Outpatient Services Agreement for PCS Collateral Participant


I want to thank you for accepting the invitation to assist a PCS client in psychotherapeutic treatment. Your participation is important, and is sometimes essential to the success of the treatment.  This document is to inform you about the risks, rights, and responsibilities of your participation as a collateral participant.

PCS Client Name(required)


A collateral participant is usually a spouse, family member, or friend who participates in the patient’s therapy in order to assist the identified patient. The collateral participant is not a patient and is therefore not the subject of the treatment. Psychologists have certain legal and ethical responsibilities to patients, and the privacy of the relationship is given legal protection. My primary responsibility is to my patient and I must place their interests first. A collateral participant is not accorded the same legal protection of privacy that a patient is.


The role of a collateral participant can vary.  Typically you will attend one to two sessions with the patient to provide information about them.  There may be times that you are called back later for additional meetings in order to update your perspective of the patient.  If issues related to you are raised, you and the patient may receive a referral for joint therapy.  We will discuss your specific role in the treatment at our first meeting and at other times throughout the patient’s therapy, as appropriate.


Psychotherapy often involves intense emotional experiences, and your participation may engender strong anxiety or emotional distress. It may also expose or create tension in your relationship with the patient. While your participation can result in better understanding of the patient or an improved relationship, or may even help in your own growth and development, there is no guarantee that this will be the case. Psychotherapy meetings are a positive experience for many, but are not helpful to all people.


No record or chart will be maintained on you in your role as a collateral participant. Notes about you may be entered into the identified patient’s chart. The patient has a right to access the chart and the material contained therein. You have no right to access that chart without the written consent of the identified patient. It is sometimes possible to maintain the privacy of our communications. If that is your wish, we should discuss it before any information is communicated.  You will not carry a diagnosis, and there is no individualized treatment plan for you.


As a collateral participant, you are not responsible for paying for my professional services unless you are financially responsible for the patient.


Patient confidentiality is protected by both federal and state law.  As a collateral participant, and not a patient of PCS, your information will not be accorded the same privacy protection under these laws. Please note, however, we will only share information you provide us for the following reasons:

    • If I suspect you are abusing or neglecting a child or a vulnerable adult, I am required to file a report with the appropriate agency.
    • If I believe that you are a danger to yourself (suicidal), I will take actions to protect your life–even if I must reveal your identity to do so.
    • If you threaten serious bodily harm to another, I will take necessary actions to protect that person–even if I must reveal your identity to do so.
    • If you, or the patient, are involved in a lawsuit, and a court requires that I submit information or testify, I must comply.
    • If insurance is used to pay for the treatment, the client’s insurance company may require me to submit information about the treatment for claims processing purposes or for utilization review.
    • A report is generated summarizing the patient’s experience at PCS.
    • Consultations with the patient’s therapist(s).

You are expected to maintain the confidentiality of the identified patient and what was discussed in the session in your role as a collateral participant.


Collateral participants may discuss their own problems in the session, in particular, problems that interact with issues of the identified patient.  The therapist may recommend formal therapy for a collateral participant. Examples of when this might occur:

    • When it becomes evident that a collateral participant is in need of mental health services. In this circumstance, the collateral participant needs to have a clinician, diagnosis, an individualized treatment plan, and medical records kept.
    • Parents, when being seen as collateral participants while their child is being treated, need couples therapy to improve their relationship so that they can function effectively as parents.

Most often, but not always, your clinician will refer you to another clinician for treatment in these situations. There are two reasons the referral may be necessary:

    • Seeing two members of the same family, or close friends, may result in a dual role, and potentially cloud the clinician’s judgment. A referral to another clinician prevents this from happening.
    • The clinician must focus on the original, primary task of treatment for the identified patient. For example, if the clinician started treating a child’s behavioral problem, and subsequently takes on couples therapy with the parents to address their relationship problems, the original focus of therapy with the child may be lost. A referral to another clinician helps the PCS clinician to stay focused.

One exception to these guidelines is when a family therapy approach can be effectively and ethically used to treat all members of the family, or each member of the couple.


The identified patient is not required to sign an authorization to release information (Authorization Form) to the collateral participant when a collateral participant takes part in therapy. The presence of the collateral participant with the consent of the patient is adequate. This provides some assurance that full consent has been given to the clinician for the patient’s confidential information to be discussed with the collateral participant in therapy. An Authorization Form is necessary on those occasions when the clinician receives a telephone call from a collateral participant, or when the clinician calls a collateral participant. In most instances, the clinician cannot take a call from a collateral participant without an Authorization Form.

Partner’s and/or Family Members Phone Call FAQ’s

What is the purpose of the call?

The purpose of providing you the opportunity of calling into your partner’s PCS IOP is for you to have a voice in your partner’s process. We believe partners and/or family members can add valuable information, helping us to have a more complete description of the issues facing our client.  The call is optional and if you chose to participate, you can share as much or as little information as you feel comfortable. If at any time it feels unsafe to participate in the call, even during the call, please let PCS or your partner know.

What type of information will I be asked to share?

You can share what you feel comfortable with. The therapist may ask you what you appreciate about your partner, about the impact of your partner’s behavior, information you feel is important for the PCS staff to know, and what you hope your partner would achieve during the PCS IOP. Once again, this call is about you sharing. If you feel at all uncomfortable, the phone call is not required or mandatory rather a chance for you to have a voice in their treatment.

What type of information will my partner be sharing?

The purpose of the call is for you to share not your partner. It will not be a couple’s session or a time for disclosing information. The therapists will ask your partner to simply listen to your feedback as an opportunity to gain empathy and for PCS staff to learn your perspective.

Who will set up the phone call?

Your partner will set up the time with you to call PCS. We must receive the signed collateral paperwork from you before we are able to take the phone call with the therapist and your partner. Please call 15 minutes after the top of the hour unless guided by your partner to do otherwise.

What if I forgot to add something?

If you desire to share something else not mentioned during the original call, please make your request known to your partner. We are open to requests being made and each situation requires clinical discretion, therefore, we may or may not accommodate your request based on our clinical judgments.

I don’t have an appointment with my therapist for a week, should I still call?

That will be your decision. PCS always suggests having support while your partner is completing their IOP. If possible; setting up a therapy appointment, going to a group, or accessing your support network could be beneficial. If you feel like you do not have the support you need to complete the phone call please either make arrangements for support or the phone call may not be appropriate to follow through with.


If you have questions about therapy, my procedures, or your role in this process, please discuss them with me. Remember that the best way to assure quality and ethical treatment is to keep communication open and direct with your clinician. By signing below you indicate that your have read and understood this document.

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