Karen Straub, LICSW

Telehealth Psychotherapy Services for adolescents & adults

Karen Straub, LICSW

Amesbury, MA 01913


[email protected]

consent for treatment

Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions you might have so we can discuss them at our next meeting. When you sign this document it will represent an agreement between us.

Psychotherapy is not easily described in general statements. It varies depending on the personalities of the therapist and the client, and the particular problems you bring forward. There are many different methods I may use to deal with the problems you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for therapy to be most successful, you will have to work on the things we talk about both during our sessions and at home.

Psychotherapy can have both benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings such as sadness, anger, guilt, frustration, loneliness and helplessness. On the other hand, psychotherapy has been shown to offer benefits to those who go through it. Therapy often leads to better relationships, solutions to specific problems and significant reduction in feelings of distress. But there are no guarantees about what you will experience.

Our first session(s) will involve an evaluation of your needs. By the end of this evaluation, I will be able to give you a sense of my impressions of what our work will include and a plan for treatment should you decide to continue with therapy. It will be important for you to evaluate this information in addition to your own feelings about whether you feel comfortable working with me. Therapy involves a large commitment of time, money and energy so much thought needs to go into deciding which therapist to choose. If there are any questions about my process, we can discuss them as they arise. If you feel that we are not a good match, I will be happy to assist you in finding another mental health professional for a second opinion.


I typically conduct an assessment which is 1-2 sessions long. During this time we can decide if I am the best therapist for you. After that, we will schedule weekly or bi weekly sessions of 50 minutes per session depending on your needs and availability. It will be requested that you provide at least 24 hours notice of a need to cancel a scheduled appointment. We will then find a suitable time to reschedule. If late cancellations or no shows seem to be a consistent occurrence, we will discuss its implications in treatment and a fee of $60 may be assessed for missed sessions moving forward.

Professional Fees:

My session fee is $150 for the first assessment session and $110 for each session thereafter. Additional services like meeting with other professionals with your authorization or phone calls lasting more than 30 minutes will incur my usual fee/per hour spent. I will not discuss your treatment or any issues related to your treatment with any attorney or in conjunction with any legal proceedings. If you find yourself involved in any legal proceedings which require a therapist’s participation, you will need to find another provider to work with you to meet those needs.

Billing and payment:

You will be responsible for the fee for the session at the time of service unless a health insurance carrier is to be billed. Please be aware that while most insurance companies are covering telehealth for behavioral health services, the policies regarding this are changing often.  Please be sure to verify that your insurance policy covers telehealth services before contacting me.  Also, often only face to face sessions are billable to insurance and any additional services (meetings, phone calls lasting longer than 30 minutes) will be the responsibility of the client. Some companies do allow telephone sessions, so, again, please confirm your coverage prior to contacting me so we can work within the parameters of your policy. 

If you find you are in significant financial stress, we can discuss a sliding fee scale to offer you access to treatment. If your account has not been paid in 30 days treatment will be suspended until it can be brought up to date. This is not only for my benefit but serves also to keep you from developing an unmanageable financial debt.

Insurance Reimbursement:

I am happy to bill your health insurance for your sessions and accept the reimbursement rate they allow. In this case, you will need to pay the indicated co-payment established by your insurance carrier. Please be aware that insurance companies require that I obtain authorization from you to provide a clinical diagnosis and other clinical information for reimbursement. This information is stored in a computer which is deemed confidential. However, I cannot be responsible for the confidentiality of information once it leaves my hands. If you are uncomfortable with that, please bring that up when we meet so we can discuss it.

Different carriers have different limits and structures for mental health services. Some policies cover you for a short term form of treatment to focus on a particular issue that impacts your functioning. In this case, a limited number of sessions may be authorized. I am often able to obtain authorization for additional visits, but there is typically a cap. This is important to know as it impacts how we work together to ensure goals are met prior to coverage ending. Should you feel that additional therapy is desired, it will need to be on a private pay basis meaning that you will be responsible for the full amount of your insurance carrier’s reimbursement rate. This is typically less than my stated session fee. It is important for you to contact your insurance carrier prior to beginning therapy to find out what these limits are and to ensure that I am a listed as a provider for your carrier.

Contacting Me:

I am often not immediately available by telephone. My phone is a cell phone which I carry all of the time. If I do not answer your call, you are encouraged to leave a voicemail message including your phone number so I can call you back as soon as I am able. I will do my best to answer the same day. Alternatively, you can text me. This is particularly useful to confirm, cancel or reschedule an appointment or to request a call back.

Professional Records:

The laws of my profession require me to keep medical records of our work together. These are available to you upon request or I can provide a summary instead. Because these are professional records, they may be misinterpreted/ or upsetting to untrained readers. If you wish to have a copy of records, I would encourage you to allow us to go over them together to enable clarification or explanation as needed.


If you are under the age of 18, be aware that the law may allow your parents access to your medical record. It is my policy to talk to parents only about treatment in general to maintain your confidentiality. The only exception to that is if I feel you are a real danger to yourself or others or that you have disclosed physical or sexual abuse or neglect. If I feel this is necessary I will discuss it with you prior to speaking with them. I will also give them a summary of your treatment when it ends. Often this comes in the form of a family meeting in which you are an active participant.


In general, the privacy of all communication between a client and a therapist is protected by law and I can only release information about our work with written consent by you. However, there are a few exceptions to this.

There are some instances when I am legally required to take action to prevent harm to someone. For example, if I become aware that a child, and elderly person or a disabled person is being abused, I am required to report this to the appropriate state agency even if that means sharing some information about treatment. If I feel this is necessary, I will do my best to discuss it with you prior to making the report.

If I feel that you are in serious danger of harming yourself or someone else, again, I am obligated to take action. This may involve arranging for evaluation by a crisis team or staff at the local emergency room, or if the danger is to someone else, it may mean notifying the target or involving the police.

As previously stated, I will not become involved in legal proceedings. I feel it has the potential to negatively impact our work together. For example, in some child custody cases, the court may seek a therapist’s professional opinion regarding any emotional issues which may impact the child. This is not my area of expertise and I would need to help you find a therapist who can assist you with this. It is your responsibility to inform me of potential legal issues as they arise so, together, we can protect the integrity of our work.

Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.

Client name:

Client signature/Authorized person signature/date:

I also acknowledge receipt and understanding of HIPAA privacy guidelines as given in a separate document.

Client name:

Client signature/Authorized person signature/date: