Informed consent

Thank you for choosing Alliance Psychology, P-LLC and Alliance Psychiatry 1, PLLC d.b.a.
Alliance Psychology(“Alliance”) to address your mental health needs.

Services Offered

About Psychotherapy

Psychotherapy is a unique experience for each person, couple, or family, and each one’s distinct background and history shapes who they are, why they are seeking psychotherapy, and what they are hoping to accomplish. Psychotherapy is most likely to be helpful in the context of a trusting, safe, and open therapeutic relationship. Your licensed Alliance mental health professional is committed to doing their best to build a professional relationship where you feel comfortable to openly express your feelings. To provide a space where this can happen, they will listen, work to understand you, and keep what is shared confidential.
Note: There are a few exceptions to confidentiality that will be explained below.

Psychotherapy can be an effective treatment for many life problems and for many people. Psychotherapy differs from most traditional medical doctor appointments by requiring a greater amount of personal investment (time, energy, and money), consistent attendance (usually weekly), and an active role on your part both in-session and between sessions. It is common for significant changes in life to happen because of psychotherapy, such as transitions in career, changes in relationships, and adoption of different perspectives and worldviews. While these changes cannot always be predicted at the outset of treatment, it is important to understand that these and other changes are a potential outcome of your care.

While psychotherapy is effective for many people, it is not a good fit for everyone nor successful for addressing every problem. Thus, although your provider will do their best to address your concerns, they cannot guarantee that psychotherapy will be effective for you. It is also important to know that some people find that they feel worse after beginning psychotherapy, at least for a time, as they discuss sensitive and upsetting topics. It is often the case that talking about these difficult and painful experiences is necessary for growth to occur. If you feel that your treatment is not addressing your concerns or helping you in ways that you had expected, it is important to speak directly with your provider. Please bring up any concerns, questions, or feelings that you have about your psychotherapy or your interactions with your provider as soon as possible, as such issues are often relevant to your growth process.

Psychotherapy sessions generally last 53 minutes from the appointment start time unless you have scheduled a longer appointment (common in group, couples and family therapy). Sessions begin promptly at the agreed-upon time, and we ask that you arrive at your appointment early or on time. If your provider is delayed, they will continue your session after the usual end time, if it is acceptable for you so you will receive a full-length session.

About Psychological Testing

Psychological testing is a broad term for the use of psychological tests that have been validated by research and/or are professionally accepted for assessment of a person’s intellectual, academic, career, neuropsychological, neurodevelopmental, and/or personality functioning. Psychologists are trained to use these tests in standardized manners to obtain data that is then generally interpreted based on norms provided by research. Psychological testing is unique in its reliance on these standardized methods that include research based normative data. Testing can be very helpful in determining diagnosis, the reason(s) why a person is having particular problems and providing informed treatment recommendations. While psychological testing can be very helpful, testing itself is not able to answer every question, nor do the results always yield the desired answer(s). It is important to speak directly with your provider about what you wish to learn through testing and to understand what the limits to testing are with regards to your unique situation.

The process of testing involves multiple appointments including an initial history gathering session, appointments for the actual testing (number and length of appointments vary), and a feedback session. During the feedback session, you will be provided with a written report and verbal explanation of the testing results. It is important to understand that anything that happens during testing appointments might be included in the final report, which will become a part of your medical record. Professional laws and standards require that we keep a medical record. Please see section below entitled “Records and Confidentiality” for further information.

About Psychiatric Services

Psychiatric services encompass the evaluation, diagnosis, treatment, and management of mental health conditions and disorders using psychopharmacology. These services are provided by licensed psychiatrists, who are medical doctors specializing in mental health. Psychiatric evaluations typically involve a thorough assessment of a person's mental health history, symptoms, and functioning. This assessment may include interviews, questionnaires, and, in some cases, referrals for psychological testing. The purpose of the evaluation is to formulate an accurate diagnosis and develop an individualized treatment plan.

