Introduction This document is a part of an online course on fees in psychotherapy and focuses on the sections of the Codes of Ethics of the major professional organizations that deal with fees. It is also designed to ensure that California psychologists, MFTs and LCSWs are provided with the relevant and most current and up-to-date information regarding the applicable professional codes of ethics and California Law. Six major codes of ethics are discussed in this paper. The relevant sections of these codes to fees in psychotherapy will be presented and direct links to the codes online will be provided. Links to the Codes of Ethics of Mental Health Professionals American Association of Marriage and Family Therapists, AAMFT American Counseling Association, ACA American Mental Health Counselors Association, AMHCA American Psychiatric Association, ApA American Psychological Association, APA California Association of Marriage and Family Therapists, CAMFT Feminist Therapy Institute, FTI National Association of Social Workers, NASW American Association of Marriage and Family Therapists (AAMFT) Code of Ethics, Effective July 1, 2001 American Association of Marriage and Family Therapists, AAMFT Principle VII Financial Arrangements Marriage and family therapists make financial arrangements with clients, third-party payors, and supervisees that are reasonably understandable and conform to accepted professional practices. 7.1 Marriage and family therapists do not offer or accept kickbacks, rebates, bonuses, or other remuneration for referrals; fee-for-service arrangements are not prohibited. 7.2 Prior to entering into the therapeutic or supervisory relationship, marriage and family therapists clearly disclose and explain to clients and supervisees: (a) all financial arrangements and fees related to professional services, including charges for canceled or missed appointments; (b) the use of collection agencies or legal measures for nonpayment; and (c) the procedure for obtaining payment from the client, to the extent allowed by law, if payment is denied by the third-party payor. Once services have begun, therapists provide reasonable notice of any changes in fees or other charges. 7.3 Marriage and family therapists give reasonable notice to clients with unpaid balances of their intent to seek collection by agency or legal recourse. When such action is taken, therapists will not disclose clinical information. 7.4 Marriage and family therapists represent facts truthfully to clients, third-party payors, and supervisees regarding services rendered. 7.5 Marriage and family therapists ordinarily refrain from accepting goods and services from clients in return for services rendered. Bartering for professional services may be conducted only if: (a) the supervisee or client requests it, (b) the relationship is not exploitative, (c) the professional relationship is not distorted, and (d) a clear written contract is established. 7.6 Marriage and family therapists may not withhold records under their immediate control that are requested and needed for a client's treatment solely because payment has not been received for past services, except as otherwise provided by law. Principle VIII Advertising 8.2 Marriage and family therapists ensure that advertisements and publications in any media (such as directories, announcements, business cards, newspapers, radio, television, Internet, and facsimiles) convey information that is necessary for the public to make an appropriate selection of professional services. Information could include: (a) office information, such as name, address, telephone number, credit card acceptability, fees, languages spoken, and office hours; (b) qualifying clinical degree (see subprinciple 8.5); (c) other earned degrees (see subprinciple 8.5) and state or provincial licensures and/or certifications; (d) AAMFT clinical member status; and (e) description of practice. American Counseling Association Code of Ethics and Standards of Practice, Effective 2005 http://www.zurinstitute.com/aca_code_of_ethics_2005.pdf Section A: The Counseling Relationship A.2.a. Informed Consent Clients have the freedom to choose whether to enter into or remain in a counseling relationship and need adequate information about the counseling process and the counselor. Counselors have an obligation to review in writing and verbally with clients the rights and responsibilities of both the counselor and the client. Informed consent is an ongoing part of the counseling process, and counselors appropriately document discussions of informed consent throughout the counseling relationship. A.2.b. Types of Information Needed Counselors explicitly explain to clients the nature of all services provided. They inform clients about issues such as, but not limited to, the following: the purposes, goals, techniques, procedures, limitations, potential risks, and benefits of services; the counselor’s qualifications, credentials, and relevant experience; continuation of services upon the incapacitation or death of a counselor; and other pertinent information. Counselors take steps to ensure that clients understand the implications of diagnosis, the intended use of tests and reports, fees, and billing arrangements. Clients have the right to confidentiality and to be provided with an explanation of its limitations (including how supervisors and/or treatment team professionals are involved); to obtain clear information about their records; to participate in the ongoing counseling plans; and to refuse any services or modality change and to be advised of the consequences of such refusal. A.10. Fees and Bartering A.10.a. Accepting Fees From Agency Clients Counselors refuse a private fee or other remuneration for rendering services to persons who are entitled to such services through the counselor’s employing agency or institution. The