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Franco Bejarano, LCSW · Francopsychotherapy.org

Francopsychotherapy@gmail.com · 470. 491.3753
Atlanta, GA 30310

Informed Consent and Psychotherapy Agreement

About Franco Psychotherapy

Franco Psychotherapy is a Limited Liability Company located in Atlanta, GA providing
professional psychological services to children, adolescents, adults, families and agencies.
Psychotherapists (alternatively called counselors or therapists) practicing counseling for a fee
must be licensed with the Georgia Composite Board of Professional Counselors, Social Workers
& Marriage and Family Therapists for the protection of the public health and safety. Licensure of
an individual with the department does not include recognition of any practice standards, nor
necessarily implies the effectiveness of any treatment. Franco Bejarano, LCSW is the owner of
Franco Psychotherapy. If you have any question, please contact him at the information above.

Things to know about confidentiality

All information you share with us, whether in sessions, email, or over the phone, become part of
your clinical record. In general, communications between client and therapist are confidential.
Such information will not be released to anyone, including other agencies, without your written
consent. This is called having the “confidentiality of the therapist”. Nevertheless, there are
EXAMEPTIONS one needs to be aware of where Confidentiality might be broken.

1. When you or other persons are in physical danger, the law requires me to tell others about
it. Specifically:
a. If I come to believe that you are threatening serious harm to another person, I am
required to try to protect that person. I may have to tell the person and the police,
or perhaps try to have you put in a hospital.
b. If you seriously threaten or act in a way that is very likely to harm yourself, I may
have to seek a hospital for you, or to call on your family members or others who
can help protect you. If such a situation does come up, I will fully discuss the
situation with you before I do anything, unless there is a very strong reason not to.
c. In an emergency where your life or health is in danger, and I cannot get your
consent, I may give another professional some information to protect your life. I
will try to get your permission first, and I will discuss this with you as soon as
possible afterwards.
d. If I believe or suspect that you are abusing a child, an elderly person, or a disabled
person I must file a report with a state agency. To “abuse” means to neglect, hurt,
or sexually molest another person. I do not have any legal power to investigate the
situation to find out all the facts. The state agency will investigate. If this might be
your situation, we should discuss the legal aspects in detail before you tell me
anything about these topics.
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2. In general, if you become involved in a court case or proceeding, you can prevent me
from testifying in court about what you have told me. This is called “privilege,” and it is
your choice to prevent me from testifying or to allow me to do so. However, there are
some situations where a judge or court may require me to testify.

3. There are a few other things you must know about confidentiality and your treatment:

a. I am required to keep records of your treatment, such as the notes I take when we
meet. You have a right to review these records with me. If something in the
record might seriously upset you, I may leave it out, but I will fully explain my
reasons to you.
b. I may sometimes consult (talk) with another professional about your treatment.
During these consultations, neither your last name nor other unique identifying
information will be used. This other person is also required by professional ethics
to keep your information confidential.
c. Furthermore, There might times where I ask if could record a session for
educational or consultation purposes. I will fully ask your permissions prior to
doing so. There might also be times where I ask if I could anonymously use your
case for academic purposes for further advance the field of psychotherapy. I will
also ask for your permission prior to this.

4. If you want me to send information about our therapy to someone else, you must sign a
“consent to release information” form. I have copies which you can see so you will know
what is involved.

a. If you have been referred directly to me by someone else, I may, as a good

business practice, acknowledge to them that you have contacted me and thank
them for the referral. I will not discuss your situation with them unless I have your
written permission.

5. Confidentiality also extends to situations where I may see you in a public place
(restaurant, store, business event, office building, etc.). I am required to keep your
identity as my client private. I will not address you in public unless you speak to me first
and if you approach me to talk I will not disclose where I know you from. If I am with
other people, I will not introduce you to them to further protect your privacy as a client.
Similarly, I will decline invitations to connect on social networking websites.

6. Any information that you also share outside of therapy, willingly and publicly, will not be
considered protected or confidential by a court. If you should choose to communicate
with me via email, confidentiality cannot be guaranteed and information may be
accessible to others.

7. In working with children (or adolescents under 18), legally the parent(s) or legal
guardian(s) of the child are the client and confidentiality lies with the client; in order to
establish and preserve the essential relationship and setting for a child's therapy, I honor
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what the child does or says in our sessions as confidential while providing parents and/or
legal guardians summaries of treatment goals, plans and progress as we

8. In working with families (and couples), the family as an entity is our client and we are
not providing individual therapy for either half of the couple or for any one member of
the family although sessions with individuals in the family may be a part of the family
therapy. We will not be a “secret keeper” nor will we facilitate secret keeping. If anything
significant is revealed in an individual session that we feel the other party needs to be
told, we will require it be brought up in the next session together so we can work through
it or we may have to terminate the therapeutic relationship and refer you to another
therapist.

Information, Authorization, Consent to Telehealth

Email
We use email to send and receive informed consent forms. Email, however, cannot be
guaranteed as a secure means of transmitting/receiving your Private Health Information. Use of
email should be for scheduling, billing or insurance matters only whenever possible. You may
email us, but please understand that by doing so you are accepting the risk and limit of your
confidentiality via email. Communications are saved under the clinical record and will be
discussed at our next scheduled appointment. There is a charge for time spent reading emails
that go beyond brief exchanges about scheduling and payment issues. Please see fee
outlined.

Texting
Texting ideally should be used for brief notification regarding scheduling or notification of
running late for an appointment. Our phones are protected with passwords but texts may show up
when the screen is locked, which may be a breach of your confidentiality. If you choose to use
texting to communicate sensitive information you do so with full knowledge and acceptance that
this is a risk and limit of your confidentiality. We do not participate in discussions with clients
via text messaging.

Phone/Video
Cell phone communications cannot be guaranteed as a confidential form of communication. We
utilize cell and Virtual business phone extensions as most of our clients do as well. We make
every effort to ensure our phone conversations are held confidential within our ability to do so.
When we have a conversation via cell phone you are acknowledging and accepting the risk and
limits of your confidentiality. If you don’t wish to take this risk, we advise you only use phone
communication to schedule an appointment in person to discuss sensitive information as part of
your Private Health Information. Under certain circumstances and only following initial face-to-
face intake session, secure chat and video sessions.

Voicemail
Per the above policy with regard to cell phone use, please be informed that our voicemail system
cannot be guaranteed confidential although we take every measure to protect your
confidentiality. It is advised that you not leave sensitive information on voicemail, rather utilize
voicemail to request a return call and/or to schedule an in-person appointment. When you leave a
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message, please leave your full name, brief reason for your call and return phone number (even if
we have it on file). We check our voicemail frequently unless we are on vacation. Although we
cannot answer phone calls while in session with clients, we will make an attempt to return calls
within the same business day if possible. This may be late in the evening. When not possible, we
will return all calls within 3 business days.

Telehealth
FrancoPsychotherapy only offers telehealth at this current time. We only use HIPPA compliant
software for our sessions.

Communication Response Time

I'm required to make sure that you're aware that I'm located in the Southeast and we abide by
Eastern Standard Time. Our practice is considered to be an outpatient facility, and we are set up
to accommodate individuals who are reasonably safe and resourceful. We do not carry beepers
nor are we available at all times. If at any time this does not feel like sufficient support, please
inform your therapist, and they can discuss additional resources or transfer your case to a
therapist or clinic with 24-hour availability. We will return phone calls or test within 24 hours if
possible. However, we do not return any form of communication on weekends or holidays. If
you are having a mental health emergency and need immediate assistance, please follow the
instructions below.

