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INFORMED CONSENT FOR TREATMENT
OUTPATIENT & IMMERSION SERVICES CONTRACT
Welcome to our Private Healing Immersion. This document contains important information about our professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them before our meeting, through email or on the telephone. When you sign this document, it will represent an agreement between us and the other members of the Immersion.
Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. While you will be helped to manage what you share in the Immersion, any disclosures you make and the impact they have on your relationships are your responsibility and are not the responsibility of the Immersion leaders. Of course, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience.
As indicated in the Immersion description, this Immersion focuses on deep emotional healing and other issues such as ways to increase fulfillment in your intimate relationship(s). One of the goals is to help reveal and begin to work through some of your defenses and protective mechanisms that interfere with your emotional expression, intimacy and fulfillment. Often, you will be asked if you are comfortable doing what is being asked in terms of the help that is offered, and this is something that is your responsibility to evaluate at each turn. It is important for you to genuinely consider this as you do the work in the Immersion, as other options will be available to help you. Just let Elicia and Doug know if you are uncomfortable.
Because this Immersion is designed to help you move through difficult psychological, emotional and relationship issues, various feelings may emerge and dynamics may change in the days and weeks following the Immersion. If these feel overwhelming or otherwise are difficult to manage, we will be available by email and/or telephone and we will return your communication as soon as we can. We will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform us of some times when you will be available. If you are unable to reach us and feel that you can’t wait for us to return your call, contact your family physician or the nearest emergency room and ask for the psychologist [psychiatrist] on call. You are also free to work with other mental health professionals and other providers as you see fit.
Psychologists are required to keep records of the professional services they provide. Because these records contain information that can be misunderstood by someone who is not a mental health professional, it is my general policy that patients may not review them; however, I will provide at your request a treatment summary unless I believe that to do so would be emotionally damaging. If that is the case, I will be happy to send the summary to another mental health professional who is working with you. You should be aware that this will be treated in the same manner as any other professional (clinical) service and you will be billed accordingly.
PROFESSIONAL CONFIDENTIALITY AND EXCEPTIONS
In general, the privacy of all communications between a patient and a psychologist is protected by law, and I can only release information about our work to others with your written permission. But there are a few exceptions.
In most legal proceedings, you have the right to prevent Dr. Miller from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it.
There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a patient’s treatment. For example, if I believe that a child [elderly person, or disabled person] is being abused, I may be required to file a report with the appropriate state agency.
If I believe that a patient is threatening serious bodily harm to another, or themselves, I am may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client. If the client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection.
These situations have occurred very, very rarely in my practice. If a similar situation occurs, I will make every effort to fully discuss it with you before taking any action.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have before our Immersion. I will be happy to discuss these issues with you if you need specific advice.
WE ARE NOT MEDICAL PROFESSIONALS
Elicia Miller and Doug Miller PhD are not medical doctors, and any opinion and advice regarding nutrition or medical issues is for you to research and/or decide what works for you. The success of an individual and group program, as well as your ability to self-heal, rests mainly on your resolve to focus on your health – now and in the future. Please consult a medical doctor before making any changes.
This Immersion is not for those actively addicted to drugs, alcohol. If you are taking psychiatric medications, please contact Dr. Miller and discuss these with him.
Please note that all services are not refundable.
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