Informed Consent for Treatment

Date

First Name *

Last Name *

Email Address *

My clinician is: *Dr. Mark ZuccoloDr. Sonia MaxwellI don't know

Please read and check each box here below. The form will not go through unless all boxes are checked.

THE PROCESS. Therapy is a very personal experience. How much you will benefit from it will be greatly determined by your commitment. While there are no guarantees as to the outcome of your therapy, we will discuss potential risks, benefits, and alternatives as they relate to the therapy you will receive.

THE THEORY. Our main theoretical belief system is cognitive behavioral therapy, which uses a collaborative approach and specific goals. A combination of evidence-based approaches will be used for couples. Family therapy will be approached from the systems perspective. Additional information will be provided as requested or as needed.

FEES. Unless otherwise agreed upon, therapy sessions are 50 minutes in length at the standard fee indicated on our website. For self-pay clients, payment is due at the time of service. A credit card on file is required of all new clients. This card may be used to charge for missed appointments. If your health insurance provider has contracted directly with the clinician, you are responsible for the co-pay at the time of service and for prompt payment of unmet deductibles.

INSURANCE: Diagnostic classification is required for health insurance billing. Insurance employees will have access to this information, which may become a permanent part of your file with your insurance company. Dr Zuccolo is not an in-network provider for health insurance companies. If you would like to submit documentation for reimbursement, our office can provide a superbill.

BETWEEN SESSIONS. Should you need to speak with your therapist between sessions or outside of regular business hours, please note that telephone conversations exceeding 5 minutes will be billed on a prorated basis.

TESTING. If we agree to utilize a testing instrument to enhance the quality of your treatment, there will be an additional fee for testing materials and for the administration of the test. Fees will be discussed with you ahead of time.

CANCEL/RESCHEDULE. Appointments must be cancelled/rescheduled 24 hours in advance. Otherwise, your credit card on file may be used to collect this charge (an exception will be made in case of medical emergency, with written proof).

WEATHER. For our mutual safety, in case of inclement weather (e.g., snow or icy roads) the office session with existing clients will not be cancelled but will instead take place at the appointed time by phone or telehealth. If the session is an intake (new client coming in for the first time), the session will be on telehealth or rescheduled to the nearest available date.

CRISIS/EMERGENCY. A confidential voicemail is available 24 hours a day and is monitored during regular business hours. If you experience a crisis or an emergency, please contact your local emergency services or go to the nearest emergency room. For non-emergencies, every effort will be made to return your call the same business day.

SPIRITUAL INTEGRATION. We provide a welcoming environment for general spirituality, religious orientation, or none. Please feel free to include it or omit it from our conversations, at your choice.

CONFIDENTIALITY. All therapy sessions are confidential. Confidentiality and privileged communication remain the rights of all therapy clients according to state law.

There are exceptions to confidentiality and privilege, which may arise from Georgia state legal mandates and/or professional ethical guidelines. The major exceptions are: The obligation of reporting to the authorities, without your consent, any suspicion of abuse, including physical, sexual, or emotional of any child, elderly person, or dependent adult• The need to take appropriate steps when it appears evident that you intend to harm another person• The need to take appropriate steps when it appears evident that you will most probably make a suicide attempt, in order to prevent such an attempt• When disclosure is required by a valid court order. In each of the above cases an attempt will be made to inform you that a report or disclosure will be made.

The therapist shall have discretion in deciding what to disclose to parents of minors (through age 17) about the content of their children’s sessions and to facilitate any necessary disclosure in a joint session with all parties present.

Neither Dr. Mark Zuccolo nor Dr. Sonia Maxwell is available to testify or to serve as expert witness in legal cases.

Audio/video recording of sessions is not permitted unless specifically agreed to by all present.

I (Client) have read, understood, and agreed to the terms and conditions stated above.

Your signature *Please type your full legal name. This will be your legally binding electronic signature.

Informed Consent for Treatment

Dr. Mark R. Zuccolo, PhD, LMFT

Bellagio Psychotherapeutics