Treatment Consent Form

Your Email Address*

So we can send a copy to you after it's signed.

INFORMED CONSENT FOR THERAPIES, NOTICE OF PRIVACY PRACTICE, WAIVER AND RELEASE*

Please read and sign the agreement below and ask for any clarification needed. Your signature means you were informed, understand, and agree to all terms listed below as of the date indicated, and you agree to consult with Dr. Shafer at this office. All certificates and licenses relevant for her scope of practice are real and current.

I agree to the terms below

Consent Terms

All consultations at this office are confidential. Any information regarding presence, attendance, and participation will be released only:
1. with your signed release
2. if it is determined you are in immediate danger to yourself or others
3. with a court order
While confidentiality is protected, there are three kinds of problems you might discuss that would involve other people:
1. If you disclose someone has been seriously hurting or abusing you, the police or The Department of Children and Families may be called.
2. If you are a minor child* or adult having thoughts or are behaving in ways that are harmful to you or others, or have a plan of action, your parents/authorities may be notified; medication or hospitalization may be necessary.
3. If you state you have a plan to hurt someone, action may be taken to protect you and/or that person.
4. If you appear to be under the influence at the office Dr. Shafer may have to make arrangements for your transport from the premises. These issues must have action taken by law. Ask for information about The Baker/Marchman Act. No consultations at this office are in replacement for any medical treatment you are currently following with a medical doctor.
Fees for are due in full at each appointment in cash, credit card (fees apply) or by check. If you choose to use your insurance coverage, forms will have to be filed informing the dates, purpose, services performed, and the diagnosis. You are responsible for knowing your benefits and when amounts you are responsible for change. Including deductibles. You may certainly pay out of pocket.
Sessions are 30- 50 minutes in length depending on your plan, or arrangement with Dr. Shafer. Please be aware that if Dr. Shafer does not participate with your insurance, out of network benefits may cover some of your therapy charges. If you choose not to use your insurance you are responsible for payment at each session. I have also received the welcome letter informing me of this and the commitment and process of therapy.
Attempts to verify insurance coverage, including co-payments and deductibles will be done by the billing office, preferably prior to the first session. However, if verification cannot be done prior to the first session, you will be responsible for payment in full should you not have an effective insurance policy or authorization.
The appointment that you make is time that is set aside for you. Therefore, any changes or cancellations are to be made with 48 hours notice prior to the appointment time and must be called in - not emailed or by text (the office phone number is not set up for texting). Full fee is charged for last minute cancellations and not showing up. INSURANCE DOES NOT PAY FOR MISSED APPOINTMENTS OR FOR LATE CANCELLATIONS and you will be charged by credit card on file.
From time to time, to provide the highest quality of care, consultation may be obtained. Disclosure about your sessions will be done in a manner to respect your privacy.
I understand if I need Dr. Shafer to write a letter on my behalf, or require services that take her out of the office, I understand and agree that I will be billed at a different rate for such additional services.
This is to verify that the HIPAA Privacy Act has been explained to me. I also understand that emails may not be responded to immediately, should be utilized only when I have a concern, and brief. I know emails are not always confidential, and that they may be printed and put in my file.
I acknowledge that I am seeking help at this office in the form of behavioral, life style, and educational advice and that this is not considered instead of medical treatment/medication. The information and therapy offered during an individual, family, or group session may involve a diagnosis. By signing this consent to treat form, I hereby take full responsibility for any actions taken regarding diet, nutritional supplements, exercise, or treatment plans suggested. If I am sick or taking antibiotics I will inform Dr. Shafer and not come to the office.
Under no circumstances is a diagnosis a means for taking legal action against this practitioner. I understand that any recommendations discussed are not intended to supplement or be perceived as a recommendation to stop taking medication or stop any medical treatments currently in place. I understand that in case of a medical emergency I need to contact my primary care physician, or nearest emergency room. I hereby hold this practitioner harmless from liability for any consultation. I understand if I am sick and/or have an infection, teletherapy options instead of live sessions are possible. I have read the welcome letter, and agree to the terms of billing and fee collection by Dr. Shafer.
This is a pet friendly office. You hereby assume all risks of personal injury or damages while in consultation at this office and do not hold this practitioner liable.

While having a session with Dr. Shafer over Zoom, Facetime, or over the phone is helpful when it is not possible to meet live in her office, due to Covid or other restrictions (out of town, etc) technology is not without problems. Please sign on 10-15 minutes early for your appointment, or call her if you have not received the Zoom or conference call email invite: 561-799-6789.

Before your session begins, please make sure your room is secure for privacy, so you will not be interrupted. Dr. Shafer recommends you create with her a code word or phrase like "I wish I was at the beach right now" or "I need to get back to my homework" in the event someone walks into the room, or you are interrupted, and no longer have privacy, and/or you need to suddenly stop the session. Also, sometimes clients get dropped during Zoom sessions which is not Dr. Shafer's fault or responsibility for either situation. If this happens please call her 561-799-6789 so you can complete/resume your session with her over the telephone. It is also requested and assumed that you are not under the influence of drugs or alcohol (including marijuana), or drinking alcohol or smoking marijuana during your telehealth session. If Dr. Shafer suspects you are under the influence and this is confirmed the session may have to be rescheduled at your expense.

Client's Name*

First Last

Is client a minor?

Yes

Minors and parents/guardians please sign consent for services by Dr. Shafer.

Date*

Patient Consent

Parent/Legal Guardian’s Name

First Last

Date

Parent/Legal Guardian Consent

Patient's or Guardian's Signature*

Comments

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Questions?

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