policies of a particular agency may make explicit provisions for agency clients to receive counseling services from members of its staff in private practice. In such instances, the clients must be informed of other options open to them should they seek private counseling services. A.10.b. Establishing Fees In establishing fees for professional counseling services, counselors consider the financial status of clients and locality. In the event that the established fee structure is inappropriate for a client, counselors assist clients in attempting to find comparable services of acceptable cost. A.10.c. Nonpayment of Fees If counselors intend to use collection agencies or take legal measures to collect fees from clients who do not pay for services as agreed upon, they first inform clients of intended actions and offer clients the opportunity to make payment. A.10.d. Bartering Counselors may barter only if the relationship is not exploitive or harmful and does not place the counselor in an unfair advantage, if the client requests it, and if such arrangements are an accepted practice among professionals in the community. Counselors consider the cultural implications of bartering and discuss relevant concerns with clients and document such agreements in a clear written contract. A.10.e. Receiving Gifts Counselors understand the challenges of accepting gifts from clients and recognize that in some cultures, small gifts are a token of respect and showing gratitude. When determining whether or not to accept a gift from clients, counselors take into account the therapeutic relationship, the monetary value of the gift, a client’s motivation for giving the gift, and the counselor’s motivation for wanting or declining the gift. A.11. Termination and Referral A.11.c. Appropriate Termination Counselors terminate a counseling relationship when it becomes reasonably apparent that the client no longer needs assistance, is not likely to benefit, or is being harmed by continued counseling. Counselors may terminate counseling when in jeopardy of harm by the client, or another person with whom the client has a relationship, or when clients do not pay fees as agreed upon. Counselors provide pretermination counseling and recommend other service providers when necessary. F. 10. Roles and Relationships Between Counselor Educators and Students F.10.d. Nonprofessional Relationships Counselor educators avoid nonprofessional or ongoing professional relationships with students in which there is a risk of potential harm to the student or that may compromise the training experience or grades assigned. In addition, counselor educators do not accept any form of professional services, fees, commissions, reimbursement, or remuneration from a site for student or supervisee placement. ACA Standards of Practice Standard of Practice Six (SP-6): Advance Understanding of Fees. Counselors must explain to clients, prior to their entering the counseling relationship, financial arrangements related to professional services. (See A.10. a.-d. and A.11.c.) Standard of Practice Twenty-Nine (SP-29): Accepting Fees From Agency Clients. Counselors must not accept fees or other remuneration for consultation with persons entitled to such services through the counselor's employing agency or institution. (See D.3.a.) Standard of Practice Thirty (SP-30): Referral Fees. Counselors must not accept referral fees. (See D.3.b.) The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry 2001 Edition http://www.psych.org/MainMenu/PsychiatricPractice/Ethics/ResourcesStandards.aspx Section 2 A physician shall uphold the standards of professionalism, be honest in all professional interactions and strive to report physicians deficient in character or competence, or engaging in fraud or deception to appropriate entities. 6. It is ethical for the psychiatrist to make a charge for a missed appointment when this falls within the terms of the specific contractual agreement with the patient. Charging for a missed appointment or for one not canceled 24 hours in advance need not, in itself, be considered unethical if a patient is fully advised that the physician will make such a charge. The practice, however, should be resorted to infrequently and always with the utmost consideration for the patient and his or her circumstances. 7. An arrangement in which a psychiatrist provides supervision or administration to other physicians or nonmedical persons for a percentage of their fees or gross income is not acceptable; this would constitute fee splitting. In a team of practitioners, or a multidisciplinary team, it is ethical for the psychiatrist to receive income for administration, research, education, or consultation. This should be based on a mutually agreed-upon and set fee or salary, open to renegotiation when a change in the time demand occurs. (See also Section 5, Annotations 2, 3, and 4.) PART II: ENFORCEMENT OPTION 9. The hearing shall provide fairness and respect for both the respondent and the complainant. The following procedures shall apply: e. A stenographic or tape record shall be made of the proceedings, and a copy shall subsequently be made available to the respondent at a reasonable charge. American Mental Health Counselors Association Code of Ethics 2000 http://www.amhca.org/code Section L: Fees and Bartering 1. Mental health counselors clearly explain to clients, prior to entering the counseling relationship, all financial arrangements related to professional services, including the use of collection agencies or legal measures for nonpayment. 