INFORMED CONSENT

for Outpatient Psychotherapy Services & Minor Addendum

  • Practice Entity: Atma Therapy PLLC
  • Provider: Joseph A. Garcia, PsyD
  • Official Contact Email: atma@garciapsyd.com

Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully. When you sign this document, it will represent a legally binding business agreement between us.

Psychological Services

Psychotherapy varies depending on the personalities of the psychologist and patient, and the particular problems you hope to address. It calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.

Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, or frustration. On the other hand, it frequently leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But, there are no guarantees as to what you will experience.

Our first session will involve an evaluation of your needs. By the end of the evaluation, I will offer you some first impressions and a treatment plan to follow. You should evaluate this information along with your own comfort level working with me. If I believe I am not the right therapist for you, I will notify you and provide referrals to other practitioners.

Meetings, Parameters, and Fees

  • Standard Session Duration: I run 60-minute sessions uniformly for both your initial intake evaluation appointment and all subsequent regular therapy sessions.
  • Cancellation and No-Show Policy: Once an appointment is scheduled, that specific hour is reserved exclusively for you. You are expected to pay for your scheduled appointment unless you provide a minimum of 24 hours advance notice of cancellation. If you fail to show up or cancel late, you will be assessed a flat fee of $100.00.

Standard Professional Rates:

  • Initial Intake Evaluation: $200.00 per 60-minute session.
  • Regular Individual Psychotherapy: $200.00 per 60-minute session.
  • Legal / Court Proceedings: $200.00 per hour (including travel, preparation, and waiting time). If I am required to participate in any legal or court proceedings involving your case, you (the client) accept full financial responsibility for reimbursement at this hourly rate, regardless of whether the request, mandate, or subpoena was issued by you, your attorney, or an opposing party.
  • Administrative Records Production: Statutory Rates, governed strictly by Virginia Code § 8.01-413.
  • Prorated Fees: If we perform clinical services beyond the standard hour, I charge accordingly based on this prorated hourly fee. This applies to report writing, extensive telephone conversations, or preparing detailed treatment summaries.
  • Sliding Scale Adjustments: My standard rate is $200.00 per session. However, a sliding scale fee adjustment may be discussed and negotiated strictly after the initial intake evaluation has been fully completed.

Self-Pay Policy & Superbill Provision

Atma Therapy PLLC operates as a Self-Pay/Private Pay practice.

  • No Direct Insurance Billing: I do not participate in, accept, or bill any health insurance panels, managed care networks, or Medicaid/Medicare programs. You are entirely responsible for full out-of-pocket payment of my fees at the time each session is held.
  • Credit Card on File Requirement: To ensure a seamless billing process, all patients are required to maintain an active, valid credit card, debit card, or HSA/FSA card on file within our secure, HIPAA-compliant patient portal. This card will be automatically processed for the full session fee at the conclusion of each scheduled appointment, as well as for any applicable late cancellation or no-show fees.
  • Superbills for Out-of-Network Claims: Upon request, I will provide you with a monthly statement of services rendered (commonly known as a Superbill). You may submit this document directly to your health insurance company to seek out-of-network reimbursement.
  • No Guarantee of Reimbursement: It is very important that you contact your insurance administrator directly to determine exactly what out-of-network mental health services your policy covers. Atma Therapy PLLC cannot guarantee that your insurance provider will reimburse you for any portion of the fees paid for services.
  • Complete Clinical Privacy Option: Paying out-of-pocket helps you maintain complete ownership over your clinical records. If you choose not to submit Superbills to your insurance, no third-party companies will have access to your diagnoses, progress notes, or treatment summaries.

Account Delinquency Note: If your account has not been paid for more than 60 days and payment arrangements have not been agreed upon, I reserve the option of using legal means (collection agency or small claims court) to secure payment, including the collection of tracking costs.

Emergency and Crisis Contact Limits

Atma Therapy PLLC operates strictly as an outpatient private practice. I do not run, staff, or maintain a 24/7 crisis line or emergency response service.

I am often not immediately available by telephone. When I am unavailable, my telephone is answered by a confidential voicemail system that I monitor frequently. I will make every effort to return your call on the same day, with the exception of weekends and holidays.

