Molly Igoe, PsyD
Suite 760
5949 Sherry Lane
Dallas, TX
75225
Dr.MollyIgoe@gmail.com
617-945-4986
INFORMED CONSENT FORM
Welcome! I am looking forward to working with you and/or your family for psychotherapy. My office is located within the Dallas Wellness group on the 7th floor of 5949 Sherry Lane in Suite 760. When you enter the office, please ring the doorbell with my name.
CONFIDENTIALITY
In accordance with Texas laws, I want to review the meaning of confidentiality and the exceptions to it at the outset of therapy. No information provided to me during therapy will be disclosed to anyone without your permission, with the exception of a few scenarios:
If I deem that you are in danger of hurting yourself or someone else, I may ask that you are evaluated by a psychiatrist or a clinician in a hospital setting to determine how best to maintain safety. In this situation, it may also be necessary to contact your family members to ensure your safety. In cases of threats or actual violence to another, I am mandated to take protective actions which may include notifying the potential victim or the police in the potential victim’s community. I am also obligated to report any abuse to a minor (under 18), elder or person with a disability. Communication during therapy is privileged meaning that you have the legal right to keep the clinician from testifying in most judicial hearings even if a subpoena is issued. Exceptions to this include cases where a patient has died or if you are involved in a child custody or adoption proceeding, lawsuit in which your mental condition is an important aspect of the case, legal proceeding related to psychiatric hospitalization, malpractice or disciplinary case against the psychologist, and finally for a court ordered psychological evaluation.
Treatment of patients under 18 years of age
If you are under 18 years of age, your parent or legal guardian must consent to your treatment and I reserve the right to advise your parent(s) or legal guardian about developments which could significantly affect your health or well-being. In such situations, the contents of specific meetings between you and I will not be discussed but your overall progress may be discussed in general terms. I may release certain information without your consent to either your parent (s) or legal authorities under the following circumstances: You tell me that you plan to cause serious harm or death to yourself or someone else, and I believe you have the intent and ability to carry out this threat in the very near future. I must take steps to inform a parent or guardian of what you have told me and how serious I believe this threat to be; if you intend to harm someone else, your therapist must inform this person. You are doing things that could cause serious harm to you or someone else, even if you do not intend to harm yourself or another person. In these situations, I will need to use my professional judgment to decide whether a parent or guardian should be informed. You tell me you are being abused physically or sexually or that you have been abused in the past. In this situation, your therapist may be required to report the abuse to Massachusetts Department of Children and Families or law enforcement. Additionally, when a child abuse investigation is being conducted I must permit a state child abuse team to inspect and copy patient records without the consent of the child, or the child’s parent/guardian. * You are involved in a court case and a request is made for information about your counseling or therapy. If this happens, your therapist will not disclose information without you and possibly your parents’ written agreement unless the court requires them to do so. Your therapist will do all they can within the law to protect your confidentiality, and if your therapist is required to disclose information to the court, they will inform you that this is happening.
Exception: Parental and/or guardianship consent does not apply if a parent refuses to be involved; if there are clear clinical indications to the contrary; if the minor has been sexually abused by a parent; or if the minor is legally emancipated. However, exceptions to confidentiality may still apply to legal authorities if any of the above circumstances arises.
Communicating with your parent or guardian: Except for situations such as those mentioned above, unless you provide your written and/or verbal consent, I will not tell your parent or guardian specific things you share with me in private therapy sessions. This includes activities and behavior that you think your parent/guardian would not approve of -- or would be upset by -- but that do not put you at risk of serious and immediate harm. However, if your risk-taking behavior becomes more serious, then I will need to use my professional judgment to decide whether you are in serious and immediate danger of being harmed. If I think that you are in such danger, I will certainly talk with you and discuss how best I can share this information with your parents or guardians.
ABOUT OUR APPOINTMENTS/FEES
The very first time I meet with you, we will need to give each other basic information. The intake session will be 60 minutes in duration. Following this, we will tailor a treatment plan to your particular needs. Sessions are typically 45 minutes though longer session can be scheduled if needed or desired. I try to be on time and I ask that you are too. In the beginning of therapy, sessions are usually scheduled weekly or every two weeks although we can discuss what makes the most sense based on your needs, goals, and schedule. After you have progressed in therapy, the hope is to spread the sessions apart by longer intervals of time. The length of therapy varies for each person. In general, many patients’ therapy can be completed within 8 to 12 sessions. In other cases, four sessions or fewer are sufficient to meet a person’s needs. There are also circumstances when a person’s difficulties may be more chronic in nature and thus we may meet for a longer period of time.
My rate is $200 per 45 minute session; $250 will be charged for the initial 60 minute intake session. I will send out billing invoices at the end of the month. Venmo and Zelle are the preferred modes of payment. Although I am not on any insurance panels and thus do not work with insurance companies directly, I am happy to complete paperwork related to getting you reimbursed for my services from your insurance company. I request 24 hours notice for a cancelled appointment so that the time can be given to someone else who needs to be seen. Please know that I charge the full fee for a cancellation with less than 24 hours notice with the exception of emergencies. I charge a prorated fee for email/phone coordination or consultation over 10 minutes per week.
On very rare occasions, your appointment may be “bumped” due to an unexpected patient emergency. If this happens, I hope you will accept my apologies and know that I will ensure we are able to reschedule an appointment for as soon as possible. A cancelled appointment delays our work. I consider our meetings very important and ask you to do the same. Please try not to miss appointments if you can possibly help it.
EMERGENCIES
Please contact me if you are a experiencing a mental health emergency. I will do my best to arrange for an immediate phone or in person appointment. Please call me at 617-945-4986 or email me at Dr.MollyIgoe@gmail.com and leave a message regarding the nature of your emergency situation and I will return your call/email as soon as I can. If I am not immediately available and the emergency requires urgent attention, please request help through your local hospital emergency room or by calling 911.
I, the patient (or his or her parent or guardian), understand I have the right not to sign this form. My signature below indicates that I have read and understand this form. If at any time during the treatment I have questions about any of what has been discussed above, I can talk with you about them, and you will do your best to answer them. I understand that after therapy begins I have the right to withdraw my consent to therapy at any time, for any reason. However, I will make every effort to discuss my concerns about my progress with you before ending therapy with you. I understand that no specific promises have been made to me by this therapist about the results of treatment, the effectiveness of the procedures used by this therapist, or the number of sessions necessary for therapy to be effective. I have read, or have had read to me, the issues and points in this document. I have discussed those points I did not understand, and have had my questions, if any, fully answered. I agree to act according to the points covered in here. I hereby agree to enter into therapy with Dr. Igoe (or to have my child enter therapy), and to cooperate fully and to the best of my ability, as shown my by signature below.
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Signature of Patient Date
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Parent/Guardian Signature (if applicable) Date
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Dr. Igoe Signature Date