This contract is for adults and children (to be read and explained also by parent).
Thank you for choosing Dr. Allen, and the Mind for Health Resources, Ltd. wellness and success program. Dr. Allen offers a variety of strategies to help clients achieve better mental and physical health, academic fitness, and career success. His programs are unique, diverse, and based on a holistic model. He also provides psychotherapy, stress management training, health education, biofeedback, and clinical hypnosis. Dr. Allen works with children, adolescents, adults, seniors, and individuals with special needs and disabilities.
During the first session, Dr. Allen will evaluate your needs and treatment aspirations. For many clients, a brief clinical interview may be sufficient, and completed in one session. For brief symptom reduction, treatment will begin immediately, and be based on the number of sessions to target goals and objectives agreed upon by both client and therapist.
Only if requested, a full testing battery is available, which may involve three or more hours, and be extended over several sessions. Through psychological testing, the objective is to target key issues and dynamics contributing to a client’s challenges, as well as to stress-related illness, and to support a proper treatment plan. Cognitive testing is available for exploring intellectual strengths and challenges, and career testing is also available to help identify career aspirations and professional goals. Additionally, testing may help identify what motivates you, your personal strengths, and how you can utilize those strengths to improve your situation, to feel healthier, and to succeed toward your goals. Testing, however, may reveal emotional issues and personal information, and the assessment process can at times feel stressful. Dr. Allen will guide you through the process, and please feel free to ask any questions about the process at any time. Your complete input in your evaluation and treatment plan is encouraged. At the completion of an assessment, Dr. Allen will provide a treatment plan with strategies toward resolving issues, treating health problems, and / or defining personal and professional objectives and aspirations.
If psychotherapy or coaching is requested, Dr. Allen will usually schedule one 50-minute session per week at a time agreed on, although some sessions may be longer or more frequent if requested or more effective in treatment objectives. The objective of psychotherapy is to improve mental health, happiness, quality of life, and hardiness toward mastering personal challenges. Psychotherapy calls for a very active effort on your part. In order for therapy to be successful, you will have to work on things we talk about both during our session and at home. Psychotherapy can have benefits and risks. Since therapy may involve discussing unpleasant or challenging aspects of your life, you may at times experience uncomfortable feelings such as sadness, guilt, anger, frustration, loneliness, and helplessness.
On the other hand, psychotherapy has also been shown to benefit individuals who go through it. Therapy often leads to better relationships, solutions to specific problems, improvement in health, and significant reduction of feelings of distress, but there are no guarantees of what you will experience. You will learn many new concepts that may increase your scope and understanding about health and mental wellness, and you may receive new benefits and skills from stress management training. The number of sessions needed to meet your needs will be determined during the clinical interview and/or assessment. If alternative therapies would be more beneficial, Dr. Allen will help you with referrals for outside resources.
The following are treatment expectations and a contract that you (or your parent or legal guardian if child) and Dr. Allen will be required to sign prior to beginning professional services. Your signature (or a signature of parent or legal guardian) indicates your understanding and agreement of the terms of this contract.
Please do your best toward success in the program: Be dedicated. Therapy is an important investment in yourself, toward improving your quality of life. However, there are risks and benefits, and alternatives of treatment if needed. Therapy requires that emotional issues be addressed, and deeper concerns brought to light. Confidentiality is always respected. Dr. Allen will discuss the risks involved in any mode of treatment. You are encouraged to read all treatment information handouts, ask questions at any time and about any treatment or methodology, practice the new and helpful strategies, cultivate a yearning to improve and make positive changes, be open-minded, and do the assignments with an interest toward healing and improving yourself.
Full payment for services rendered will be required at the end of each session: Dr. Allen’s fees are within the usual and customary range for this community. Full fee of $ /hour is to be paid at the time of service, regardless of insurance reimbursement. Sessions are 60 minutes, although time can be extended at a pro-rated hourly fee. Your hourly fee also covers cost of handouts and materials, healing tapes, ongoing training preparation of materials and resources, administration of your file, phone consult and collaboration with your health care providers or other designated personnel, and brief phone time in between sessions. Other fees charged include testing and test materials, report writing, lengthy phone sessions, ongoing email coaching in between sessions, and attendance at meetings with other professionals you have authorized.
Dr. Allen is an out-of-network provider, by which many PPO’s and private insurance companies pay a percentage of the fee / session, often 50-60%, based on mental health benefits available. Dr. Allen will provide an insurance superbill and submit it monthly to your insurance company for reimbursement. HMO’s will most likely not pay for services out of network. Please authorize and confirm insurance benefits by contacting your insurance company, and providing Dr. Allen’s information on the superbill handout. Also, consider your insurance co-payment and deductible. Receipts for services are also available. For payment of services, Dr. Allen accepts checks, Visa or Mastercard, or cash. Dr. Allen reserves the right to terminate the doctor- client relationship for non-payment of services. If financial difficulties arise, an alternative payment schedule may be provided at Dr. Allen’s discretion. Brief therapy is available and may be effective if financial constraints arise.
