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Consent For Treatment

This document contains important information about the professional services and business policies of both your Lyra Clinical Associates (LCA) treatment team (which may include but is not limited to a therapist, peer support, physicians, clinicians, and operational support) , and Lyra Clinical Associates P.C. Please read it carefully and discuss any questions you have with your therapist.

Confidentiality:

Your treatment team and LCA take your privacy and confidentiality very seriously. LCA complies with Federal and California laws regarding confidentiality of client information. LCA’s Notice of Privacy Practices details how we use any information we collect, including for treatment, coordination of care, payment and other business operations. We will minimize the amount of information we share without your express consent, however we want to bring your attention to certain circumstances in which we may disclose details of your care:

  • Your treatment team may share information about your assessment and treatment in an anonymized way with the clinical team at LCA in order to improve your experience and guarantee that we are providing you with the most effective care possible. You may let us know that you do not want your information shared in this way by speaking with your treatment team.
  • If there is suspected elder, dependent adult, or child abuse or neglect.
  • If, in your treatment team’s judgment, you are in danger of harming yourself or another person, or are unable to care for yourself.
  • If you communicate to your treatment team a serious threat of physical violence against another person; in these circumstances, your treatment team is required by law to inform both potential victims and legal authorities.
  • If your treatment team member is ordered by a court to release information as part of a legal proceeding. As otherwise required by law and/or detailed in our Notice of Privacy Practices.

Confidentiality of Alcohol and Drug Abuse Records:

As described in LCA’s Notice of Privacy Practices, patient medical records are protected by federal and state laws and regulations. Certain substance use disorder records are also protected by the federal regulations governing the Confidentiality of Substance Use Disorder Patient Records (42 CFR Part 2 (“Part 2”)). LCA works with certain Part 2 behavioral health providers who may provide therapeutic services involving substance use disorder (“Part 2 Program”). Records from any Part 2 Program that may be created in the course of your care through LCA are protected as described in this Notice. The following is a summary of the Part 2 regulations:

  • Generally, a Part 2 Program may only acknowledge that an individual is present or disclose outside the Part 2 Program information identifying a patient as having or having had a substance use disorder in the following instances:
    • The patient’s written consent is obtained,
    • An authorizing court order is entered,
    • The patient’s records are disclosed to medical personnel to the extent necessary to meet a bona fide medical emergency,
    • The disclosure is for the purpose of conducting scientific research, or
    • The disclosure is for the purpose of an audit or evaluation.

Violation of the federal law and regulations at Part 2 is a crime and suspected violations may be reported as follows:

  • Any violation of Part 2 may be reported:
    • To our Chief Privacy Officer at 270 East Lane, Burlingame, CA 94010; (800) 505-5972; or at [email protected]. 
    • The report of any violation of the regulations in this part may be directed to the United States Attorney for the judicial district in which the violation occurs.
    • To the Substance Abuse and Mental Health Services Administration (SAMHSA) office responsible for opioid treatment program oversight at: SAMHSA Opioid Treatment Program Compliance Officer contact the SAMHSA Center for Substance Abuse Treatment (CSAT) at 866-BUP-CSAT (866-287-2728) or [email protected] .
  • If a patient commits a crime against personnel of the Part 2 Program, information related to the commission of that crime is not protected.
  • Reports of suspected child abuse and neglect made under state law to appropriate state or local authorities are not protected.
  • After receiving and reviewing this form, we will ask you to acknowledge that you have received it.  If you have questions, or need to reach us for any other reason, you may contact the Chief Privacy Officer at 270 East Lane, Burlingame, CA 94010; (800) 505-5972; or at [email protected].

The Process of Psychotherapy:

The process and outcome of psychotherapy may vary depending on the particular problems addressed, the personalities of the therapist and client, and various other factors. While we cannot predict exactly what your experience will be like, we are committed to providing you with the most professional and ethical treatment possible.

Participation in therapy can result in a number of benefits to you, including improved interpersonal relationships, resolution of specific problems, and positive personal change. In order for therapy to be successful, you will need to make an active effort both during and outside of your sessions. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable and intense feelings like sadness, guilt, anxiety, frustration and anger. In addition, it may result in changes that were not originally intended (such as divorce or remaining in a relationship you believed you would leave). Change can often happen quickly, but may also occur more slowly. There are no guarantees about what you will experience. Your therapist’s role is to help guide you through the therapy process by offering emotional support, actively listening to your concerns, asking relevant questions, providing treatment plans and recommendations, and monitoring your treatment progress.

During your first session, you will discuss with your LCA therapist the reasons you are seeking therapy, goals you would like to achieve, and any background information related to your presenting concerns. In subsequent sessions, you and your therapist will work collaboratively towards achieving your goals of therapy. Subsequent sessions may focus on understanding thought patterns, feelings, and behaviors that are relevant to presenting concerns and work towards more effective ways of coping. If you are in care with another therapist or your symptoms are mild, you may do individual sessions with a peer support person.

