Consent for Couples Counseling

Single Comingled Chart:

I give consent for couples/marital counseling, understanding that my confidential record and the other party’s confidential therapy record will be co-mingled in the same notes and records. I understand that if either I or the other party requests records, or signs a release to a third party for these co-mingled records, that these co-mingled records can be released. Comingled records may also be subpoenaed by the court in legal proceedings, such as a divorce or child custody case. These records cannot be separated, as documentation of the sessions includes discussion of the interaction of the parties and has both clients’ names listed in the notes

No Secrets Policy:

When working with couples, in conjoint sessions or family sessions, you agree that information you discuss can be shared with others you bring into your sessions. Our clinicians may also staff your case internally or consult with each other, in order to provide the best continuity of care.

Non-Covered Service with Insurance:

I understand that this is a non-covered service with my insurance, as partners are not assessed for individual diagnoses. Instead, a single chart with both names is created, and the diagnosis of “Relationship Stress with Spouse or Intimate Partner (Z63.0)” will given for both partners. This does not meet criteria for medical necessity. Since couples’ work is a self-pay service; insurance codes, insurance documentation and required medical diagnoses are not used, and therefore clients will not be able to receive reimbursement from their insurance even if they file the claim themselves.

I have read and fully understand the above statements about comingled charts and that Spencer Psychology will not be filing claims for my service, nor will they use diagnoses or coding that would allow me to file myself. I voluntarily authorize this consent.

Client Name:
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Electronic Signature of Client:
Enter your full name
Date: