Social Anxiety Help
Larry Cohen, LICSW
Notice of Your
Rights & Responsibilities
Our ethical obligations
1. I and the associates of Social Anxiety Help are dedicated to serving the best interest of each client.
2. We will not discriminate between clients or professionals based on age, race, creed, sexual orientation, disabilities or HIV status.
3. We maintain an objective and professional relationship with each client.
4. We respect the rights and views of other mental health professionals.
5. We will appropriately terminate services or refer clients to other providers or programs whenever clinically appropriate.
6. We will evaluate our personal limitations, strengths, biases, and effectiveness on an ongoing basis for the purpose of self-improvement. We will continually attain further education and training.
7. We will adhere to the Code of Ethics of the National Association of Social Workers.
Your rights as a client of ours
1. You are encouraged to discuss with Larry Cohen, LICSW, any questions, concerns, suggestions and/or complaints you may have regarding any aspect of the services I or an associate of Social Anxiety Help provides you. I will respond to your concerns in a timely manner. You may also submit a complaint to the U.S. Department of Health and Human Services and/or the District of Columbia Social Work Board. If you file a complaint, I and the associates of Social Anxiety Help will not retaliate in any way.
2. Your civil rights are protected by federal and DC laws.
3. You may request services from someone with training or experience from a specific racial, cultural, spiritual, gender, or sexual orientation background. If these services are not available, we will help you in the referral process.
4. You have the right to take part in formulating your psychotherapy goals and treatment plan.
5. We will inform you of how much you will pay for each service prior to being provided that service.
6. You may refuse services offered to you and will be informed of any potential consequences.
7. We will inform you as to what behaviors could lead to termination of services at our clinic.
8. You may terminate psychotherapeutic services with us at any time for any reason. Should you decide to do so, we strongly encourage you to attend one additional session to discuss your reasons, to try to resolve any concerns you may have, to discuss how to maintain the progress you have made in therapy and how to prevent relapse, and to consult about any follow-up services to which we can refer you.
9. You may discuss your treatment with your doctor or another psychotherapist. We encourage you to notify us when doing so.
10. You have all the rights concerning your protected health information that are specified in the Notice of Privacy Practices.
1. You are responsible for your financial obligations to Social Anxiety Help as outlined in the Payment Contract for Services.
2. You are responsible for adhering to the norms in any group therapy contract which you have signed.
3. You are responsible for treating me, my associates and other clients in a respectful manner in which their rights are not violated.
4. You are responsible for providing accurate information about yourself.
5. You are responsible for following any other policies or rules of Social Anxiety Help of which we have informed you.
Benefits and risks of treatment
The potential benefits of psychotherapy services with me and my associates are: to help you reach your personal goals which we have mutually agreed upon early in our work together; and to help you develop cognitive and behavioral strategies, skills and techniques which you can continue using on your own after services have ended. Success in psychotherapy does require hard and consistent work on your part both during and between sessions. Potential risks of psychotherapy services include: experiencing uncomfortable feelings, thoughts and other symptoms; and working with or otherwise experiencing unpleasant life situations.
Non-voluntary termination of services
Services to a client may be terminated non-voluntarily if: 1. the client exhibits violence or verbal abuse, carries weapons, or engages in illegal acts–or threatens violence or other illegal acts–at my office or home, or directed against me, or against any Social Anxiety Help associate or client; 2. the client refuses to comply with stipulated rules, or does not make payment or payment arrangements in a timely manner. The client will be notified of the non-voluntary discharge in writing. The client may appeal this decision with me
Consent to Treatment
I, [print your full name] ____________________________________________________, the undersigned, hereby attest that I have voluntarily entered into psychotherapeutic treatment, or give my consent for the minor or person under my legal guardianship mentioned above, with Larry Cohen, LICSW, or with one of his associates at Social Anxiety Help. I certify that I have received and read a copy of this Notice of Rights and Responsibilities, and that I understand its content. I know I may ask Larry Cohen, LICSW or one of his associates for further explanation of the provisions of this documents at any time.
Signature: ________________________________________________________________________ Date: _____/_____/_____