Appointments and Fees

Individual sessions last for 50 minutes. When I see couples or families the session will often be
1.5-2 hours long. One session hour lasts 50 minutes, so a 2- hour session would last for 100
minutes. If you are unable to attend a scheduled session, please call to cancel or reschedule at
least 24 hours in advance of your appointment to avoid being charged for the visit. If you miss
a session I have the right to bill your credit card directly, I will try to let you know but can not
guarantee this will happen. It is very important for you to know if you are using Out of
Network Insurance reimbursement they will not reimburse for a missed session. If there is a
true, unavoidable emergency or serious or contagious illness, please call as soon as possible
and I will work with you to reschedule and you may request waiver of the 24 hour policy.

My standard fee is $130 per 50 minute session, although it may be adjusted on a sliding scale, if
requested. The sliding scale is dependent upon gross household income and family size. The fee
you will be charged is discussed and set during our first session. It may be renegotiated later in
treatment depending on changes in your financial status. Changes in fees will be made only after
a discussion with you has taken place at least one session before the change is to be
implemented. This fee is standard regardless of the number of people attending the session. I do
not often do phone sessions, but can if it is determined to be beneficial for you. I would ask that
this is kept to a minimum and that we discuss this before we agree to a phone session.

If I am doing work related to your treatment that is outside the bounds of our scheduled
counseling, unless pre-discussed, you will be billed on an hourly basis for all the time I spend on
your case. This includes travel time to another location (such as the hospital, your home, an
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attorney’s office, or another setting), meeting with other professionals regarding your case,
writing reports, preparation time, etc. My hourly fee for this type of work is the same as the fee
you are charged for your therapy session.

Finally, you are free to terminate therapy at any time, and if requested, I can aid in finding
another therapists of your choice.

Uses and Disclosure of Protected Health Information

I may use and disclose Protected Health Information without written authorization, excluding
Psychotherapy Notes, for certain purposes as described below.
1. Treatment: I may use and disclose PHI in order to provide treatment to clients.
2. Payment: I may use or disclose PHI so that services are appropriately billed to, and
payment is collected from, health plans.
3. Health Care Operations: I may use and disclose PHI in connection with health care
operations, including quality improvement activities, training programs, accreditation,
certification, licensing or credentialing activities.
4. Required or Permitted by Law: I may use or disclose PHI when I am required or
permitted to do so by law. For example, I may disclose PHI to appropriate authorities if I
reasonably believe that a client is a possible victim of abuse, neglect, or domestic
violence or the possible victim of other crimes. In addition, I may disclose PHI to the
extent necessary to avert a serious threat to the health or safety of a client or the health or
safety of others. Other disclosures permitted or required by law include the following:
disclosures for public health activities; health oversight activities including disclosures to
state or federal agencies authorized to access PHI; disclosures to judicial and law
enforcement officials in response to a court order or other lawful process; disclosures for
research when approved by an institutional review board; and disclosures to military or
national security agencies, coroners, medical examiners, and correctional institutions or
otherwise as authorized by law.
5. Records of Disclosure: Records of disclosure of PHI without client authorization will be
maintained in the case record as required by HIPAA standards. Records of disclosure will
include:
a. A description of the information to be disclosed;
b. Who (individual or organization) is making the request;
c. Expiration date of the request;
d. A statement that the individual has the right to revoke the request;
e. A statement that information may be subject to re-disclosure by the receiving
party;
f. Signature of the client or their representative and date;
g. If signed by a representative, a description of their authority to make the
h. disclosure. Records of disclosure will be maintained for at least six years.

Uses and Disclosures Requiring Written Authorization

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1. Psychotherapy Notes: Notes documenting the contents of a counseling session

(“Psychotherapy Notes”) will not be used or disclosed without written client
authorization.
2. Marketing Communications: I will not use health information for marketing
communications without written authorization.
3. Other Uses and Disclosures: Uses and disclosures other than those described in Section
A above will only be made with written client authorization. Clients may revoke such
authorizations at any time.

My signature below indicates that I have received a copy of this information.

________________________________ ________________________________

Client Name Signature & Date

________________________________ ________________________________

Therapist Name Signature & Date