INFoRMed consent and practice policies.
Lindsay Mayott, Ph.D.
Counseling Psychologist, PSY34129
Phone: (415) 594-5241
Informed Consent and Practice Policies for Telehealth Psychological Services
GENERAL INFORMATION
The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.
PSYCHOLOGY LICENSURE
My psychology license (PSY34129) was issued in April of 2023. Licensure ensures that I have passed examinations administered by the Board of Psychology and am therefore competent to engage in the independent practice of psychology. The state of California provides complaint and discipline recourse procedures for consumers. Inquiries about my professional qualifications and practices may be directed to the agency listed below:
Department of Consumer Affairs
Board of Psychology
1422 Howe Avenue, Suite 22
Sacramento, CA 95825-3200
800.263.2699
TRAINING AND EDUCATION
2021-2023
Psychological Associate: Kaiser Permanente Department of Psychiatry
San Rafael, CA
2020-2021
Postdoctoral Fellow: Kaiser Permanente Department of Psychiatry
San Rafael, CA
2015-2020
Ph.D. Counseling Psychology, Purdue University
West Lafayette, Indiana
2019-2020
Predoctoral Intern: Kaiser Permanente Department of Psychiatry
Fresno, CA
2018
Grief Group Co-Facilitator: Purdue University, Purdue Counseling & Guidance Center
West Lafayette, IN
2017-2018
Psychology Trainee: Richard L. Roudebush VA Medical Center - Psychosocial Rehabilitation and Recovery Center (PRRC)
Indianapolis, IN
2016-2017
Psychology Trainee: Wabash Valley Alliance, Community Mental Health Clinic
Lafayette, IN
2015-2016
Psychology Trainee: Purdue Counseling and Guidance Center, Purdue University
West Lafayette, IN
2013-2015
Columbia University, Teachers College
M.A., Clinical Psychology: Trauma and Global Mental Health Concentration
New York, NY
2003-2007
University of California, Santa Cruz
B.A., Psychology
Santa Cruz, CA
THE THERAPEUTIC PROCESS
You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort and some risks. For example, remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, and other difficult feelings. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and a reduction in feelings of distress. Depending on your clinical needs, there are many methods I may use to address those problems. In order for the therapy to be most successful, you will have to work on things we talk about both during and between our sessions. There are no guarantees as to what you will experience. I cannot promise that your behavior or circumstance will change. However, I can promise to support you and do my very best to understand you and to help you clarify what it is that you want for yourself.
Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include, and a treatment plan to follow if you decide to continue with therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. If I do not believe that I am the right therapist for your specific needs, I will notify you of this at the end of the evaluation and provide referrals to other practitioners whom I believe are better suited to help you.
Therapy involves a large commitment of time, money, and energy. You should be thoughtful about the therapist you select. If you have questions about my procedures or practices, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. You have the right to terminate therapy at any time, although I recommend doing so after discussing this decision together.
A decision on my part for early or premature termination of our professional relationship would be for one of the following reasons: it is reasonably clear that you no longer need, are not benefitting from, or are being harmed by treatment, if you or someone in a relationship with you threatens or endangers me, if you are in need of services that I am not able to provide, financial non-cooperation, or any other needs of mine. Should we prematurely end our professional relationship, you will be provided with appropriate referrals and recommendations about how to proceed, unless your actions make it impossible by declining to attend our therapy sessions.
OUTPATIENT SERVICES
For those seeking individual outpatient therapy services, I typically conduct an initial 90-minute evaluation followed by one to two 50-minute follow up sessions. These follow up sessions are to gather any additional information that we may not have fully discussed during our initial meeting. During this time, we can decide collaboratively if I am the best person to provide the services you need to meet your treatment goals. If we decide to proceed with the therapy, we will schedule one 50-minute session per week at a consistent day and time that we agree on. Depending on your clinical needs and treatment goals, some sessions may be longer, or more frequent. Regardless of frequency and duration, the last five minutes of every session will be reserved for scheduling-related needs.
Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 72 hours (3 working days) advance notice of cancellation. For example, if your appointment is on Friday at 3pm, you will need to cancel by Wednesday at 3pm. If your appointment is on Monday at 9am, you will need to cancel by Thursday at 9am. Appointments must be cancelled by calling me at (415) 594-5241 or email at lindsaymayottphd@gmail.com. If you are choosing to cancel by phone, please do not text.
A late cancellation fee will be waived under circumstances where we both agree that you were unable to attend due to circumstances beyond your control. Examples of circumstances beyond your control include medical emergencies, automobile accidents, natural disasters, and childcare emergencies. Examples of circumstances that are not beyond your control include changes in work schedule/meetings, changes in travel plans, or forgetfulness. If it is possible, and when given reasonable notice, I will try to find another time to reschedule our appointment for that week. If it is possible to find a later time in the same week, I will waive the cancellation fee.
REMOTE SERVICES
If you and I have agreed to meet remotely, I ask that you use your best judgement regarding where you take these sessions. Attending therapy from public spaces (on the bus, in an Uber/Lyft, walking on a busy street or public setting, sitting in a busy cafe) detracts from both of our abilities to be fully present and compromises your privacy. Under these circumstances, I will need to discontinue our session and charge for the missed therapy hour.
In order for us to engage in meaningful work, it is an expectation that you present for sessions sober and not under the influence of any substances. If we are meeting remotely, I ask that you refrain from engaging in activities that you would not otherwise in the therapy office (e.g. vaping, checking email, texting, making food during session).
MEETING CONSIDERATIONS
I see the majority of my patients virtually. While I am flexible and encourage a conversation around this matter, please be aware that, unless otherwise agreed upon, our sessions will take place virtually. The topic of how and where services are delivered is something that you and I will have discussed during an initial consult call and prior to your intake appointment. If we are agreeing to meet in person, I will send you a separate informed consent for in-person psychotherapy services.
While research has shown that remote therapy can produce equivalent outcomes as in-person therapy, there are some limitations to remote therapy. There is the possibility of decreased privacy, increased distraction, and issues with internet connection that may on occasion cause disruptions during sessions.
CONFIDENTIALITY
In general, the privacy of all communications between a patient and a psychologist is protected by law, and I can only release information about our work to others with your written permission. However, there are a few exceptions.
In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some legal proceedings, a judge may order my testimony if they determine the issues demand it, and I must comply with that court order. Please note, I am unable to provide, formal legal advice may be needed, as the laws governing confidentiality are quite complex and I am not an attorney.
There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a patient’s treatment. Under California statutes, confidentiality may not be maintained in some situations, including but not limited to those listed below:
If a client threatens or attempts to commit suicide or otherwise conducts themselves in a manner in which there is a substantial risk of incurring serious bodily harm.
If a client threatens grave bodily harm or death to another person.
If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
Suspected neglect of the parties named in items #3 and # 4.
If a court of law issues a legitimate subpoena for information stated on the subpoena.
If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.
It is important that you know that if you communicate a threat of harm to yourself or another person to a family member, friend, or other person who then communicates that threat to me, confidentiality may not be maintained.
Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.
If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.
PROFESSIONAL FEES
My fee for an initial 90-minute intake and evaluation is $450. My hourly fee for additional 50-minute sessions is $250.00. If our session runs over and we meet for longer than the usual time, I will charge accordingly and in five-minute increments. Please be aware that I will still charge the full rate for the therapy hour (as opposed to prorating the amount) if you are late to session or need to leave early.
In addition to weekly appointments, I charge this same hourly rate for other professional services you may need. I will prorate the hourly cost if I work for periods of less than one hour. Other professional services include telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of treatment summaries, and the time spent performing any other service you may request of me. If you leave more than 10 minutes worth of phone messages in a week, or if I spend more than 15 minutes reading and responding to emails from you during a given week, I will bill you on a prorated basis for that time. As part of my practice, I do not write emotional support animal (ESA) letters.