2. In establishing fees for professional counseling services, mental health counselors consider the financial status of their clients and locality. In the event that the payment of the mental health counselor's usual fees would create undue hardship for the client, assistance is provided in attempting to find comparable services at an acceptable cost. 3. Mental health counselors ordinarily refrain from accepting goods or services from clients in return for counseling service because such arrangements create inherent potential for conflicts, exploitation and distortion of the professional relationship. Participation in bartering is only used when there is no exploitation, if the client requests it, if a clear written contract is established, and if such an arrangement is an accepted practice among professionals in the community. Section M: Pro Bono Service Mental health counselors contribute to society by devoting a portion of their professional activity to services for which there is little or no financial return. American Psychological Association's Ethical Principles of Psychologists and Code of Conduct 2002 http://www.apa.org/ethics/code2002.html 6. Record Keeping and Fees 6.01 Documentation of Professional and Scientific Work and Maintenance of Records Psychologists create, and to the extent the records are under their control, maintain, disseminate, store, retain, and dispose of records and data relating to their professional and scientific work in order to (1) facilitate provision of services later by them or by other professionals, (2) allow for replication of research design and analyses, (3) meet institutional requirements, (4) ensure accuracy of billing and payments, and (5) ensure compliance with law. (See also Standard 4.01, Maintaining Confidentiality.) 6.02 Maintenance, Dissemination, and Disposal of Confidential Records of Professional and Scientific Work (a) Psychologists maintain confidentiality in creating, storing, accessing, transferring, and disposing of records under their control, whether these are written, automated, or in any other medium. (See also Standards 4.01, Maintaining Confidentiality, and 6.01, Documentation of Professional and Scientific Work and Maintenance of Records.) (b) If confidential information concerning recipients of psychological services is entered into databases or systems of records available to persons whose access has not been consented to by the recipient, psychologists use coding or other techniques to avoid the inclusion of personal identifiers. (c) Psychologists make plans in advance to facilitate the appropriate transfer and to protect the confidentiality of records and data in the event of psychologists' withdrawal from positions or practice. (See also Standards 3.12, Interruption of Psychological Services, and 10.09, Interruption of Therapy.) 6.03 Withholding Records for Nonpayment Psychologists may not withhold records under their control that are requested and needed for a client's/patient's emergency treatment solely because payment has not been received. 6.04 Fees and Financial Arrangements (a) As early as is feasible in a professional or scientific relationship, psychologists and recipients of psychological services reach an agreement specifying compensation and billing arrangements. (b) Psychologists' fee practices are consistent with law. (c) Psychologists do not misrepresent their fees. (d) If limitations to services can be anticipated because of limitations in financing, this is discussed with the recipient of services as early as is feasible. (See also Standards 10.09, Interruption of Therapy, and 10.10, Terminating Therapy.) (e) If the recipient of services does not pay for services as agreed, and if psychologists intend to use collection agencies or legal measures to collect the fees, psychologists first inform the person that such measures will be taken and provide that person an opportunity to make prompt payment. (See also Standards 4.05, Disclosures; 6.03, Withholding Records for Nonpayment; and 10.01, Informed Consent to Therapy.) 6.05 Barter With Clients/Patients Barter is the acceptance of goods, services, or other nonmonetary remuneration from clients/patients in return for psychological services. Psychologists may barter only if (1) it is not clinically contraindicated, and (2) the resulting arrangement is not exploitative. (See also Standards 3.05, Multiple Relationships, and 6.04, Fees and Financial Arrangements.) 6.06 Accuracy in Reports to Payors and Funding Sources In their reports to payors for services or sources of research funding, psychologists take reasonable steps to ensure the accurate reporting of the nature of the service provided or research conducted, the fees, charges, or payments, and where applicable, the identity of the provider, the findings, and the diagnosis. (See also Standards 4.01, Maintaining Confidentiality; 4.04, Minimizing Intrusions on Privacy; and 4.05, Disclosures.) 6.07 Referrals and Fees When psychologists pay, receive payment from, or divide fees with another professional, other than in an employer-employee relationship, the payment to each is based on the services provided (clinical, consultative, administrative, or other) and is not based on the referral itself. (See also Standard 3.09, Cooperation With Other Professionals.) 9.03 Informed Consent in Assessments (a) Psychologists obtain informed consent for assessments, evaluations, or diagnostic services, as described in Standard 3.10, Informed Consent, except when (1) testing is mandated by law or governmental regulations; (2) informed consent is implied because testing is conducted as a routine educational, institutional, or organizational activity (e.g., when participants voluntarily agree to assessment when applying for a job); or (3) one purpose of the testing is to evaluate decisional capacity. Informed consent includes an explanation of the nature and purpose of the assessment, fees, involvement of third parties, and limits of confidentiality and sufficient opportunity for the client/patient to ask questions and receive answers. 