If you are experiencing a life-threatening mental health emergency or a severe clinical crisis, you must immediately utilize direct emergency response services:

  • Call or text 988 to connect with the National Suicide & Crisis Lifeline.
  • Call 911 immediately or proceed directly to the nearest hospital emergency room.

Confidentiality, Court Mandates, and Legal Exceptions

The privacy of all communications between a patient and a licensed psychologist is protected by law. I can only release information about our work with your written permission. However, there are explicit exceptions where I am legally required to disclose information without your consent:

  • Judicial Proceedings, Subpoenas, and Court Orders: If I receive a subpoena, court order, or mandate to release information for legal proceedings, I will do everything within my legal and ethical power to protect your privacy and keep your confidential information out of the court system if you wish. This includes discussing protective options with you or your legal representative. However, please be aware that if a judge ultimately issues a direct, non-negotiable court order compelling testimony or records production, I am legally obligated to comply with the law.
  • Child Abuse or Neglect: I am mandated by Virginia state law to file an immediate report if I suspect a child is being abused or neglected.
  • Elder or Vulnerable Adult Abuse: Mandated by law to report suspected abuse, neglect, or exploitation to Adult Protective Services.
  • Serious Threat of Harm to Others: Legally required to take protective actions (notifying the potential victim and police) if an explicit threat is made.
  • Serious Threat of Harm to Self: If imminent self-harm risk exists, I am obligated to intervene to ensure safety, which may involve family contact or involuntary hospitalization.

ADDENDUM FOR CHILD/ADOLESCENT PATIENT

(Applicable only if the primary client is under the age of 18)

1. Parent Authorization & Custody Requirements

To authorize mental health treatment for a child, you must hold either sole or joint legal custody. If you are separated or divorced, you must notify me immediately and provide a copy of the most recent custody decree proving your legal right to authorize treatment.

Notification Policy: If you are separated or divorced, it is my policy to notify the other parent that I am meeting with the child. All parents have the right to know their child is receiving mental health care unless exceptional, legally documented circumstances apply.

2. Designated Client Status

In the course of treatment, I may meet with parents/guardians separately or together. Please be aware that, at all times, my designated patient is your child—not the parents, guardians, or siblings. Notes of family meetings will be placed in the child’s treatment record and are accessible to any party with legal rights to that record.

3. The Minor’s “Zone of Privacy”

Therapy is most effective when a trusting relationship exists. Privacy is vital to keeping that trust, especially for adolescents developing autonomy.

  • General Progress Only: It is my policy to provide parents with general updates regarding treatment progress, but NOT to share specific information your child has disclosed to me without their agreement. This includes behaviors you might disapprove of, provided they do not put your child at immediate risk.
  • Safety Overrides: If risk-taking behavior becomes serious and dangerous (e.g., severe substance abuse or dangerous sexual behavior), I will use my professional judgment and communicate this immediate danger to you instantly.
  • Records Restriction Agreement: Although Virginia law may give parents a legal right to request written medical records, by signing this agreement you explicitly agree to respect your child’s therapeutic privacy and agree not to request access to your child’s written session notes or treatment records.

4. Exclusion from Custody Litigation

When a family is in conflict or divorce proceedings, my role is strictly limited to providing clinical treatment to your child. You explicitly agree that in any child custody, visitation, or related legal proceedings, neither parent will seek to subpoena my clinical records or ask me to testify in court, whether in person or by affidavit.

If I am legally compelled by a judge to testify despite this agreement, I am ethically bound not to give an opinion about either parent’s custody suitability or fitness. Furthermore, if I am required to appear as a witness or perform work related to any legal matter involving the minor, the signing parent(s)/guardian(s) accept full financial responsibility and agree to reimburse Atma Therapy PLLC at the professional rate of $200.00 per hour for all time spent traveling, speaking with attorneys, reviewing files, preparing documents, or waiting/testifying in court, regardless of which party or attorney issued the subpoena.

Consent and Signatures

Your signature below indicates that you have read this comprehensive document, understand and accept the professional fees, self-pay requirements, credit card policies, and cancellation rules of Atma Therapy PLLC, and explicitly agree to honor these terms throughout our professional relationship.