each matter. My internal allocation of values for my time as well as for my psychological assistant, research assistant, and other personnel changes periodically to account for increases in cost of delivering professional services and other economic factors. The following applies to individuals who require case management or other forensic services, which may include consultations with third parties you have consented for me to confer with about your case, letters written to attorneys, judges etc. or other matters requiring services in addition to therapy sessions.Services based on hourly rates are applied perspectively, as well as to unbilled time previously expended. My office records and bills time in one-quarter hour (15-minute) increments. Generally telephone calls under 15 minutes will not be billed, however calls in excess of 15 minutes will be billed accordingly. This will also include email exchanges.In addition to my professional fees, my statements may include out-of-pocket expenses that my office has advanced on behalf of the client or the client’s project.Any additional fees will be expected to be paid by the next therapy sessions, as it will be added to your usual fee.Forensic fees will be established on an individual basis. These fees are higher and require a retainer if court testimony is involved. I bill for time spent preparing your report, for depositions and court testimony, even if I never make it to the witness stand, if I spent time preparing I bill accordingly.By signing this, below, I agree to the above policy and to have my credit card charged in the event I forget other form of payment, unless other arrangements are made, or if I fail to show for an appointment or do not cancel in a timely fashion. No-shows and cancellations without 48 hour notice will result in a $180.00 (more for evaluations/hypnosis) fee being charged, unless other arrangements are made. Premium rates apply for services rendered on weekends or holidays. These fees also apply to anyone with insurance who does not follow the cancellation policy, regardless of what the set insurance fees are. Forensic fees and evaluation fees typically range from $250-300.00 an hour, should legal issues warranting my services surface during or post-treatment, please be aware of these fees.  Should anyone decide to be deceptive and change anything on these forms, I agree that what is on this site and Dr. Umfer’s office policy will prevail.

Fees are subject to change with notice or upon other arrangements.
HIPPA Privacy Notice

It is standard policy to obtain a general written permission to use and disclose your protected health information for  treatment, payment or health care operations purposes. You will be asked to sign a Consent form to permit all such uses and disclosures of your information if necessary.

Emergencies. If there is an emergency, I will disclose your protected health information as needed to enable people  to care for you. Otherwise you must sign a release to be able to talk to any family, friends etc.

Disclosure to health oversight agencies. I may be legally obligated to disclose protected health information to certain government agencies, including the federal Department of Health and Human Services.

Disclosures to child protection agencies. I will disclose protected health information as needed to comply with state law requiring reports of suspected incidents of child abuse or neglect or elderly persons suspected of abuse.

Other disclosures without written permission. There are other circumstances in which I may be required by law to disclose protected health information without your permission. They include disclosures made:

  • Pursuant to court order;
  • To public health authorities;
  • To law enforcement officials in some circumstances;
  • To correctional institutions regarding inmates;
  • To federal officials for lawful military or intelligence activities;
  • To coroners, medical examiners and funeral directors;
  • To researchers involved in approved research projects; and
  • As otherwise required by law.

Disclosures with your permission. No other disclosure of protected health information will be made unless you give written

Authorization for the specific disclosure.

Your Legal Rights


Right to request confidential communications
. You may request that communications to you, such as appointment reminders, bills, or explanations of health benefits be made in a confidential manner.

Right to request restrictions on use and disclosure of your information. You have the right to request restrictions on use of your protected health information for particular purposes, or disclosure of that information to certain third parties.
I am not obligated to agree to a requested restriction, but I will consider your request.


Right to revoke a Consent or Authorization
. You may revoke a written Consent or Authorization for me to use or disclose your protected health information. The revocation will not affect any previous use or disclosure of your information.

Right to review and copy record. You have the right to see records used to make decisions about you. I will allow you to review your record unless it is determined that it would create a substantial risk of physical harm to you or someone else.

 

Right to “amend” record. If you believe your records contain an error, you may ask me to amend it. If there is a mistake, a note will be entered in the record to correct the error. If not, you will be told and allowed the opportunity to add a short statement to the record explaining why you believe the record is inaccurate. This information will be included as part of the total record and shared with others if it might affect decisions they make about you.
Right to an accounting. You have the right to an accounting of some disclosures of your protected health information to third parties. This does not include disclosures that you authorize, or disclosures that occur in the context of treatment, payment or health care operations. I will provide an accounting of other disclosures made in the preceding six years. If requested by law enforcement authorities that are conducting a criminal investigation, I will suspend accounting of disclosures made to them.

Right to a paper copy of this Notice. You have the right to a paper copy of any Notice of Privacy Practices posted on this web site.


How to Exercise Your Rights

Questions about these policies and procedures, requests to exercise individual rights, and complaints should be directed by dialing (813) 385-7974.

 

I have read and understand my privacy rights and limitations. I have read and understand the benefits and risks of hypnosis outlined in my information packet, (online see FAQ), and I understand that this does not replace medical treatment. I have read and understand the fee and no-show policy. I also agree to have a credit card on file to be charged when appropriate. By signing this form, I agree to and understand  the above terms, and I am making a knowing, voluntary, and willing acknowledgement of the above. Should anyone decide to be deceptive and change anything on these forms (if printed from the internet), I agree that Dr. Umfer’s policy will prevail.

Client/Representative: ___________________________
Print Name

Psychologist:_________________ __________

Laura Umfer, Psy.D.,LLC

PY 7289

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