For assessment and evaluation services I charge a rate of $300 an hour, and the totally cost of services depends of the service provided. I will provide an approximate cost of services prior to beginning the assessment, however please note that as the assessment progresses, additional testing may be needed which may increase the cost I will notify you if there is an expected increase in cost of services beforehand
In unusual circumstances, you may become involved in a litigation which may require my participation as ordered by a judge. You will be expected to pay for the professional time required, even if I am compelled to testify by another party. I do not write letters for patients who are wishing to further their case in personal or professional legal matters. Because of the complexity and difficulty of legal involvement, I charge $700.00 per hour (charged at five-minute increments) for preparation for, transportation to, and attendance at any legal proceedings. If you know you will be involved in legal proceedings related to your psychological health, I suggest that you engage a forensic psychologist for such assistance.
BILLING AND PAYMENTS
You will be expected to pay for each session at the time it is held unless we agree otherwise. Payment schedules for other professional services will be agreed upon when such services are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan.
If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, these costs will be included in the claim. In most collection situations, the only information I will release regarding a patient’s treatment is their name, the dates, times, the nature of services provided, and the amount due.
REIMBURSEMENT
As a psychologist in private practice, I have chosen not to be paneled with insurance. As an “out of network” provider, patients pay me directly at time of service. At the end of each month, I provide patients with a Superbill (an itemized statement listing the dates, service codes and payments made) which they submit for reimbursement to their insurance company for out-of-network benefits if eligible. If you have a health insurance policy, it may provide some coverage for mental health treatment. Many insurance plans have a high deductible to be met before any out-of-network benefits take effect. Before engaging in any form of psychotherapy, I recommend that you contact your health insurance administrator to obtain a clear understanding of your coverage. This allows us to set reasonable treatment goals and expectations. I will provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. If the process of completing additional forms is time consuming in nature, I will bill accordingly.
ELECTRONIC COMMUNICATION
The use of various types of electronic communications is common in our society, and many individuals experience this as the preferred method of communication whether the relationship is social or professional in nature. Many of these common modes of communication put your privacy at risk and can be inconsistent with the laws and standards of my profession. Consequently, the following information has been prepared to assure the security and confidentiality of your treatment that is consistent with both the ethics and law. As new technology develops and the Internet changes, there may be times when I need to update this information. If I do so, I will notify you in writing of any policy changes and make sure you have a copy of the updated policy.
Email: My email address is as follows: lindsaymayottphd@gmail.com. I prefer using email only to arrange or modify appointments. Please do not email me content related to your therapy sessions, as email is not completely secure or confidential. If you choose to communicate with me by email, be aware that all emails are retained in the logs of your and my internet service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the internet service provider. You should also know that any emails I receive from you and any responses that I send to you become a part of your legal record. If you need to discuss a clinical matter with me, please feel free to call me so we can discuss it on the phone or wait so we can discuss it during your therapy session. Telephone and video/face-to-face context is a far more secure mode of communication.
Text Messaging: Because text messaging is a very unsecure and impersonal mode of communication, I do not send or respond to text messages from anyone in treatment with me. Please do not text message me unless we have made other arrangements.
Social Media: I do not communicate with, or contact, any of my patients through social media platforms like LinkedIn and Facebook. In addition, if I discover that I have accidentally established an online relationship with you, I will cancel that relationship. This is because these types of casual social contacts can create significant security risks for you.
With so much of our world taking place online and in electronic format, there is a possibility that you may encounter me online by accident. If that occurs, please discuss it with me during our next therapy appointment. I believe that any communications with patients online have a high potential to compromise the professional relationship. In addition, please do not try to contact me in this way. I will not respond and will terminate any online contact, no matter how accidental.
Web Listing: I have a web listing for my practice that you are free to access. I use it for professional reasons to provide information to others about me and my practice. You are welcome to access and review the information that I have on my website. If you have questions about this listing, we should discuss it during your therapy session.
Web Searches: I do not search for patients on Google, Facebook, or other search engines, and I do not follow current or former patients on any type of web platform. If there are things you want to share with me that you feel are relevant to your treatment, whether they are news items or things you have created, I encourage you to bring these items of interest into our sessions.