Once a diagnosis is established, psychiatric treatment often involves medication(s). Medication management involves prescribing and monitoring appropriate psychiatric medications to alleviate symptoms and promote mental well-being. Psychiatric services also encompass ongoing monitoring of treatment progress, adjustment of medications if necessary, and providing support and guidance throughout the recovery process.

Alliance’s psychiatrists work collaboratively with other mental health professionals, such as psychologists, counselors, social workers, and other physicians to ensure comprehensive, holistic care. Additionally, psychiatric services may involve crisis intervention and management, addressing acute mental health emergencies, and providing referrals to specialized treatment programs or facilities when needed.

About Telemental Health Services

Telemental health refers to the use of technology to deliver mental health services, encompassing both telepsychology and telepsychiatry. Alliance Psychology offers both telepsychology and telepsychiatry in the form of real-time video appointments using a secure and encrypted video conferencing platform in cases where it is deemed appropriate and clinically indicated. Research to date has shown that telemental health is just as effective as in-person care in many cases. The same fee rates will apply for telemental health as apply for in-person services.

It is important to review and sign this informed consent form to indicate that you understand the risks and benefits of receiving mental healthcare via video conferencing technology. By signing, you also agree to adhere to certain telemental health specific policies relevant to your geographical location at the time of your appointment as laid forth below.

RISKS

Confidentiality

We use a video conferencing vendor who complies with the HIPAA rules and with whom we have entered into a HIPAA business associate agreement. However, there always remains a risk that telehealth sessions may be compromised, unsecure, or accessed by others.

Privacy

Sometimes it is more difficult to find privacy at home, at your place of employment, or in dorm rooms. We will ensure that we conduct your sessions from a private space and discuss ways that you can maximize privacy at your location.

Technology failures

There is always a risk of poor connectivity/loss of connectivity during an appointment due to equipment failure or network problems. In cases such as these, appointments will be conducted by telephone.

Crisis management

Before engaging in telemental health, we will develop an emergency response plan to address potential crises. We will always ask for your physical address at the time of session and need to have an emergency contact on file. For non-local clients, we will ensure that we know how to access emergency services in your area prior to meeting.

BENEFITS

Saves Time

Telemental health appointments often mean less time off work and smoother logistics for things like transportation and childcare since you don’t have to factor in commute time to and from your appointment.

Expanded Access

Individuals in rural areas, individuals without means of transportation, and individuals with mobility issues or other specific healthcare needs can more easily access care. Individuals in areas with long wait times to see providers can choose professionals in other areas.

Reduced Expenses

Travel expenses are eliminated.

Ease of Stigma

Unfortunately, one of the most persistent barriers to mental health care is stigma. Telemental health can ease anxieties around appearing publicly at a practitioner’s office and promote acceptance of treatment.

• I agree not to record my appointments

• I understand that I must use my own equipment and that I am responsible for network or data plan charges incurred during my appointment.

• I understand that is important to use a secure internet connection rather than public or free Wi-Fi.

• I agree to attend session from a quiet, distraction free space that has a physical address, and I agree to provide that address to my provider at the beginning of our appointment in case of emergency.

• I agree to notify my provider ahead of time if I plan to be out of state or out of the country during a scheduled appointment, as this may impact whether or not the appointment can take place.

• I understand that the no-show/cancellation policy is the same for tele-mental health appointments as it is for in-person appointments.

• I understand that, in the event of problems with connectivity, my provider will contact me by telephone to complete the appointment.

• I understand that my provider may contact my emergency contact in the event of an emergency during a telemental health appointment.

• I understand that my provider may determine that, due to certain circumstances, telehealth is no longer appropriate and that in-person sessions would be therefore recommended.

FOR TELEPSYCHIATRY CLIENTS ONLY: Controlled substances cannot be provided without an in-person consultation.

