Consent for Telehealth

Welcome

Before starting your therapy, it's important to know what's coming and to understand your rights and responsibilities. This form is designed to be as clear as possible about what couples therapy involves so you're fully informed before we start.

What to expect

Couples who enter into Gottman Method Couples Therapy begin with an assessment process that then informs the therapeutic framework and intervention:

1. Assessment*:** A conjoint session, followed by individual interviews with each partner, is conducted. Couples complete online questionnaires and then receive detailed feedback on their relationship.*

2. Therapeutic Framework*:** The couple and therapist decide on the frequency and duration of the sessions.*

3. Therapeutic Interventions*:** Interventions are designed to help couples strengthen their relationships in three primary areas: friendship, conflict management, and the creation of shared meaning.*

Interventions aimed at boosting closeness and intimacy are employed to enhance friendship, deepen emotional ties, and bring about changes that further the couple's common objectives. Couples are taught to swap negative conflict behaviors for positive interactions and to mend previous emotional wounds. Strategies for preventing setbacks are also discussed.

Limitations to couples therapy

However, it's essential for you to also be aware of the risks involved. Even though this approach is practical, it will require you to confront challenging areas in your relationship. Consequently, you or your partner may experience uncomfortable emotions like sadness, guilt, anxiety, anger, loneliness, and helplessness. The therapy may also involve revisiting distressing parts of your shared or individual history. Issues between you might temporarily worsen. Moreover, complications with other important people in your lives may arise, family secrets could be revealed, and despite our best efforts, the therapy may not yield positive results. Success in couples therapy hinges on both partners genuinely committing to working on their issues and the relationship. Dishonesty, a reluctance to self-reflect and take responsibility, or a lack of enthusiasm in participating in the process by either partner will undermine the therapy. Therefore, we can't make any promises regarding how the therapy will specifically impact you both or what the end result for your relationship will be.

Additionally, couples therapy is not recommended in the following situations:

• If either or both partners are actively struggling with alcohol and/or drug addiction.

• If there is severe violence in your relationship, threats of severe violence from either partner or fear of such violence by either of you.

• If either partner currently has an untreated serious mental illness, such as schizophrenia, recurring psychotic depression, or bipolar disorder. This doesn't include past, successfully treated psychotic episodes, like post-partum depression with psychosis.

• If there is an ongoing, undisclosed affair that you're not willing to reveal (such undisclosed affairs typically result in therapy failure).

• If either partner is currently experiencing suicidal or homicidal thoughts or has a past of inflicting serious harm on themselves or others.

24-hour cancellation policy

If you're unable to make it to your scheduled session and fail to cancel your appointment at least 24 business hours in advance, be aware that you will be billed the full fee for the session. Charging for no-shows or last-minute cancellations is a common practice in this field. It reflects not just the cost of the service provided, but also the reservation of a time slot that your therapist can't readily fill with another client on short notice.

Confidentiality

When you participate in sessions with a psychologist, your shared information is safeguarded by stringent confidentiality regulations. Without your explicit written consent, we are prohibited from acknowledging whether you are a client or from discussing any session details with third parties.

However, there are specific exceptions to this rule

• If either of you presents an immediate risk to yourselves, each other, or another person, we are permitted to disclose necessary information to law enforcement or hospital staff to ensure safety and coordinate appropriate care.

• If discussions in session lead us to suspect that a child under 18 or an elderly or disabled individual is at risk of emotional, physical, or sexual abuse; neglect; or exploitation, we are legally obligated to report this to California Child or Adult Protective Services.

• If a Judge instructs us to release specific information or if we are compelled to respond to a legally issued subpoena.

The couple is the client

When you participate in couples therapy, the "client" is considered to be the couple as a unit, and the mental health records consequently belong to both of you. This means that, aside from the exceptions previously outlined, we will need written consent from both of you to release any information from your records to a third party.

