Online Intake
In efforts to make filling out forms more convenient we’ve made them available to fill out online. This process is simple and will take 5-15 minutes, and can be initiated by one or both individuals. The following is a summary of the steps just so you know what’s ahead.
Step 1) Read INFORMED CONSENT and sign (once per couple)
Step 2) Complete the PERSONAL INFORMATION Form (one form per couple)
Step 3) Spouse/Partner #1 – Complete the RELATIONSHIP INFORMATION Form.
(Steps 1-3 will be submitted together.)
Step 4) Spouse/Partner #2 – Complete the RELATIONSHIP INFORMATION Form. This doesn’t need to be completed at the same time. A link to this form will be emailed upon submission of Steps 1-3 and is also available on the “Intake Forms” page.
Informed Consent
Please read this Informed Consent Agreement before meeting with your counselor. When you meet with the counselor, you can discuss any questions or concerns you have before signing the document. This document contains important information about our professional services and business policies. When you sign this document, it will represent an agreement between us.
Counseling is a collaborative process between you (“Client”) and the counselor (“Therapist”) employed by Leavitt Institute for Marriage & Family, a Utah limited liability company (“Company”). The purpose for this Informed Consent (“Agreement”) is to inform you of your rights, to provide sufficient information to make an informed decision if to proceed with counseling, and to clarify and delineate the obligations and responsibilities of the Therapist, Client, and Company (the “Parties”).
Therapists: Services at the Leavitt Institute for Marriage and Family are rendered by Licensed Associates and Licensed Marriage and Family Therapist professionals. Our therapists have received professional training at the Master’s or Doctoral level and have nearly 25 years of combined clinical experience. Along with psychiatry, psychology, and social work, marriage and family therapy is seen as one of the core mental health professions. Marriage and Family Therapists provide a holistic approach to mental health, in that they evaluate biological, psychological, social, and spiritual dimensions of human behavior. Furthermore, they are not only concerned with the well being of the individual, but the individual’s family system. Marriage and family therapists address behavioral and health problems, mental and emotional issues, and relational concerns all within the framework of the family.
Therapeutic Process: In a way the Therapist is a process consultant, helping clients recognize and reprocess the negative cycles they tend to develop as an attempt to fulfill their emotional, attachment, and security needs. Emotions such as anger, hurt, fear, loneliness, detachment, inadequacy, withdrawal, and depression are signs and the gateway to understanding the unmet needs a person longs for. Emotions motivate and organize our behavior, and determine how we respond to others. Unfolding key emotions and bringing them to prime new responses and ways of being with significant others is the heart of change.
Confidentiality: Unless specified otherwise herein, information obtained in the counseling session or in electronic or written form will not be disclosed to any outside person(s) or agency without your written permission except when such disclosure is necessary to “protect you or someone else from imminent harm” or is otherwise legally required and/or allowed by law. Situations arise in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a Client’s treatment. For example, if I believe that a child, elderly person or disabled person, is being abused, I must [may] be required to file a report with the appropriate state agency. If I believe that a Client is threatening serious bodily harm to another, I am [may be] required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the Client. If the Client threatens to harm him or herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he or she determines that the circumstances demand it.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, but if you need specific advice concerning the complexities of the laws governing confidentiality, you will need to consult an attorney.
Unknown Outcome: Within nearly any psychotherapeutic process, neither party knows at the outset in what directions the therapy might evolve, what information or understanding may unexpectedly emerge, what roadblocks the therapy will need to surmount, or what the outcome will be. In a therapeutic relationship, each party influences the other in ways both obvious and subtle and operates simultaneously at multiple concurrent levels. One does not know what a client will do in unexpected situations nor how his or her spouse, friends, and relatives will react and how this will impact the client, and so on. Thus, clear and probable outcomes cannot realistically be stated. The one constant is my desire to employ my best efforts to facilitate positive outcomes in concert with the Client.
Cancellation: If you find it necessary to cancel an appointment, please email or call at least 24 hours in advance. Cancellations with less than 24 hours advanced notice will be charged a no-show fee of half the cost of their session. I may also terminate counseling in the event the Client has missed two appointments without calling to cancel 24 hours prior to the scheduled appointment. The cancellation charge is waived in case of emergency. If the therapist cancels a session with less than 24 hours advanced notice, the Client will receive a $25 credit toward their next session.
Emergencies: If an emergency situation for which you believe immediate attention is necessary, please contact emergency services (911) immediately or go to your nearest hospital emergency room.
Time Parameters: Sessions last approximately 50 minutes. Sessions begin at the scheduled time, whether the Client arrives on time or not. Sessions will not exceed the allotted time unless in the case of emergency.
Payment: Depending on the therapist, there is a charge of $50-$100 per hour (50 minute hour). Payment for the session is to be given in full at the end of each therapy session, unless it is a phone/online session or we have made other arrangements. Payment for phone/online sessions is to be given before the sessions begins. We accept cash, check, credit, or debit.
Insurance: Due to the size and time constraints of our practice we do not file insurance. If you desire to file for yourself, I will provide you with a detailed receipt that you can use to file with your insurance company. Since insurance coverage varies from company to company, your treatment may not be covered. I will be happy to provide you with whatever information you request. I am dedicated to protect your confidentiality and your privacy, and therefore, will not answer questions from insurance claims representatives without your written permission.
Arbitration: Any dispute, claim or controversy arising out of our professional relationship or related to this Agreement shall be settled by arbitration in Provo, Utah, in accordance will the rules of The American Arbitration Association, and judgment entered upon the award rendered may be enforced by appropriate judicial action. The parties hereto submit to the jurisdiction of such tribunal and waive any objection that such forum is inconvenient or otherwise improper. The arbitration panel shall consist of one member, which arbitrator shall be experienced in the area of mental health and who shall be knowledgeable with respect to the subject matter area of the dispute. The initiating party shall bear any fees and expenses of the arbitrator, other tribunal fees and expenses. Each party shall pay their own attorney’s fees, any costs of producing witnesses and any other reasonable costs or expenses incurred by him or her. By executing this agreement you are agreeing to have disputes decided by neutral arbitration and you are giving up any rights you might possess to have such disputes litigated in a court or jury trial. By executing this agreement you are giving up your judicial rights to discovery and appeal. Your agreement to this arbitration provision is voluntary.
Contacting Me: I am not always available by telephone. When I am in my office, I am usually involved with other clients. When I am out of the office, I am typically involved in personal and familial activities unrelated to counseling. If you leave a message by phone or e-mail, I will make every effort to return your call or e-mail on the same day I receive it, with the exception of weekends and holidays. If you cannot reach me and think that you cannot wait, contact your family physician or the nearest emergency room and ask for the psychologist [psychiatrist] on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary.
Venue: This Agreement shall be construed, enforced and interpreted in accordance with the internal laws of the State of Utah, without regard to the conflicts of law provisions and principles thereof. Any action relating to or arising out of this Agreement shall be subject to binding arbitration, as provided above.
Please feel free to ask questions about this statement at any time. By signing below, you are acknowledging that you have read, you understand and accept the terms of this disclosure statement, and that you are consenting to treatment.
WITNESS WHEREOF, the Parties hereto have executed this Agreement the date and year shown below
