Informed Consent for Psychotherapy

Informed Consent

Last Updated: March 31, 2026

Thank you for choosing my practice on your search for support. This document contains important information about my professional services and business policies. Although it may seem lengthy, your understanding of this information is key, as signing it represents an agreement between us. We can discuss any questions you have in advance of signing or any time in the future.

Therapeutic Process

Beginning psychotherapy is an important step and involves benefits and risks. Risks include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, or frustration, as therapy involves discussing life’s challenges. Extensive research shows therapy has many benefits. The safe, accepting environment and skills developed through therapy can support a significant reduction in distress, increased relational satisfaction, greater awareness and insight, improved management of thoughts, feelings, and behaviors, and enhanced problem-solving abilities. That said, there are no guarantees about the outcomes of our work together. Progress requires consistent and active effort on your part. Your engagement between sessions is often the strongest determinant of success. I cannot promise your circumstances, thoughts, emotions, or behavior will change; however, I can promise to do my very best to understand and support you, and help you clarify what it is you want for yourself.

Our first session will focus on your concerns, needs, goals, and expectations for the therapeutic process. These are essential elements of our work that we will revisit over time. I’ll also share impressions of what our work may involve. As we begin working together, you should assess whether you feel comfortable working with me. You have the right to ask questions about any aspects of therapy, my approach, and my training and experience whenever they arise.

Telehealth

Services are provided via secure telehealth platforms. You are responsible for ensuring you are physically located in New York State at the time of each session and for maintaining a private, secure environment on your end. While telehealth is widely used and effective, it carries potential risks related to technology failures or interruptions. You have been provided with a document entitled, “Consent for Telehealth & Telephone Therapy”, which further outlines telehealth procedures and considerations.

Attendance

Sessions are approximately 50 minutes in length and typically occur weekly or biweekly at a mutually agreed-upon time, although some sessions may be longer or more or less frequent as needed.

To remain an active client with this practice, we must routinely meet at least every eight weeks. For regulatory compliance, your chart will be closed if we have not met within 90 days and can be reopened to resume our work upon your request. Chart closure is administrative and does not prevent you from requesting to resume services in the future.

Your appointment time is assigned to you alone. You are responsible for coming to your appointment on time; if you arrive late, your session will still need to end on time. Arrival 15 or more minutes past your scheduled start time will be considered a missed appointment. At least two calendar days of notice by phone or secure client portal message is required to cancel an appointment. Cancelling or rescheduling a session on the calendar day prior to the appointment will result in a fee of $50. Cancelling or rescheduling an appointment on the calendar day of the appointment will result in a fee of $100. These fees apply whether you are cancelling, rescheduling, or discontinuing therapy; they are not insurance reimbursable and apply to all, regardless of payment method. Missing an appointment without notice will result in the full fee of either $135 or $240 depending on the scheduled session length. Exceptions are made only in the case of a serious and unforeseen emergency (e.g., sudden illness, medical emergency, or immediate family crisis), and are determined at my discretion.

To prevent excessive costs for unused time, more than three missed sessions without notice in any six-month period will likely result in ending our work together, at least temporarily. In this case, I will gladly assist you with any information or resources needed for continued or future support.

Office Closings

While reserved for extenuating circumstances, it is possible that my office may close on short notice due to illness, severe weather, or urgent personal matters. The decision of an office closing is typically made on the morning of the date of closing and will be communicated via secure client portal message, along with options for rescheduling as appropriate.

Continuity of Care

In case I am suddenly unable to continue to provide professional services or maintain client records due to incapacitation or death, I have designated a colleague who is a Licensed Clinical Social Worker (LCSW) in New York State as my professional executor. My professional executor is bound by the same confidentiality and ethical obligations as I am. Should I die or become incapacitated, my professional executor would be granted access to my client records and contact you directly to inform you of my death or incapacity, to facilitate continued care with another qualified professional if needed, and/or to share your records with other providers at your request.

