Paul F. Schmidt, Ph.D.
INFORMED PERMISSION TO TREAT
FOR IN-PERSON OR PHONE SESSIONS
Confidentiality: I understand that unless I can be assured that Dr. Schmidt will protect the privacy and confidentiality of what I tell him, he could not expect me to open up to him very fully, and he could not help me reach my goals in counseling. So I will take responsibility for insuring privacy near my phone or computer: Dr. Schmidt will not communicate if others are around. Unless I request otherwise and take responsibility for the privacy of the call, we will communicate through a private telephone and video-conferencing service (Zoom) which he pays to protect our messages and pictures with encryption (they are scrambled at each end, and unscrambled at the other, so they can’t be recorded or intercepted). I realize that the only times he will reveal to anyone else what I have told him, even the fact that we have a professional relationship, is when law requires him to:
- If I sign a release directing him to do so, of if a judge or court order requires him to;
- If he is told that someone has been or may be abused or neglected without it being reported;
- If I tell him that someone else or I pose a serious threat for physically harming someone, or
- If I confess to him an unreported crime.
Emergencies: If Dr. Schmidt feels that an emergency such as those in the four previous lines above may occur or may have occurred, he is required by law to report this. To help him do so, I will do all my calling from my home address: _______________________________. When Dr. Schmidt is not immediately available by phone, I know I can leave a message on his cellphone, 502 633 2860. If my need is more urgent, I will call my physician, or the local mental health hotline, such as 800 221 0446 in Louisville, or 800 928 8000 in Lexington. Scheduling: My telephone sessions (teletherapy) are scheduled with Dr. Schmidt directly. Except for reasons of illness or unsafe roads, cancellations need to be the day before to avoid the late cancel charge of $70. Phone calls: There is no charge for most phone calls, but I will get more out of them if I have decided before calling what is bothering me, and what I want him to do about it for me. His time dealing with my unscheduled calls, texts, emails, etc. is given free up to 15 minutes a week. If I schedule a time, I agree to pay for that time at the rate of $140 per hour, with a $40 minimum. Working with more than one member of the same family: I am responsible with my family member for considering and discussing together the pros and cons of this option as presented under the tab “How I Work” on his website above. If we do this, we will trust each other to work toward common goals, and work within limits given there. Social Media: I am encouraged to follow Dr. Schmidt on social media, but he won’t contact me back that way, as it isn’t private enough. Details of this policy are on his website above. Fees: A meeting in my office or home in-person costs $150 per hour. My teletherapy fees are $140 per hour. The first session lasts at least 75 minutes, includes free phone calls etc. as spelled out above, and costs 50% more ($200 if by Zoom or phone, $225 in person). Sessions are paid at time of service. Forgotten sessions, or those canceled earlier the same day except for reasons of health and road safety, cost half a session $75. Insurance: I am responsible for finding out what my coverage is for a state-licensed out-of-network provider, which Dr. Schmidt is and will always be (why is explained under the tab for “Managed Care”). How to discuss coverage and payment with my insurance company is on his website above, under the left tab for “Insurance”. Need for an in-person session with him or another local counselor (transferring my case): if Dr. Schmidt ever believes I need either of these for safety or better communication, I’ll do as he directs.
________________________________ _______________ Signature Date
Cell phone and email I may use privately: _____________________________________________________________________