You may find my psychology practice on sites such as Yelp, Healthgrades, Yahoo Local, Bing, or other places which list businesses. Some of these sites include forums in which users rate their providers and add reviews. Many of these sites comb search engines for business listings and automatically add listings regardless of whether the business has added itself to the site. If you should find my listing on any of these sites, please know that I did not create this site nor did I list my practice on the site. This listing is not a request for a testimonial, rating, or endorsement from you as my patient. The American Psychological Association’s Ethics Code states under Principle 5.05 that it is unethical for psychologists to solicit testimonials: “Psychologists do not solicit testimonials from current therapy patients/patients….”
Of course, you have a right to express yourself on any site you wish. Due to confidentiality, I cannot respond to any review on any of these sites whether it is positive or negative. I urge you to take your own privacy as seriously as I take my commitment of confidentiality to you.
If we are working together, I hope that you will bring your feelings and reactions to our work directly into the therapy process. This can be an important part of therapy, even if you decide we are not a good fit. None of this is meant to keep you from sharing that you are in therapy with me wherever, and with whomever, you like. Confidentiality means that I cannot tell people that you are my patient, and my ethics code prohibits me from requesting testimonials. However, you are more than welcome to tell anyone you wish that I’m your therapist or how you feel about the treatment I provided to you, in any forum of your choosing.
CONTACTING ME
While I am usually available by phone during my business hours which are 9am-3pm Monday through Thursday, I do not answer my phone while I am with patients. When I am unavailable, my telephone is answered by voicemail that I monitor regularly. I will make every effort to return your call on the same day you make it. However, calls may not be returned within a 24-hour period.
Direct email at lindsaymayottphd@gmail.com is best for quick, administrative issues such as changing appointment times. You may also leave a brief voice message at (415) 594-5241. Calls after 5:00pm Monday through Wednesday may not be returned until the next day, and calls after 5:00pm on Thursday, Friday, weekends, and holidays will be returned on the next business day (Monday). While I do not work on Fridays and weekends, if patients contact me with a pressing matter, I take that outreach seriously and will do my best to get back to you in a timely manner. If you are difficult to reach, please provide me the times when you will be most available. If I will be unavailable for an extended time (vacation, attending a professional conference) I will provide you with sufficient warning of my leave and provide you with the name and phone number of a colleague of mine who can be contacted.
Emergencies
Please be aware that I do not provide emergency services or wear a pager and I am not “on call.” If you are unable to reach me and feel that you cannot wait for me to return your call and/or if you are experiencing a life-threatening emergency, please dial 911 or go to or contact the nearest emergency department and ask for the psychologist or psychiatrist on call. In addition, you may call 988 to reach The 988 Suicide and Crisis Lifeline (formerly known as the National Suicide Prevention Lifeline). They offer 24/7 call, text and chat access to trained crisis counselors who can help people experiencing suicidal, substance use, and/or mental health crises.
PROFESSIONAL RECORDS
You have specific rights with regard to your clinical record. Your file will remain active while you are participating in treatment. You may request amendments to your record if you believe an amendment may more accurately reflect our work together, request to restrict the information disclosed to others, request an accounting of disclosures, and determine the location to which protected health information is sent (please see your Notice of Privacy Practices for more information). The laws and standards of my profession require that I keep treatment records while you are actively engaged in treatment and for a specified period of time after you have discharged from my care. Except in specific circumstances, you are entitled to examine your clinical record and/or receive a copy at a rate of ¢25 per page. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. In the event that you do review the full records, I recommend that they are reviewed in my presence so that we can discuss the contents. Patients will be charged an appropriate fee for any professional time spent in responding to information requests.
Your signature below indicates that you have read the information in this document, understand its contents, and agree to abide by the terms listed during our professional relationship.
CONSENT AND AGREEMENTS
Your signature below indicates that you have read the information in this document, understand its contents, and agree to abide by the terms listed during our professional relationship.