Litigation limitation

The ethical guidelines and regulations of our profession prohibit us from acting in a dual capacity as both your therapist and an evaluator. This means we cannot provide formal evaluations that would offer opinions for legal or disability-related matters. Additionally, due to the confidential nature of therapy, it's agreed that this process should remain private. In the event of legal proceedings, such as but not limited to divorce, custody disputes, lawsuits, or injuries, neither you, your attorney, nor anyone else representing you will call on our clinicians to testify in court or any other legal setting, nor will a request be made for the disclosure of your therapy records. If we are mandated to provide testimony on your behalf, you agree to a fee of $300 per hour, covering all time spent on correspondence, record review, document preparation, travel to and from court, and waiting time at court.

Between-Session Contact

For administrative or scheduling inquiries, please call the office. On weekdays, we typically return such calls within a 24-hour period. We don't discuss clinical issues over the phone or without a scheduled appointment. If you're facing a clinical emergency, such as immediate thoughts of harming yourself or others or undergoing a traumatic event, you can leave a message on your provider's confidential voicemail detailing the emergency. Your provider will return your call as soon as they can. If you believe you're in immediate danger or your health is critically at risk, go to your nearest emergency room, dial 9-1-1, or contact the National Crisis Lifeline for free.

E-mail and/or text message appointment notifications

Upon scheduling appointments, automated email and text reminders will be sent to the email address and phone number you provided when you booked your initial session. By signing this consent form, you agree to receive these notifications and acknowledge that email and text are not confidential methods for transmitting health-related information.

Termination by the therapist

We retain the right to end treatment under specific conditions that either hinder our ability to deliver effective services, impede your ability to benefit from these services, or when it's legally or ethically the right course of action.

These conditions include but are not limited to:

• Three missed appointments or late cancellations within a six-month timeframe.

• Failure to stick to the treatment plan.

• Not following practice policies and procedures.

• Rejection of recommendations for a more intensive or additional type of care.

• Conduct that is disrespectful, diminishing, threatening, or otherwise inappropriate towards the provider, staff, other clients, or any individuals present in the building.

• Providing inaccurate or incomplete clinical information.

• Outstanding fees not paid.

No secrets

As therapists specializing in couples therapy, we operate under a "No Secrets" policy. This means we can't commit to keeping secrets from one partner that are shared by the other, particularly if those secrets are detrimental to the therapy process or counter to the agreed-upon goals of the therapy.

Permission for Digitally Recording Couples Therapy Sessions

Video feedback is utilized as a primary tool in Gottman Method Couples therapy. This means that therapy sessions will be video recorded, and certain exercises and dialogues will be reviewed from time to time. By reviewing the recordings in session, we can “stop action” and process how each partner might approach a discussion in a more productive way. Viewing the recordings also enables you to witness your progress as your relationship becomes more satisfying.

In addition to in-session use, your therapist may use brief segments of video recordings to receive consultation from Drs. John or Julie Gottman; Dr. Nancy Young, a certified master-trainer in the Gottman method; and/or another assigned Gottman master-trainer consultant or to provide such training. Case consultation is an important feature of Gottman therapy that assures quality care and continuing education among Gottman therapists. If a segment of a video recording in which you are featured is reviewed, your name will remain confidential at all times. Furthermore, all matters discussed in consultation will remain completely confidential within the aforementioned Gottman Institute Staff. Video recordings are not a part of your clinical record and will be erased when they are no longer needed for in-session feedback or consultative purposes.

Video recordings are the property of AtReef LLC Group and will remain in our possession or stored in locked facilities at all times. Copies may be sent to the Gottman Institute for the purposes noted above. Should you wish to review the recordings for any reason, we will arrange a session to do so.

Clients’ Agreement

I understand and accept the conditions of this statement and give my permission to have my therapy sessions videotaped or digitally recorded. I understand I may revoke this permission in writing at any time, but until I do so, it shall remain in full force and effect until the purposes stated above are completed.