Throughout therapy, you will work with your therapist to tailor treatment to meet your goals and assess whether your goals are being met. If at any point you are unhappy about the progress, process, or outcome of the treatment, please discuss this with your therapist. There are many different methods your therapist may use to address the concerns that bring you to therapy. Your therapist strives for genuineness and a nonjudgmental stance in all of his/her patient relationships. However, if at any time you feel that you are not connecting or that he/she has misunderstood you in an important way, you should discuss them in session with your therapist. In addition, the Lyra Care Team is always available to work with you, and may also reach out to you to discuss your overall satisfaction with the therapy.

The Process of Groups:

Groups can be a helpful way to learn more, build skills and discuss progress between individual sessions. Groups may be facilitated by an unlicensed member of your care team. Topics will include learning about healthy habits, developing coping skills and managing difficult periods. Group sessions also allow members to learn from one another and receive/provide peer support. Your participation is voluntary and you may stop attending groups at any time (and should discuss with your individual treatment team member). If you violate any of the terms of the group parameters, as deemed by the group leader(s), you may be prevented from joining groups in the future. The following are parameters for group participation:

  • Sharing information in groups can help yourself and others and is voluntary. You may choose to share as much or as little as you feel comfortable with. Do not share group information outside of the group setting.
  • You agree to not disclose any information to people outside of the group that may reasonably be used to identify another member of the group. You agree to not record any voice conversations, videos, and/or create still images of any information shared in the group by the use of any recording device, application, or otherwise. You agree to join the group in a private location and take measures such as wearing a headset to prevent those outside of the group from seeing or hearing the group.
  • LCA and its contracted partners reserve the right to make disclosures of any information gathered in the group in a manner which is consistent with our Notice of Privacy Practices and Privacy Policy and/or as otherwise required by applicable state and federal laws.
  • You agree to hold harmless LCA, and its contracted partners, in any and all claims related to misuse and/or misappropriation of your personal and/or protected health information, shared during group sessions, by another group member or persons who obtain your information through another group member.

Your Group facilitator may share additional parameters from time to time. To the extent you have questions about these or any other Group parameters, or would like to receive a copy in writing, you should reach out to your care team. If you continue to attend Group sessions, we will assume that you have agreed and consented to the additional parameters.

The Lyra Website:

As part of therapy you will use the Lyra Website. You will need to access the Lyra Website to participate in the video sessions, submit assessments and practices in between sessions, as well as to connect with your therapist via secure messaging.

Your therapist will orient you to using the Lyra Website for the above purposes during your first therapy session. If you decide to have your sessions with your therapist by phone (without using the video option in the Lyra Website), your therapist will call you at the number you provided at registration. You will still need to use the Lyra Website to complete assessments and submit records of therapy practices..

Therapy Assessments:

Before your first session, your therapist will ask you to answer a set of questions that will help them get to know you and better tailor treatment to respond to your situation. Throughout treatment, your treatment team will also assign other assessments to be completed before your sessions to inform treatment.

Therapeutic Focus:

LCA clinicians do not make recommendations, write letters of recommendation or complete application forms related to medical leave, medical disability, fitness to work, child custody, or emotional support animals.

Video Therapy:

Please note that:

  • As part of this program you will engage in telehealth sessions with your LCA Treatment Team.
  • All telehealth sessions are held by video using the Lyra Website. Group sessions will be held on a secure third-party HIPAA compliant platform.
  • Your treatment team member will initiate the video session with you at the scheduled time using the Lyra Website.
  • The video conferencing technology will not be the same as an in-person session due to the fact that you will not be in the same room as your treatment team member.
  • In order to have the best results for this session, you should be in a quiet and private place with limited interruptions when you start the session.
  • There are potential risks to this technology, including interruptions, unauthorized access and technical difficulties.
  • Your Lyra treatment team or yourself can discontinue the telehealth session if it is felt that the videoconferencing connections are not adequate for the situation.
  • Your LCA treatment team will inform you and obtain your consent if another person is present during the session, for any reason.
  • There are alternatives to a telehealth session available, including the option of finding an LCA provider to see in-person.
  • You can direct questions about your telehealth sessions at any time to your LCA treatment team or Lyra Care Team.
  • This consent will last for the duration of the relationship with your LCA treatment team and this program, and it covers all telehealth sessions you may have.
  • You can withdraw your consent for telehealth sessions at any time, and Lyra will work with you to find a suitable alternative.
  • The same confidentiality protections, limits to confidentiality, and rules around your records apply to a telehealth session as they would to an in-person session.
  • Your LCA treatment team may decide to terminate telehealth services, if they deem it inappropriate for you to continue therapy through video sessions. Your LCA treatment team will work with other team members to identify another LCA provider for in-person care.
  • By signing this consent you agree to work with your LCA therapist to come up with a safety plan, including identifying one or two emergency contacts, in the event of a crisis situation during your sessions.

Video Recording:

Your clinician will record all video sessions using the Lyra Website for ongoing quality improvement and quality assurance of our services. The recordings are kept for 2 weeks and then deleted. If you do not agree to have your sessions recorded for quality purposes, please let your clinician know at your first appointment.

Your Location During Video Sessions:

Like all health care providers, LCA’s clinicians are licensed to offer services on a state by state basis. In order to ensure your LCA clinician is appropriately licensed, we ask that you please search for a provider based upon your planned location at the time your session takes place. If your location changes at any point from one state to another, please let your LCA clinician know as soon as possible. Please be aware that your LCA clinician may not be able to provide services when you travel to a different state and is not able to provide services when you travel outside of the U.S.

Missed Appointments and Cancellations:

Your clinician requires at least 24 hours advance notice for cancellation of an appointment. If you are unable to attend your scheduled appointment due to circumstances beyond your control, please message your clinician in the Lyra Website as soon as possible so we can reschedule your appointment to a more suitable time. Once an appointment is scheduled, you will be expected to attend unless you contact your clinician to reschedule. You can also use email to reschedule; however, please note that receiving emails in your personal account may be unsecure. Failure to provide sufficient notice for cancellations and/or repeated no-shows for your appointment may impact your ability to schedule additional appointments with your clinician. If you cancel or reschedule within 24 hours of a scheduled session, or you do not attend a scheduled session you may be charged a $105.00 Late Cancellation Payment.

Messaging and Email Communication:

If you need to contact your LCA clinician between sessions, for non-urgent issues, please message them within the Lyra Website and they will address them as soon as possible. Your clinician checks his/her messages in the Lyra Website regularly during business hours and will make every effort to return your message by the next business day.

Emergency Procedures:

In a crisis, please call 911 or go to the local emergency room. Please do not use the Lyra Care messaging or email if you are experiencing an emergency. If you are experiencing withdrawal symptoms requiring medical attention, please call 911 or be transported to the local emergency room. LCA is not able to provide emergency care or medical management of withdrawal.

If you experience an emergency during your sessions with your LCA treatment team, or if your LCA treatment team becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, your LCA treatment team and LCA will do whatever possible within the limits of the law to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, LCA or your LCA treatment team may contact the person whose name you have provided on the biographical sheet as your emergency contact.

Social Media Policy:

LCA and our treatment team members believe that adding clients as friends or contacts on social media sites (e.g., Facebook, LinkedIn, etc.) can compromise clients’ confidentiality and privacy. Consequently, given the importance of client confidentiality, your LCA treatment team will not accept friend or contact requests from current or former clients on any social networking site. If you have questions about this, please bring them up during your session.

Billing and Payments:

The fees for your sessions may be partially or fully paid for by your, or your eligible sponsor’s, employer or Health Plan, with or without any cost share to you, as long as you are an eligible employee in good standing with the company, and as long as further sessions are considered clinically appropriate. Please note that certain professional services outside of the presenting problems, such as chart preparation requests and participation in legal proceedings, may be outside the services paid for by your employer or Health Plan and may incur additional fees. Any additional fees will be discussed and agreed upon when they are requested. Fees for services may be subject to change in the future and may also change if you move to another state. We will notify you of any changes.

Research, Writing, Teaching:

Your clinician and others at LCA conduct internal research, training, and supervision. Your clinician may use information about you and your treatment in any of these ways. Your clinician or others at LCA may also prepare publications for professional and/or lay audiences; any use of information about your treatment would be only in an anonymized and/or de-identified way for these publications.

Length of Therapy:

Evidence-based treatments, or treatments that have been rigorously tested and proven to be helpful, typically are shorter-term treatments than general counseling or the general provision of support. Most clients notice some initial changes or relief within the first few sessions of treatment. Your course of treatment will be individualized depending on the intensity and duration of your presenting concerns, your level of engagement and active participation in the treatment plan, and the specific nature of your concerns.

Ending Treatment:

You may withdraw from treatment at any time. Your treatment team recommends that you discuss your plan to end treatment with them before taking action, so that they have an opportunity to offer further recommendations or referral options.

If at any point during treatment your treatment team member assesses that the sessions are not effective in helping you reach the therapeutic goals, he/she will discuss this with you and, if appropriate, end treatment. In such a case, they will work with you and the Lyra Care Team to identify alternative options.

If you do not keep your scheduled appointments and do not respond to communications from your therapist, we will assume you have elected to end your treatment and we will close your case. If this occurs, and you wish to resume your treatment, please contact the Lyra Care Team to reinitiate therapy.

TREATMENT AGREEMENT

If at any time you have questions about the details above, please ask your therapist, treatment team, or the Lyra Care Team. By continuing your sessions with your therapist and/or treatment team, you accept and agree to abide by the contents and terms of this agreement and consent to participate in evaluation and/or treatment.