Non-Discrimination

If you are unhappy with what is happening in therapy, I hope you will talk with me so I can hear and respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request I refer you to another therapist and are free to end therapy any time. You have the right to considerate, safe, and respectful care, without discrimination based on age, disability, ethnicity, gender identity or expression, marital or familial status, national origin, race, religion, sexual orientation, or source of payment.

Confidentiality & Communication

You have been provided with a document entitled, “Notice of Privacy Practices”, which outlines the Health Insurance Portability and Accountability Act (HIPAA), a federal law providing privacy protections and patient rights for use and disclosure of Protected Health Information (PHI) for treatment, payment, and health care operations purposes.

When communicating about personal matters, you may contact me by phone at (716) 222-9066 or secure message in the online client portal. Encrypted e-mail is used for initial inquiries and business matters only, as it may pose added security and confidentiality risks. In order to preserve your information security, I am unable to communicate about therapy via text message. By signing this agreement, you consent to the electronic transmission of information as needed for your care or upon your request. I am often not immediately available by telephone and do not answer calls when in session or otherwise unavailable, and am not considered to be on-call. At these times, you are encouraged to leave a confidential voicemail, available 24 hours per day and 7 days per week, and your call will be returned by the end of the next business day. If you are unable to reach me and feel unable to keep yourself safe, or in the event of an emergency, please go to your local hospital emergency room or call 911. Should you need immediate support before I am able to respond, please consider calling 988 for the Suicide & Crisis Lifeline.

If we accidentally see one another in public, I will not acknowledge you first; your confidentiality is of great importance to me and I will not jeopardize your privacy. If you acknowledge me first, I will happily speak briefly with you. To maintain your privacy, I find it inappropriate to engage in extended discussions outside of the therapy space. In accordance with my personal and professional ethics, I will not pursue any form of personal relationship with you outside of our working professional relationship.

Payment for Services

The standard private pay rate is $135.00 per 50-minute individual therapy session. Extended 90-minute sessions are available for more focused or in-depth work at a rate of $240.00 per session. With advance notice, a prorated fee of $120.00 per hour applies for any additional professional services you request, such as report writing, telephone conversations, meeting attendance, or other forms of professional collaboration, when amounting to over 15 minutes in any given calendar week.

All major credit and debit cards, including Visa, MasterCard, American Express, and Discover, Health Savings Accounts (HSA), Flexible Spending Accounts (FSA), and some wellness cards are accepted as payment. You are responsible for any required documentation or demonstration of eligibility for HSA, FSA, or wellness card use or reimbursement. A payment method must be kept on file in order to begin therapy. By enrolling in our autopay system with the card of your choosing, you agree to automatic charges for the cost of sessions attended, missed, and/or cancelled late at the rates outlined earlier in this agreement. You are responsible for full payment at the time of each session unless prior arrangements have been made. Mindful of the medical debt burden, I do not offer payment plans at this time; we will need to pause scheduling if there is a balance due on your account.

Fees are subject to change with advance notice.

Insurance Participation

To support your privacy, autonomy, and continuity of care, I do not participate as an in-network provider with any health insurance plans. Superbills are available upon request to assist you in seeking reimbursement through any out-of-network benefits your plan may offer. Superbills will be issued beginning on the date of your request and are not available retroactively for prior sessions.

Full payment is due at the time of each session. Any reimbursement you receive is determined solely by your insurance carrier and depends on your specific plan, including factors such as deductible status, out-of-network benefits, and co-insurance. You are responsible for verifying your out-of-network benefits and submitting claims. I cannot guarantee reimbursement for any services.

Please note that some services may not be eligible for insurance reimbursement. These may include, but are not limited to, telephone-only sessions, 90-minute extended sessions, or services that are not deemed medically necessary by your insurance provider.

Contact Information

If you have any questions about this informed consent documentation, please contact:

Andrew Wilton LCSW
(716) 222-9066
andrew@andrewwiltonlcsw.com