OUTPATIENT SERVICES AGREEMENT FOR COLLATERALS
I want to thank you for accepting the invitation to assist in __________________________’s psychotherapeutic treatment. Your participation is important and may be essential to the success of the treatment. This document is to inform you about the risks, rights and responsibilities of your participation as a collateral participant.
WHO IS A COLLATERAL?
A collateral is a spouse or partner, family member, or friend who participates in therapy to assist the identified client. The collateral is not considered to be a client and is not the subject of the treatment. Psychotherapists have certain legal and ethical responsibilities to their clients, and the privacy of this relationship is given legal protection. My primary responsibility is to my client, and I must place their interests first. They have more privacy protection; you would have less privacy protection.
THE ROLE OF COLLATERALS IN THERAPY
The role of a collateral will vary greatly. For example, a collateral might attend only one session, either alone or with the client, to provide information to the therapist. Or, a collateral might attend a number of the client’s therapy sessions and the relationship between the client and the collateral may be one focus of treatment. We will discuss your specific role in the treatment at our first meeting and other appropriate times.
BENEFITS AND RISKS
Psychotherapy often engenders intense emotional experiences, and your participation may engender strong anxiety or emotional distress. It may expose or create tension in your relationship with the client. While your participation can result in better understanding of the client and an improved relationship, and may even help your own growth and development, there is no guarantee that this will be the case. Psychotherapy is a positive experience for many, but it is not helpful to all people.
As a collateral, no record or chart will be maintained on you. However, notes about you may be entered into the client’s chart. The client has a right to access that chart and the material contained therein. It is sometimes possible to maintain the privacy of your communications with me. If that is your wish, we should discuss it before any information is communicated. You have no right to access the client’s chart without the written consent of the client. You will not have a diagnosis, and there is no individualized treatment plan for you.
As a collateral, you are not responsible for paying for my professional services. The client is responsible for paying for my professional services.
The confidentiality of information in the client’s chart, including the information that you provide me, is protected by both federal and state law. It can only be released if the client specifically authorizes me to do so. There are some exceptions to this general rule:
- If I suspect you are abusing or neglecting a child or a vulnerable adult, I am required to file a report with the appropriate agency.
- If I believe that you are a danger to yourself (suicidal), I will take actions to protect your life even if I must reveal your identity to do so.
- If you threaten serious bodily harm to another, I will take necessary actions to protect that person even if I must reveal your identity to do so.
- If you, or the client, is involved in a lawsuit, and a court requires that I submit information or testify, I must comply.
- If insurance is used to pay for the treatment, the client’s insurance company may require me to submit information about the treatment for claims-processing purposes or for utilization review.
You are expected to maintain the confidentiality of the client in your role as a collateral.
DO COLLATERALS EVER BECOME A FORMAL CLIENT?
Collaterals may discuss their own problems in therapy, especially problems that interact with issues of the identified client. The therapist may recommend formal therapy for a collateral. Here is a example of when this might occur:
- It becomes evident that a collateral is in need of mental health services. In this circumstance the collateral needs to have a clinician, a diagnosis, and chart/records kept.
Most often, but not always, your clinician will refer you to another clinician for treatment in these situations. Here are two reasons the referral may be necessary:
- Seeing two members of the same family, or close friends, may result in a dual role, and potentially cloud the clinician’s judgment. Making a referral helps prevent this from happening.
- The clinician must keep a focus on the original, primary task of treatment for the client. A referral helps the clinician stay focused.
RELEASE OF INFORMATION
The client is not required to sign an Authorization to Release Information to the collateral when a collateral participates in therapy. The presence of the collateral with the consent of the client is adequate. This provides assurance that full consent has been given to the clinician for the client’s confidential information to be discussed with the collateral in therapy.
However, an Authorization to Release Information from the client is helpful to the clinician when and if the collateral and the clinician communicate outside of session for one reason or another. In most instances the clinician cannot take a call from a collateral without an Authorization form.
If you have questions about therapy, my procedures, or your role in this process, please discuss them with me. Remember that the best way to assure quality and ethical treatment is to keep communication open and direct with your clinician. By signing below, you indicate that you have read and understood this document.