10.01 Informed Consent to Therapy (a) When obtaining informed consent to therapy as required in Standard 3.10, Informed Consent, psychologists inform clients/patients as early as is feasible in the therapeutic relationship about the nature and anticipated course of therapy, fees, involvement of third parties, and limits of confidentiality and provide sufficient opportunity for the client/patient to ask questions and receive answers. (See also Standards 4.02, Discussing the Limits of Confidentiality, and 6.04, Fees and Financial Arrangements.) 4.05 Disclosures (b) Psychologists disclose confidential information without the consent of the individual only as mandated by law, or where permitted by law for a valid purpose such as to (1) provide needed professional services; (2) obtain appropriate professional consultations; (3) protect the client/patient, psychologist, or others from harm; or (4) obtain payment for services from a client/patient, in which instance disclosure is limited to the minimum that is necessary to achieve the purpose. (See also Standard 6.04e, Fees and Financial Arrangements.) 8. Research and Publication 8.02 Informed Consent to Research (b) Psychologists conducting intervention research involving the use of experimental treatments clarify to participants at the outset of the research (1) the experimental nature of the treatment; (2) the services that will or will not be available to the control group(s) if appropriate; (3) the means by which assignment to treatment and control groups will be made; (4) available treatment alternatives if an individual does not wish to participate in the research or wishes to withdraw once a study has begun; and (5) compensation for or monetary costs of participating including, if appropriate, whether reimbursement from the participant or a third-party payor will be sought. (See also Standard 8.02a, Informed Consent to Research.) California Association of Marriage and Family Therapists http://www.camft.org/scriptcontent/index.cfm?displaypage=../CamftBenefits/EthicalStandards1.html NON-PAYMENT OF FEES: Marriage and family therapists do not terminate patient relationships for non-payment of fees except when the termination is handled in a clinically appropriate manner. 9.3 DISCLOSURE OF FEES: Marriage and family therapists disclose, in advance, their fees and the basis upon which they are computed, including, but not limited to, charges for canceled or missed appointments and any interest to be charged on unpaid balances, at the beginning of treatment and give reasonable notice of any changes in fees or other charges. Feminist Therapy Institute: Code of Ethics (revised 1999) http://www.feministtherapyinstitute.org/ethics.htm III. Overlapping Relationships C. When accepting third party payments, a feminist therapist is especially cognizant of and clearly communicates to her client the multiple obligations, roles, and responsibilities of the therapist. When working in institutional settings, she clarifies to all involved parties where her allegiances lie. She also monitors multiple and conflicting expectations between clients and caregivers, especially when working with children and elders National Association of Social Workers, NASW http://www.socialworkers.org/pubs/code/code.asp 1.13 Payment for Services (a) When setting fees, social workers should ensure that the fees are fair, reasonable, and commensurate with the services performed. Consideration should be given to clients' ability to pay. (b) Social workers should avoid accepting goods or services from clients as payment for professional services. Bartering arrangements, particularly involving services, create the potential for conflicts of interest, exploitation, and inappropriate boundaries in social workers' relationships with clients. Social workers should explore and may participate in bartering only in very limited circumstances when it can be demonstrated that such arrangements are an accepted practice among professionals in the local community, considered to be essential for the provision of services, negotiated without coercion, and entered into at the client's initiative and with the client's informed consent. Social workers who accept goods or services from clients as payment for professional services assume the full burden of demonstrating that this arrangement will not be detrimental to the client or the professional relationship. (c) Social workers should not solicit a private fee or other remuneration for providing services to clients who are entitled to such available services through the social workers' employer or agency. 1.16 Termination of Services (c) Social workers in fee-for-service settings may terminate services to clients who are not paying an overdue balance if the financial contractual arrangements have been made clear to the client, if the client does not pose an imminent danger to self or others, and if the clinical and other consequences of the current nonpayment have been addressed and discussed with the client. 2.06 Referral for Services (c) Social workers are prohibited from giving or receiving payment for a referral when no professional service is provided by the referring social worker. 3.05 Billing Social workers should establish and maintain billing practices that accurately reflect the nature and extent of services provided and that identify who provided the service in the practice setting. 