Jennifer M. Batterman, Ph.D.
417 Main Street, Suite 202
Rockland, ME 04841
Phone & Fax: (207) 596-0330
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Informed Consent for Psychological Services
The Nature of Therapy
Psychotherapy is not easily described in general statements. It varies depending on the particular problems the
client brings and the personality of both the client and the therapist. There are several different approaches that can
be used to address problems. Unlike visiting a medical doctor, psychotherapy requires a very active effort on your
part. In order to be most successful, you will have to work on things we talk about both during our sessions and at
home.
Psychotherapy has both benefits and risks. Therapy often leads to a significant reduction in feelings of distress,
better relationships, and resolutions of specific problems. Risks sometimes include experiencing uncomfortable
feelings such as sadness, guilt, anxiety, anger and frustration, loneliness, and helplessness. Psychotherapy often
requires discussing unpleasant aspects of your life.
During the first few sessions we will largely focus on an evaluation of your needs. I will then be able to offer you
some initial impression of what our work will include and an initial treatment plan for you to follow. You should
evaluate this information along with your own assessment about whether you feel comfortable working with me. At
any time during the therapy process you should feel free to raise any questions or concerns that may arise and you
may, of course, discontinue treatment at any time.
HIPAA Regulations
Beginning in April 2003, the federal government instituted a set of required guidelines regarding the privacy of
patients’ health information. This new privacy rule is called the Health Insurance Portability and Accountability Act
(HIPAA) of 1996. By law, my privacy practices have to conform to these federal standards. A notice containing a
description of these laws is available for your review. HIPAA also allows you several rights with regard to your
clinical record. These standards now allow that you may: request that I amend your record; request restrictions on
what information from your clinical record is disclosed to others; request an accounting of most disclosures of your
protected health information that you have not specifically consented to; determine the location to which protected
information is sent; under some specific circumstances, to examine and/or receive a paper copy of your record; have
your complaints about my policies and procedures recorded in your record; and to have a paper copy of this
agreement as well as of the notice of HIPAA regulations and my privacy policies and procedures.
Confidentiality
In general, all communications between a patient and a psychologist are protected by law and are kept in strict
confidence. I can only release information from your record to others with your written permission. Although I
may request or suggest that you allow me to communicate with specific individuals, this is your choice and I must
have written permission before any such communication takes place. Some of your personal information (e.g.,
name, address, dates of service, etc…) is shared with my administrative and billing staff for the purposes of
collecting fees and performing secretarial services. My staff is also bound by the limits of confidentiality and the
privacy regulations imposed by HIPAA.
Confidentiality, however, is not absolute. The HIPAA regulations, as well as other ethical and legal standards, now
allow and require me to release information from your record under specific circumstances. These situations in
which confidentiality cannot be guaranteed include, but are not limited to, the following.
 You or someone else appears to be in immediate danger
 There is a reason to suspect that child abuse or neglect has occurred
 If you are involved in a court proceeding and a request is made for information concerning the
professional services that I provided to you, such information is protected by the psychologistpatient privilege law. I cannot provide any information without your written authorization. In
some cases, however, a court may order the release of information which would then require me to
release your protected health information and psychotherapy notes.
 If a government agency requests the information for the purposes of evaluating my conduct with
regard to your case, I may be required to provide this information. Similarly, if a patient files a
complaint or lawsuit against me, I would also be required to disclose relevant information from
their record for purposes of my defense.
 If I am providing treatment for conditions directly related to a worker’s compensation claim, I may
have to submit such records to the Worker’s Compensation Board or Chairman.
 An insurance company requires information to substantiate a claim
Confidentiality as it Relates to Minors
For psychotherapy to be most effective with children, the child or adolescent must feel safe with the therapist and
understand that the therapist will not tell others about specific things which are discussed. Yet, the situations
mentioned above apply to minors as well as to adults.
In Maine, children of any age have the right to independently consent to and receive mental health treatment without
parental consent. Even with parental consent, children over the age of 12 have the right to control access to their
treatment records. However, parental involvement is essential to successful treatment of children and adolescents.
Therefore, it is my policy not to provide treatment to a child under the age of 12 unless he/she agrees that I can share
whatever information I consider necessary with his/her parents. For children over the age of 12, I request an
agreement between my patient and his/her parents allowing me to share general information about the progress of
the child’s treatment. It is also understood that general concerns and issues will be discussed with parents as well as
specific topics the therapist and minor client have mutually decided to discuss with family members or the guardian.
In addition, I would need to inform parents/guardians of any dangerous, suicidal, or self-injurious behaviors.
Release of Information to Insurance Company
I am required to obtain extensive and detailed information on each client and each client’s family. Insurance and
managed care companies require that much of this information be disclosed to them as a condition of paying for
mental health treatment. Insurance companies also reserve the right to inspect therapists’ records and treatment
plans to see that their standards have been met. Communications with your insurance company may require the
release of confidential information such as progress notes and reports, personal and family history, any information
concerning pre-existing conditions and previous treatment, and psychological reports, as well as my therapist’s
diagnostic impressions and opinions. If you chose to use your insurance benefits to pay for treatment, you are
agreeing to the release of confidential information to your insurance company.
Fee and Cancellation Policies
Appointment times are by arrangement. Most individual and family therapy sessions are 50 minutes in length.
Frequency of appointments varies depending on the specific circumstances of your situation. If you have an
appointment scheduled and need to cancel the appointment, please call at least 24-hours in advance to cancel the
appointment. This allows us to fill the appointment from the waiting list. There is a $75 fee for all sessions that you
do not attend and do not cancel in advance. Fees for sessions that you do not attend are not covered by your
insurance policy and you are solely responsible for these charges.
I participate in many insurance plans in Maine and serve on many provider panels. You will need to consult your
employer or health insurance company to determine your mental health benefit. Co-payments for mental health
services are usually higher than for medical appointments. My standard fees are $150 for an initial assessment
appointment, $125 for an individual session, and $150 for a family session. In some circumstances, I may negotiate
a fee adjustment or payment installment plan. Payments / co-payments for services is due at the time of your
appointment. If it is not possible to pay for services at the time of your appointment, please discuss the situation
with me.
Other professional services you may need may include: report writing, telephone conversations lasting more than 10
minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment
summaries, and the time spent performing any other service you may request of me. I charge an hourly rate of $125
for these services although I will break down the hourly cost if I work for periods of less than one hour.
In the very rare situations in which people do not pay for services they have received, I will make every effort to
collect. If your account has not been paid for more than 60 days and arrangements for payment have not been
agreed upon, I have the option of using legal means to secure payment. This may involve hiring a collection agency
or going through small claims court.
Handling Emergencies and Backup
Most problems that come up between sessions are best discussed during a therapy session. However, if you have an
emergency situation that can't wait until your regularly scheduled appointment, I can usually be reached through the
office number. Your call will be forwarded to my cell phone and will answer it as soon as I am able. If you leave a
message indicating that you have an emergency situation, I will return your call as soon as possible. If it is not an
emergency, I will, of course, return your call as soon as possible during the business day.
Occasionally it is not possible to reach me immediately. If you are unable to reach me during a crisis, you should
call one of the following community psychiatric services:
State Wide Crisis Number
1-888-568-1112
MidCoast Mental Health Mobile Crisis Outreach
(207) 701-4400
Consent for Treatment
I have been informed of my rights and responsibilities as a client and agree to the policies outlined above. I also
understand and agree with the limits of confidentiality and agree to the release of information as detailed above. I
have been informed of and agree with the treatment plan that my therapist has developed for me (and/or my child).
Please sign below if you understand and agree to these policies.
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HIPAA Notification
Your signature below indicates that you have been given the opportunity to review the HIPAA guidelines.
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