Informed Consent outlines in writing the client and clinician's plan and guidelines for treatment. Please read the following carefully and be sure to ask any questions/concerns that you may have regarding the contents of this document. I am a licensed psychologist in private practice, working with adolescents and adults. My approach integrates Cognitive Behavioral/Client Centered and Dialectical Behavioral Therapies. I incorporate influences from mindfulness, meditation, and mind/body practices. Special interests include working with adolescents and adults experiencing depression, anxiety, symptoms of complex trauma, and difficulty managing emotions. *

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***CONFIDENTIALITY *** Privacy between a client and a psychotherapist is protected by law. Information may only be released with written permission except when there are concerns about danger to you or others, if required by court orders, licensing requirements, or for your insurance provider. If I believe that you may harm yourself or someone else, or if a child or dependent adult has been harmed, I am a mandated reporter. This may involve informing the police, reporting information to Child Protective Services or Adult Protective Services, seeking emergent hospitalization and/or requesting a court-ordered evaluation for continued treatment. If I am seeing a child who is under eighteen years of age, notwithstanding the rights of the parents to the records, you agree that Dr. Cohen shall have the right to withhold any information or records at her discretion.  While the specific content of my communications to your child is confidential, parents have a right to receive general information on the progress of treatment.  I can protect the privacy of the child unless safety is at risk.  In that case, I may have to communicate that to the parents. *

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***IN PERSON SERVICES *** My goal is to keep my clients, their families and myself safe and healthy. Face masks, hand washing, and social distancing are required at my in-person space at Mindful Medicine. If you feel sick for any reason or have been exposed to someone who has tested positive for Covid-19 in the past two weeks, please let me know so we can reschedule. As you know, the Covid situation is unpredictable. I follow the guidelines of our County Executive Marc Erlich and Maryland Governor, Larry Hogan. *

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*** TELETHERAPY SERVICES *** We agree to use the Zoom platform for our virtual therapy sessions for convenience and/or flexibility of scheduling. • As your psychologist, I may determine that due to certain circumstances, telepsychology is no longer appropriate and that we should resume our sessions in-person. • We will both be connected to an electronic device (laptop, desktop, tablet, or smartphone) during the session. • We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems. • We need a safety plan that includes at least one emergency contact and the closest emergency room to your location, in the event of a crisis. *

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*** PRIVACY AND CONFIDENTIALITY *** There are potential benefits and risks of telehealth (e.g., limits to patient confidentiality) that differ from in-person sessions. As you know, the use of email and text messages is not 100% confidential. • Confidentiality still applies for telepsychology services, and sessions will not be recorded without your consent. • If you are not 18 or older, we need the permission of your parent or legal guardian (and their contact information) for you to participate in telepsychology sessions. • It is important to participate in our virtual sessions in a quiet, private space that is free of distractions (including cell phone or other devices) during the session. • It is important to use a secure internet connection rather than public/free Wi-Fi. • To provide the best possible treatment, it is important for me to collaborate with other providers as needed, including school personnel, primary care physician/pediatrician, former psychotherapist, and psychiatrists/nurse practitioner. • I am approved by BCBS and Cigna insurance, both of which reimburse for telepsychology. If your plan does not reimburse for telepsychology or if you have a deductible at the beginning of the new year, you are responsible for full payment. • I have been approved by PSYPACT to provide telepsychology across state lines with clients in states who have a PSYPACT agreement. • Our first session is an initial assessment. During this assessment we will discuss the history of the concerns you bring to therapy, information about how these concerns impact your life including thoughts, feelings, and behaviors. At the end of our initial meeting, we will discuss goals for therapy and create a treatment plan. The treatment plan outlines the goals and objectives of our work together. You may terminate therapy at any time. *

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*** APPOINTMENTS *** Appointments can be scheduled weekly, bi-weekly, or monthly. This can always be adjusted. Sessions are typically 45 – 60 minutes and will be scheduled at a mutually agreed time and day. • Thank you for logging in on time. If you need to cancel or change your therapy appointment, thank you for letting me know as soon as possible. *

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*** CANCELLATION POLICY *** You will receive a text message reminder two days prior to your therapy appointment. You will receive an email reminder (and Zoom link for teletherapy) the day before your scheduled appointment. If you are unable to attend a scheduled appointment, please provide at least 24 hours’ notice. My no show fee is the amount I would normally receive from your insurance company. If you miss the scheduled appointment or cancel the appointment with less than 24 hours’ notice, and it is not due to illness, family emergency, or any other circumstance beyond your control, a no-show fee will be charged to your credit card. I am willing to waive the no show fee once. *

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*** PROFESSIONAL FEES and PAYMENT *** The hourly rate for psychotherapy self-pay is $180.00. I am a provider for BCBS, Cigna, and Webtpa insurance carriers. Your insurance benefits will be reviewed prior to your first session. I will request a photo of the front and back of your insurance card to verify coverage before our first meeting. I recommend that you consult with your insurance plan administrator to evaluate any coverage you have, and the limits and conditions of coverage. Judy Parks is my competent and experienced billing person. If you are covered by insurance, my office will seek reimbursement from your insurance carrier. Judy submits your insurance claims and manages your copayments through My Clients Plus. *** Please contact Judy at 410-893-7266 and leave her your credit information for your copayment. Payment of your insurance co-payment will be billed with your credit card following each session. If your insurance company denies payment, YOU are responsible for payment. If you are experiencing financial hardship after therapy has been initiated, please consult with my office. If you are in a crisis, you will not be denied care, regardless of your ability to pay. *

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*** MY CONTACT INFORMATION *** In a life-threatening emergency, call 911. My phone number is 443-940-8258. The best way to reach me is a dr.monyacohenyoga@gmail.com. *

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*** CLIENT RECORDS *** Client treatment records are kept for seven years after termination of therapy or three years after the 18th birthday of the client. You are entitled to a copy of your records, unless viewing the records would cause emotional harm to you. Upon signing a release of information, records may be sent to other providers as you wish. IF YOU ARE A MINOR, your parents have access to your treatment records. Parents are typically not encouraged to request viewing the records as doing so may prevent you from sharing those things necessary for you to progress in treatment. A general statement of progress towards treatment goals will be provided to your parents on a regular basis. *

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By typing your name below you provide your electronic signature, and you indicate that you have read, understand, consent and have discussed this document with me and agree to the contents of this document. By signing this document, you are agreeing to begin treatment. *

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LEGAL GUARDIANS: If you are a legal guardian for a patient, type YOUR NAME above and the NAME OF THE PATIENT FOR WHOM YOU ARE PROVIDING CONSENT below.

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