FOR OUT-OF-STATE PSYCHOTHERAPY CLIENTS ONLY: I understand that my provider is a licensed psychologist, social worker or licensed professional counselor in the state of Texas. Some Alliance providers have Authorization to Practice Interjurisdictional Telepsychology (APIT) in PSYPACT participating states. Alliance provider’s will adhere to the laws of your state regarding the practice of psychology as it concerns your health and safety, including not but limited to the following:

• Reporting of the abuse or neglect of children, older adults, or individuals with disabilities

• Reporting of domestic violence

• Informed consent procedures

• Duty to warn victims of potential risk of physical or psychological harm

• Involuntary hospitalization

My provider will review relevant state-specific information with me during our first appointment, and I understand that I may be required to provide separate written acknowledgement of and consent to procedures that differ between my state and the state of Texas.

About Executive Coaching

Many people spend more time at work than in any other environment. As a result, obtaining professional coaching from a licensed mental health professional to address work related problems or professional development needs can improve mental health. Executive coaching is an increasingly popular way for professionals to improve their performance, enhance their leadership skills, and achieve their career goals. Alliance offers executive coaching from a psychoanalytic viewpoint. This approach combines the principles of psychoanalysis, which emphasizes the importance of understanding unconscious motivations, with the practical strategies of executive coaching. The benefits of executive coaching may include increased self-awareness, improved communication skills, enhanced problem solving, greater emotional intelligence and increased resilience. Executive coaching sessions begin with gathering your history and establishing your specific goals for coaching. Depending upon your unique history and stated goals, psychological testing may be utilized as part of the coaching process. For many executives and high-level professionals, the difference between performing well and optimal performance is correlated with their own mental health.

About Organizational Consultation

Organizational consultation is a service that varies depending on the needs of your organization. Our providers can be contracted to present trainings on specific mental health or organizational health topics, to work with leadership or subgroups within an organization on specific objectives, to provide support groups to support organizational health, or to assess the general organizational health of your company or specific individuals within the company and provide feedback. The nature and framework for consultation will depend on your organizations needs and will involve establishing a specific contract with Alliance.

About Clinical Supervision & Consultation Services

Alliance providers offer clinical consultation and supervision services to those seeking licensure or licensed providers seeking deeper learning, training, and clinical support. Our providers are well-trained and are sought for their respective areas of knowledge and clinical conceptualization skills. The nature and framework of consultation or supervision will vary depending on your needs and will be discussed at the outset of supervision or consultation.

Practice Policies

Integrated Practice

At Alliance, we believe that integrated care is the highest quality of care. The integration of psychology and psychiatry holds immense significance in the realm of mental health and well-being. By combining the insights and methodologies of both disciplines, a comprehensive and holistic approach to understanding and treating patients is achieved at Alliance. Psychology, with its focus on understanding thoughts, emotions, relationships, and personality in the context of life history, provides valuable insights into psychological processes that underlie functioning. Psychiatry, on the other hand, brings the medical perspective, with a deep understanding of biological and systemic knowledge, to treat patients. By integrating these fields, clinicians can develop a more nuanced understanding of mental health, consider the biological, psychological, and social factors at play, and tailor treatment plans accordingly. This collaboration facilitates a more patient-centered approach, where individuals receive personalized care that addresses both their psychological and psychiatric needs. Ultimately, the integration of psychology and psychiatry enhances the quality of mental health care, leading to better outcomes and improved overall well-being for individuals facing mental health challenges. If you have multiple providers within Alliance, we will collaborate on your treatment to ensure you are receiving holistic care.

Voluntary Nature of Treatment

You are under no obligation to continue treatment and can terminate at any time without consequence. You will only be responsible for any unpaid balance you have accrued. At any time, your provider can provide you with referrals for other mental health professionals who can assist you with your needs and concerns.

Cancellations

Please provide as much notice as possible if you need to cancel or reschedule an appointment. In general, we require a 24-hour notice or you will be billed for the missed appointment. We understand that life can bring unforeseeable circumstances. If an emergency or illness occurs within 24 hours of your appointment time, your provider will offer another time to meet within the week (if mutually agreeable) without charging an additional fee. If, however, there is not another appointment time that is mutually agreeable, you will be charged the full fee for the missed appointment. If your provider is unable to attend your appointment, your provider will inform you as soon as possible and offer to reschedule your session for the first suitable meeting time available after your originally scheduled appointment.

