When an appointment time is scheduled, that time is set aside just for you. I ask you to please consider it with forethought, responsibility, and courtesy. Sessions are scheduled in advance based on mutual agreement, and this appointment slot is held exclusively for you for the duration of our time together. If you have to miss a session, it must be rescheduled no later than 24 hours in advance for another time the same week. Any session canceled with less than 24 hours' notice (or where rescheduling is not possible) will be charged the full fee of the scheduled appointment. Clients being seen through insurance will be charged the insurer/provider agreed upon amount. Missed appointment fees will automatically be charged to the card on file at close of business on Friday of the scheduled week.

Note: Cancellation fees are not billable through insurance.

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.

Mentalyc Informed Consent

General Notice

I have a legal and ethical responsibility to make my best efforts to protect all communications that are part of our psychotherapy sessions. I have chosen to use Mentalyc's note-taking system for psychotherapy as part of my effort to provide the best care to my clients. It provides me with an automatically generated transcript and summarization of our sessions. Mentalyc's system is HIPAA compliant and uses up-to-date encryption methods, firewalls, and backup systems to help keep your information private and secure. You are consenting for me to record our sessions using Mentalyc's system.

Details

Recordings of our sessions will be transcribed and summarised by Mentalyc's HIPAA-compliant technology. Mentalyc doesn't store the recordings and client personal information. I may choose to keep the summarised notes as part of your confidential medical record. Mentalyc only keeps anonymized data to help improve the tool. As with any technology, there are certain risks and benefits, which I will list here:

Risks:

●       All technology contains a risk of confidential information being disclosed.  You can ensure the security of our communications by only using trusted secure networks for psychotherapy sessions and having passwords to protect the device you use for psychotherapy. Mentalyc mitigates this risk by ensuring up-to-date technological security and storing the data with as little identifying information as possible.

●       Mentalyc Researchers will have access to your de-personalized transcripts (transcript content with removed names, emails, and other identifying information). 

●       The system may contain unknown bias in the way it generates the session summary and presents clinical information. This risk is mitigated by your therapist's commitment to review and modify the note as needed using their clinical expertise.

Benefits:

●       The technology allows the therapist to focus more of their attention on therapy.

●       Removes the need for taking notes or trying to remember information during and after the session.

●       Mentalyc reduces the therapist's workload and may help with compassion fatigue.

●       The technology may provide additional clinical insights for the therapist which helps improve outcomes in the therapeutic process.

By signing this consent, you are agreeing to allow your therapist to use the Mentalyc software.

Name:  _____________________                       Date: ____________________

Signature: _________________________