INFORMED CONSENT and THERAPY CONTRACT
The decision to begin counseling may impact significant areas of your life. When you enter therapy with a good understanding of what you are about to undertake, you are likely to achieve more favorable results. This form contains information to help you make informed decisions about the process of
therapy, my services, and policies.
1) Therapist qualifications and credentials- I am a Licensed Marriage and Family Therapist in Kansas (#2728) and an LMFT in Missouri (#2016002905). Walter D. Disney is trained to diagnose and treat a wide array of presenting problems. I am a member of the American Association of Marriage and Family Therapists and the Missouri Association of Marriage and Family Therapists.
2) Goals of the therapeutic relationship- I work with the goals established by the clients. Therapy is solely for the benefit of the client. If I believe new goals should be added or deleted I will share these suggestions that are always conditional to the approval of the client.
3) Services the therapist can provide- I provide therapy from a systemic frame of reference and work with adults, teens, children, couples and families on a wide range of issues in mental health. I utilize assessment instruments for relationships, personality inventories, career assessments, and check lists to screen for mental health issues. I will suggest an approach tailored to meet your goals, and obtain your approval before proceeding. I will also inform you of any additional fees for assessment instruments. In addition to conventional evidence based theories, I utilize EMDR. By endorsing this document, you have either: agree to the use of this treatment modality or I have been advised about it specifically and agree to the utilization of it as Walter Disney offers as fit for my goals.
4) Rights of the client- In the event of an emergency, you may contact Walter D. Disney or Disney Family Therapy at any time at 913.963.7772 by text or voicemail or email Walt at walt@disneyfamilytherapy.com. Walt will get back to you as soon as possible. If I am out of town and there is an emergency, another therapist will be on call for me. Every client has a right to terminate counseling at any time, however, please discuss termination or taking a therapy break during a regular session. You have the right to know your diagnosis and have it explained to you. I am bound by the Code of Ethics set forth by the American Association of Marriage and Family Therapy (AAMFT) and the states of Missouri and Kansas in which I work. You have a right to request a copy of those ethics. You have a right to discuss your treatment approach and
refuse any treatment. You have a right to ask for an estimate of the length of therapy. You have a right to request a referral to another therapist.
5) Behavior desired of the client- Therapy can provoke some very strong emotions. However, decorum and safety are necessary and the client is expected to regulate their emotions enough to maintain decorum and safety. At times the therapist will give direction to maintain emotional physical safety. It is expected that the client will respond accordingly to the therapist’s directions.
Walt often makes recommendations of things to do between sessions. Completing these should facilitate therapy and reduce the number of sessions needed. Please bring up any concerns that you have about therapy or your therapist so they can be resolved. Please be as open as possible concerning any issues that relate to your problems. Withholding information may cause therapy to take longer. Parents of minor children need to be involved in the therapy in order for Walt to
be effective. Please give 24 hours notice of needing to reschedule and preferably 48 hours for evening appointments.
6) Risks and benefits of therapeutic procedures- A benefit to therapy is evidence based treatment may help you personally, and with your relationships. Therapy may not itself resolve your problem. I will assess your progress with you periodically to ensure movement toward your goals. Another risk is that you may feel discomfort talking about uncomfortable topics, such discussions are intended to help you accomplish your therapy goals. An additional risk is that as one member of a family grows and changes it will affect all the relationships in that family. There is no guarantee that therapy will work. The success of therapy is always dependent upon
the efforts of the client.
7) Financial considerations and arrangements- A session is a 50 minute hour. The session fee will be:
a. $195 for intake session
b. $150 per clinical hour, thereafter.
c. $225 for 90 min session
d. $300 for 110 min session
e. Premarital packages are available with Prepare & Enrich assessment
(Six 1.5 hour sessions with Prepare & Enrich)
Disney Family Therapy will issue a receipt that you may file with your insurance if you wish to seek reimbursement. You may pay cash, check, or credit card. A full session fee will be charged for appointments cancelled with less than 24 hours’ notice.
There is a $50 charge for all letters sent to physicians, employers, or schools.
There is a fee of $350 per hour for legal reports and testimony including all required time and
expenses to fulfill requests or be present for court proceedings.
8) Limits to confidentiality- All information in therapy is confidential with some exceptions. In order to coordinate services with other entities, you and your family members over 12 years may be asked to sign a written release. Other exceptions to confidentiality according to the laws of Kansas and Missouri state regulations are:
(a) If you reveal the intent to harm yourself and/or others.
(b) If there are reasons to suspect child or elderly abuse, or dependent disabled person.
(c) In legal cases, the court orders the therapist or your records.
9) Technology policy statement- I understand that although both I will take precautions to ensure you or your family’s confidentiality of information transmitted through the use of computers, electronic mail, fax machines, cell phones, text messaging, voicemails, and other electronic or computer technology; You have been informed and understand the risks to privacy and the limits to confidentiality by these forms of communication.
Email: You understand that should Walt contact me via email, the intent of the email will be to communicate information for my use or to confirm an appointment, logistics, but not content of therapeutic interaction.
Texting: I understand that the intent of any use of text messaging between you and Walt will be limited and include confirming or changing a scheduled appointment time.
Social Networking: Online social networking sites like Twitter, Facebook, Linkedin or MySpace are strictly prohibited as a means of communication with Walter D. Disney or Disney Family Therapy LLC. I will not respond to requests or communications through said media.
10) TeleBehavioral Health consent: I consent to conduct TeleBehavioral Health through technology which includes telephone, email, text or video conferencing. Telemental health services are not appropriate for all clients. Generally, those who are experiencing suicidal ideation or altered mental status are not appropriate. Should telemental health services not be a good fit for you, I will assist you in finding alternative options. Benefits and Risks Telemental health refers to psychotherapy services that occur via phone, email, or synchronous video conferencing. All of our interactions will fall under this term. When using technology there is always the risk of security issues, as well as technical issues (phone not charged, computer or software not working, etc.). You will develop an individualized plan for how best to address technical issues that may arise and will take steps to facilitate the security of interactions with your therapist. In addition to the identified risks, there are several benefits that come from using technology. For instance, it allows therapists to connect with people who may otherwise not be able to access services, there is an opportunity for more flexibility in scheduling, and convenience in
being able to connect from a space of your choosing. In order to protect your confidentiality and to facilitate the security of your information as much
as possible, here is a list of recommendations:
a. Engage in sessions in a private location where you cannot be heard by others.
b. Use a private phone.
c. Do not record any sessions.
d. Password protect any technology you will be interacting with your therapist on.
e. Always log out or hang up once sessions are complete.
My signature indicates that I understand and agree with the therapist’s policies and give informed consent to receive therapy services from Walter D. Disney. To be signed by all participating family members 12 years old and over. I/we authorize Walter D. Disney to release our name only to our referral source to thank them for our referral to her, unless the referral source is from advertising or an insurance company. I acknowledge that I have received a copy of the therapist’s Notice of Privacy.
I have read and agreed to the above patient consent form.