Parent/Guardian Involvement

If your child is receiving services at Alliance, a positive and collaborative relationship between you and their provider is crucial to the success of the treatment. Alliance reserves the right to modify, suspend, or terminate services if it is determined, at the sole discretion of the provider, that the actions of parents/guardians impede Alliance's ability to meet the treatment objectives, disrupt sessions, or demonstrate uncooperative, unreasonable, or unsupportive behavior towards Alliance providers, or any other significant person involved in the treatment of the child. In the case of coparenting or divorcing families, it is critical that each party commits to remaining cordial and collaborative for the sake of their child. If this is not possible, then it places both Alliance and your child in a difficult bind. If parents/guardians provide misleading or inaccurate information, Alliance may, at its sole discretion, discontinue therapy services and terminate this agreement.

If any family member or guardian engages in disruptive, intimidating, overly aggressive behavior, or displays a lack of confidence in or disagreement with Alliance's treatment methods, approaches, or interventions, either within or outside of therapy sessions, or if their actions interfere with the therapeutic process or the well-being of others, Alliance reserves the right to restrict the family member's involvement in treatment or related activities. Alliance may also choose to terminate services for a family member due to other appropriate reasons determined by the provider. Furthermore, Alliance reserves the right to decline or rescind an offer for services based on a family member's violation of the expectations outlined in this informed consent. In the event of termination, any outstanding balance for therapy services rendered will remain payable in full as per the terms of this agreement.

Professional Fees

Money is an important symbol which elicits individual meanings that differ for each of us. As a result, your provider views any thoughts or feelings associated with payment as relevant to your care and asks that you discuss them directly.

Insurance is not accepted. Our stated fees, due at each appointment, provide real-time transparency of the cost of services. A written good-faith estimate of expected charges is available upon request.

Alliance Psychology offers services from a variety of mental health professionals with differing licenses and fees:

For testing, the above fees include up to two initial appointments to gather history, all appointments associated with test administration, test interpretation, report writing, all time spent consulting with referring professionals, and up to two testing feedback sessions. Any additional request for sessions will be billed at the listed hourly rate.

We charge the listed hourly rate for other non-forensic (meaning not involving the legal system) professional services including report writing, telephone conversations lasting longer than 5 minutes, attendance at professional meetings you have requested/authorized, preparation of records (including treatment summaries), and time spent performing any other services requested by you. These out-of-session costs will be assessed in 15-minute increments for accurate billing.

If you become involved in legal proceedings and your provider’s presence is required or requested by either party, you will be expected to pay for their professional time. Due to the difficult and complicated nature of legal proceedings and involvement, our psychologists/therapists charge $500 per hour for preparation, travel time, and attendance at any legal meeting or proceeding. Alliance Psychiatrists charge $750 per hour for preparation, travel time, and attendance at any legal meeting or proceeding.

Payment

Payment is due at the time of service. Acceptable forms of payment include cash, credit card, debit card, or checks made payable to “Alliance Psychology” or “Alliance Psychiatry” depending upon provider. The payment software “Square” provides us with a convenient device to process credit and debit card payments. We will do our best to ensure that your use of the above payment services is as secure and private as possible.

It is important that you are aware that Square might send you, by email or text, receipts for payment messages that include our business name, which would indicate that you have paid for a mental health service. This is controlled by Square, not our providers. For maximum privacy, you can select the “no receipt” option when you pay.

Receipts are provided on request. There is a $25 fee for any returned check. If payment is not rendered after 60 days, we have the right to take legal action to obtain payment including, but not limited to, the use of a collection agency or reporting the unpaid amount to a credit bureau.

If you are obtaining psychological testing services, it is important to understand that while we will complete testing administration, your provider will only begin interpreting the testing results and writing the report once full payment is received. We do not interpret results or write any report until full payment is received.

Medication Changes

If you are receiving psychiatry services through Alliance, all medication changes must be made during a scheduled appointment with your provider. Medication changes will not be made over the phone. You are encouraged to schedule an appointment if you would like to discuss medication adjustments.

Prescription Refills

Please allow two full business days for Alliance and your pharmacy to fill or refill your medication. Medications refill requests are not processed over the weekend. If you are prescribed a controlled substance, you are required to be seen in the office every 90 days. Refills will not be given without regular attendance at appointments.

Medication Compliance

Misuse or non-compliance with prescribed medication will be discussed on a case by case basis and may be grounds for termination of treatment.

Insurance

Alliance providers operate on a fee-for-service basis and do not accept or bill any form of insurance. Many insurance companies will authorize services for out-of-network providers or make an exception so that, in certain cases, out-of-network providers can be seen. If you desire to utilize any insurance benefits, it is your responsibility to first ensure that you have your insurance company’s authorization and sufficient benefits available to meet the cost of the visit with your provider. Your provider will, upon request, provide receipts, complete any necessary forms or paperwork that you furnish, and provide clinical information necessary to you for billing purposes. Many insurance companies require personal health information to approve services. This information might include, but is not limited to, a clinical diagnosis, symptom checklist, and/or treatment plans and/or summaries. We have no control over what your insurance company does with this information once it is received by them. In some instances, insurance companies might authorize only a limited number of sessions for brief, problem-focused treatment. It is important at the outset of treatment to understand what benefits you have and to discuss this with your provider to determine what would be best for you given your benefits, financial resources, and goals.

If you are planning to submit for out-of-network insurance and undergoing psychological testing, please read the funding statement in the above section entitled “Payment.”

Medicare Opt out for Psychiatry Patients 65 or Older

If you are 65 or older and are seen for psychiatry, you will need to sign a separate document acknowledging that you are opting out of Medicare. This will be provided to you.

Records and Confidentiality (Notice of Privacy Rights & Policies)

Professional laws and standards require that we inform you of your privacy rights and our policies around keeping your protected health information (PHI) safe and protected. This complies with the Health Insurance Portability & Accountability Act of 1996. We are required to keep treatment records. In general, these records are kept confidential and only seen by your provider and/or administrative personnel. We use a program called “Breezy Notes EHR” and/or “AdvancedMD” to generate and store your record electronically. Both electronic health records are obligated under federal law to protect these records from unauthorized use or disclosure under HIPAA (Health Insurance Portability and Accountability Act of 1996). These EHR systems maintain a log of transactions in their system for various purposes, including maintaining the integrity of the records and for use in security audits. If you are seen for Psychiatry, you will communicate with your doctor through a patient portal through AdvancedMD. This will be discussed with your provider. Please let your provider know if you have questions or concerns.

You have the right to obtain copies of your records unless your provider believes that they may be misunderstood, misinterpreted, and/or emotionally damaging in some way. You may also have the right to amend inaccuracies in your record. In these cases, your provider will review the records with you so that you can discuss the content together. An appropriate fee will be charged for any time spent preparing information based on Alliance’s financial policies described in this document.

As previously mentioned, there are some exceptions to confidentiality that are set forth by professional laws and ethical standards. If your provider becomes concerned for you or someone else’s safety, they may have to reveal some information about you or your treatment in order to ensure safety. This information may be disclosed in the course of seeking hospitalization, contacting police, family members, or potential victims. If they suspect that a child, elderly person, or disabled person is being abused or neglected, they must file a report with the appropriate state agency. If there are any crimes on the premises of the Alliance property observed or directed at you, your information may be shared. Your provider is also legally required to testify or provide information subpoenaed when ordered by a judge. These situations are quite rare. Your provider will attempt to discuss any disclosure of information with you before any action is taken unless there is no opportunity due to urgent circumstances. You have the right to know when your information is disclosed.

In couples or family therapy, your provider will not usually “keep secrets” between spouses or family members. It is important to know that, as a general rule, anything you tell your provider in the course of couples or family therapy will not intentionally be kept confidential from a spouse or other family members. In the case of a minor being seen for treatment, the legal guardian must consent for treatment, but the minor should have rights to privacy and must assent to treatment with their provider. While it is natural for guardians to want to be involved and get feedback, discretion will be used to determine what is shared about their minor’s treatment.