Please be on time for every appointment: Therapy and coaching sessions are 60 minutes. Testing and evaluation sessions may be 2 hours or longer depending on the extent of the assessment. Lateness affects attitude and focus toward success in the program, and it reduces the amount of time in a session. The 60-minute time slot scheduled will not be extended or changed for any lateness. Please contact Dr. Allen at least 24 hours before an appointment to cancel or reschedule. You will be expected to pay for any canceled or missed sessions unless given at least 24-hours notification to Dr. Allen, and insurance companies don’t pay for missed appointments. Allen will work to help you find a comfortable weekly time slot, to help keep rescheduling to a minimum.
Emergency situations: Any discussion in therapy about suicide or aggressive behavior toward others will be taken seriously, as your safety and the safety of others is most important. If in need, Dr. Allen will take necessary measures to help you be safe during therapy and build a support network or crisis management plan. For serious emotional concerns or suicidal feelings outside of therapy, always go to the emergency room at a local hospital first. Dr. Allen can be reached at his 24-hour pager during non-working hours, only in emergencies (847) 564-8755 – (page 2-3 times), and I will try to respond to your call as soon as its
Contact outside of therapy: Dr. Allen can be reached at his office (847) 205-9605 or leave a message if you have any questions or need support. Your phone call will be returned soon, but within 24 hours. Please let Dr. Allen know phone numbers where you can be reached, and how to leave confidential voice messages for
Request for records and contact with current practitioners: To optimize treatment, Dr. Allen may (only if relevant and agreed upon by you or a parent if child) request previous medical, academic, psychiatric or psychological records. Further, Dr. Allen may request to contact your physician(s) or current health practitioner to align goals and report treatment progress. Dr. Allen may be required to contact your health insurance company. Before any contact is initiated, you will need to sign a release of information form, and give full consent. Dr. Allen also recommends a medical check-up with a physician prior to or during treatment for major health issues, and medical support when
Termination policies: Ethical termination from Dr. Allen requires that in his clinical judgment, a client is ready to terminate therapy, or an outside referral for services would better suit the needs of the client at that particular time. If you decide to initiate termination, please contact Dr. Allen for a final session or phone conversation to discuss the reasons, explore alternatives, and for closure. Referrals for outside resources are available if necessary or requested. Following termination, Dr. Allen will provide you with a termination summary and any information you need for insurance or in regard to your
Confidentiality: The information you tell your therapist will be treated with great care. The psychology APA ethical code and the professional laws of the state require that your therapist not reveal to any other person what you confide during your sessions without your prior written permission. These rules and laws are the way our society recognizes and protects the privacy of what is disclosed during sessions with your therapist. However, there are some situations when the law requires your therapist to share information with others. You need to be aware of these so you don’t tell your therapist something as a “secret” that cannot be kept a
Exceptions to confidentiality:
If your therapist comes to believe that you are threatening serious harm to another individual, he may have to tell the person(s) involved, tell the police, or perhaps try to temporarily have you put in a hospital for safety
If you seriously threaten or act in a way that is likely to harm yourself, your therapist may have to seek hospitalization for you, or contact a family member or another who can help protect you. If such a situation arises, he will fully discuss the situation with you before taking action, unless there is strong reason not
In emergency situations, where your life or health is in danger, and your therapist cannot get your consent, he may give another professional some information to protect your life. He will attempt to get your consent first, and will discuss it with you as soon as possible afterwards.
If your therapist suspects that you are abusing a child, an elder, or a disabled person, or (if you are any of these) you are the victim of abuse, he must file a report with a state agency. To “abuse” means to neglect, hurt, or sexually molest another person. Dr. Allen does not have any legal power to investigate the situation to find out all of the facts. Instead, the state agency will investigate. If this might be your situation, you and Dr. Allen should discuss these topics. Additionally, you may also want to talk with your
If subpoenaed by the court, your therapist may be required to reveal confidential information that occurred or was revealed in therapy. The right to confidentiality may be challenged depending on the nature of legalities or the plead (i.e., lawsuit, unfit for trial, insanity, ).
Only with your written permission, Dr. Allen may send records and treatment status reports to your insurance company, physician(s), or another healthcare provider. As such, they will have access to your confidential
There are situations where Dr. Allen may consult with a supervisor (e.g., biofeedback training supervisor). You are encouraged to ask questions about the supervision and how it can help benefit your treatment. Dr. Allen will never reveal your identity to the supervisor. Name and phone number of supervisors:
I the client (or his or her parent or guardian) have read the above information on all three pages of this treatment contract and I understand and agree to its contents. I have gone over this contract with Dr. Allen, and I understand these policies, rules, questions, issues of confidentiality, payment issues, my rights in therapy, and the therapist’s answers. I have had all of my initial questions answered fully, and I understand that I may ask questions at any time concerning all aspects of my therapy. I do hereby seek and consent to take part in the treatment by Dr. Ben Allen. I understand that developing a treatment plan with this therapist and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process. I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this therapist. I am aware that I may stop my treatment with this therapist at any time. The only thing I will still be responsible for is paying for the services I have already received.
Signature of Client (or parent/guardian)
Date
Minor’s Signature (if client is over 12 years old)
Date
Printed Name
I, the therapist, have discussed these issues with the client (and/or his or her parent or guardian). I believe this person fully understands the issues, and I find no reason to believe that this person is not fully competent to give informed consent to treatment.
Signature of Therapist
Date
Return to Areas of Clinical Practice for Children and Adults
Mind for Health Resources Ltd. 