Information You Have a Right to Know 
When you come for therapy, you are buying a service. Therefore, you need good information to make the best decision. Below are some questions you might want to ask me. You can ask me any of these questions, and I will give you the best answers I can. If my answers are not clear or not complete enough, please ask me again.

1. Tell me about yourself.
	a. Are you a psychologist? Psychiatrist? Family therapist? Counselor? 
	b. What are the advantages and limitations of your credentials?
	c. What is your training and experience? Are you licensed by the state? Supervised? Board certified?
	d. What is the name of your kind of therapy?
	e. How did you learn how to do this therapy? Where?

2. Tell me about therapy.
	a. How does your kind of therapy work?
	b. What percentage of clients improve? In what ways? How do you know? 
	c. What percentage of clients get worse? How do you know?
	d. What percentage of clients improve or get worse without this therapy? How do you know?
	e. Are there negatives or possible risks in this therapy?
	f. About how long will it take?
	g. What will I notice when I am getting better?
	h. What should I do if I feel therapy isn't working?
	i. Is there someone I can talk to if I have a problem or a complaint about therapy which we can't work out? 
	j. Will I have to take any kind of tests or questionnaires?
	k. Do you follow a therapy manual with planned steps?
	l. Do you do therapy over the phone? Over the Internet?

3. Tell me about other kinds of therapy and help.
	a. What other types of therapy or help are there? 
	b. How does your kind of therapy compare with other kinds of therapy?
	c. How often do they work? How do you know?
	d. What are the risks and benefits of these other approaches? 
	e. What are the risks and benefits of no therapy? 
	f. Do you prescribe medication? Do you work with others who do?

4. Tell me about appointments
	a. How do we arrange appointments? 
	b. How often to we meet?
	c. How long are sessions? Do I have to pay more for longer ones?
	d. How can I reach you in an emergency?
	e. If you are not available, is there someone I can talk to?
	f. What happens if the weather is bad, or I'm sick?

5. Tell me about confidentiality
	a. What kind of records do you keep? 
	b. Who can see them? 
	c. When do you have to tell others about the things we discuss?
	d. Can members of my family, or the group if I am in group therapy, see my records?
	e. What do the laws and government regulations say about the privacy of my records? 

6. Tell me about money
	a. What is your fee?
	b. Will you even charge me more?
	c. How do you want to be paid?
	d. Do I need to pay for missed sessions?
	(cont.) 
Information You Have a Right to Know (p. 2 of 2) 

	e. Do I need to pay for telephone calls, letters, or emails?
	f. If I lose my job or my source of income, can my fee be lowered?
	g. If I do not pay my fee, what will you do to collect?

7. Tell me about health insurance and managed care
	a. What kind of information do you have to give to my health insurance company about our treatments?
	b. What will the insurance company decide about my therapy?
	c. What if you disagree with the insurance company about the best treatment?
	d. How would therapy be different if I did not use insurance and just paid you myself?

I have already given you some written information. This has included a contract, privacy statement, brochure, and/or consent form. We have also talked about some aspects of our work together. This information has dealt with most of these questions. I will be happy to explain them, and to answer other questions you have. This will help make your decision a good one. You can keep this information. Please read it carefully at home. We will also look this over from time to time.

I, the client (or his or her parent or guardian), have gone over this list with the therapist, and I under­stand these questions and the therapist’s answers. 

_________________________________________________ 	__________________	__________________________________ 
Signature of client (or parent/guardian) 						Date 					Printed name 

I, the therapist, have discussed these issues with the client (and/or his or her parent or guardian). I believe this person fully understands the issues, and I find no reason to believe that this person is not fully competent to give informed consent to treatment. 

_________________________________________________ 	__________________	
Signature of therapist 									Date 

❑ Copy accepted by client  	❑ Copy kept by therapist