There may be cases where it would be useful for us to collaborate with others in your life including other providers outside of Alliance, family members, or close relationships. Any outside consultation would require you to consent to release information and you have the right to revoke this at any time. If there is a breach of unsecured PHI, we will notify you.

Consultation and Case Conference

In accordance with the ethical standards of state and national mental healthcare, your provider is required to seek consultation when necessary, as a way to ensure your quality of care. Consulting with other providers is a key aspect of effective, ethical treatment, and is done in a way that maintains your privacy (e.g., information is shared in a de-identified manner to protect your PHI).

The most common type of consultation takes place in a "one-on-one" format, whereby your provider seeks support from another individual provider to discuss your case privately. An alternative type for consultation is known as a "case conference," whereby your provider formally presents your case to a group of providers in a structured meeting format. Doing so ensures that consultation occurs within a collaborative, professional environment, with multiple clinicians sharing feedback to improve your quality of care. In both consultation formats, information about your treatment may be openly discussed.

As a group practice, Alliance providers participate in both one-on-one and case conference formats for consultation. Alliance providers and outside consultants who attend case conferences are licensed mental health professionals or trainees adhering to the same code of ethics to maintain your confidentiality. While your provider is ethically bound to consult when necessary, it is understandable that you may not be comfortable with your treatment being presented within the case conference format.

Communicating Via Email & Text

Please consult with your specific Alliance provider and agree upon your preferred methods of communication. Email and text communication are not private, and confidentiality cannot be guaranteed. If you exchange email or text with your provider, be aware that you are accepting a risk that your confidentiality could be breached. To protect your privacy, please do not disclose important clinical information electronically. Using email or text messaging should generally be reserved for scheduling or other administrative matters if utilized. If you are seen for psychiatry, you will communicate with your provider through a secure patient portal through the electronic health record, AdvancedMD.

Contact Information and Emergency Procedures

Our phone number is 210-926-5777. You may call your provider seven days a week at any time; most often, you will reach your provider’s voicemail. Your provider will return your phone call in a prompt manner, usually within the same day.

However, if you need immediate assistance, as in the case of an emergency, and you are unable to reach your provider, you should contact your family physician or call the local emergency room and ask for the psychiatrist or psychologist on duty. If neither of these options meets your needs, dial 911.

If your provider is going to be away or unavailable for an extended period, they will inform you of their absence in advance and provide contact information for a colleague who can address your needs while they are away.

Professional License and Credentials

Your provider is licensed by their respective board in the state of Texas. The Texas Behavioral Health Executive Council consists of the Texas State Board of Examiners of Marriage and Family Therapists, Texas State Board of Examiners of Professional Counselors, Texas State Board of Examiners of Psychologists, and the Texas State Board of Social Worker Examiners. Postdoctoral fellows work under the supervision and licensure of a Licensed Psychologist. Psychiatrists are licensed by the Texas Medical Board.

If, at any time, you have questions or concerns about any situation that might impact your care, please speak directly with your provider to reach a mutually acceptable agreement. Additionally, please let your provider know if you would like a copy of the applicable laws and rules that govern the practice of psychotherapy described in this document. If Alliance Psychology is unable to resolve your complaints, you may send a written complaint to the respective boards listed above.

Forensic Service Policy

Alliance providers do not provide forensic services. This means that they will not become involved in a case that is undergoing legal proceedings. This includes child custody evaluations, risk evaluations, competency evaluations, or any services that are recommended or required by a court or attorney. If there is concern that your case may become involved in forensic proceedings, you should seek services from a board certified forensic psychologist or psychiatrist. The courts have many court-appointed providers who can provide such services. Alliance providers may ask you to sign a contract agreeing to our forensic policy if there is any concern related to the potential for legal involvement.

We provide these policies and information as answers to frequently asked questions. Other likely circumstances and possible events not addressed here might occur; if you have a concern, please reach out to your provider directly for advice and guidance to resources and support.