1.03 Informed Consent (a) Social workers should provide services to clients only in the context of a professional relationship based, when appropriate, on valid informed consent. Social workers should use clear and understandable language to inform clients of the purpose of the services, risks related to the services, limits to services because of the requirements of a third-party payer, relevant costs, reasonable alternatives, clients' right to refuse or withdraw consent, and the time frame covered by the consent. Social workers should provide clients with an opportunity to ask questions. Addendum: California Law and Regulation on Fees in Psychotherapy Those parts of California Law most relevant to the topics of law and dual relationships, sexual relationships and boundaries in psychotherapy and counseling are in the following sections of the Business and Professional Code of California. Psychologists: Chapter 6.6 MFTs: Division 2, Chapter 13, Articles 1-7, Sections 4980 - 4989. LCSWs: Division 2, Chapter 14, Articles 1-4, Sections 4990 - 4998.7. For regulations online: Business and Professional Code of California at: http://www.leginfo.ca.gov/calaw.html Psychologists, BOP: http://www.psychboard.ca.gov/lawsregs/2008lawsregs.pdf MFTs and LCSWs, BBS: http://www.bbs.ca.gov/pdf/publications/lawsregs.pdf BUSINESS AND PROFESSIONS CODE CHAPTER 6.6 PSYCHOLOGISTS http://www.psychboard.ca.gov/lawsregs/2008lawsregs.pdf Licensure Requirement; Practice of Psychology; Psychotherapy; Fee 2903. No person may engage in the practice of psychology, or represent himself or herself to be a psychologist, without a license granted under this chapter, except as otherwise provided in this chapter. The practice of psychology is defined as rendering or offering to render for a fee to individuals, groups, organizations or the public any psychological service involving the application of psychological principles, methods, and procedures of understanding, predicting, and influencing behavior, such as the principles pertaining to learning, perception, motivation, emotions, and interpersonal relationships; and the methods and procedures of interviewing, counseling, psychotherapy, behavior modification, and hypnosis; and of constructing, administering, and interpreting tests of mental abilities, aptitudes, interests, attitudes, personality characteristics, emotions, and motivations. The application of these principles and methods includes, but is not restricted to: diagnosis, prevention, treatment, and amelioration of psychological problems and emotional and mental disorders of individuals and groups. Psychotherapy within the meaning of this chapter means the use of psychological methods in a professional relationship to assist a person or persons to acquire greater human effectiveness or to modify feelings, conditions, attitudes and behavior which are emotionally, intellectually, or socially ineffectual or maladjustive. As used in this chapter, ''fee'' means any charge, monetary or otherwise, whether paid directly or paid on a prepaid or capitation basis by a third party, or a charge assessed by a facility, for services rendered. BOP on Online via the Internet and Fees: Sections on fees from: http://www.psychboard.ca.gov/consumers/internet-thrpy.shtml The Board of Psychology would like to make the following recommendations to California consumers who choose to seek psychological services over the Internet. Individuals who provide psychotherapy or counseling, either in person, by telephone, or over the Internet, are required by law to be licensed. Licensing requirements vary by state. Individuals who provide psychotherapy or counseling to persons in California are required to be licensed in California. Such licensure permits the consumer to pursue recourse against the licensee should the consumer believe that the licensee engaged in unprofessional conduct. Be a cautious consumer when seeking psychological services over the Internet, or by any other means, by doing the following: Verify that the practitioner has a current and valid license in the State of California. Be sure you understand the fee that you will be charged for the services to be rendered and that you fully understand how and to whom the fee is to be paid. BUSINESS AND PROFESSIONS CODE OF CA CHAPTER 13. MARRIAGE AND FAMILY THERAPISTS http://www.bbs.ca.gov/pdf/publications/lawsregs.pdf ARTICLE 2. DENIAL, SUSPENSION, AND REVOCATION §4982. UNPROFESSIONAL CONDUCT The board may refuse to issue any registration or license, or may suspend or revoke the license or registration of any registrant or licensee if the applicant, licensee, or registrant has been guilty of unprofessional conduct. Unprofessional conduct shall include, but not be limited to: n. Prior to the commencement of treatment, failing to disclose to the client or prospective client the fee to be charged for the professional services, or the basis upon which that fee will be computed. o. Paying, accepting, or soliciting any consideration, compensation, or remuneration, whether monetary or otherwise, for the referral of professional clients. All consideration, compensation, or remuneration shall be in relation to professional counseling services actually provided by the licensee. Nothing in this subdivision shall prevent collaboration among two or more licensees in a case or cases. However, no fee shall be charged for that collaboration, except when disclosure of the fee has been made in compliance with subdivision (n). §4992.3. UNPROFESSIONAL CONDUCT; EFFECT ON LICENSEE OR REGISTRANT The board may refuse to issue a registration or a license, or may suspend or revoke the license or registration of any registrant or licensee if the applicant, licensee, or registrant has been guilty of unprofessional conduct. Unprofessional conduct includes, but is not limited to: n. Prior to the commencement of treatment, failing to disclose to the client or prospective client the fee to be charged for the professional services, or the basis upon which that fee will be computed. o. Paying, accepting, or soliciting any consideration, compensation, or remuneration, whether monetary or otherwise, for the referral of professional clients. All consideration, compensation, or remuneration shall be in relation to professional counseling services actually provided by the licensee. Nothing in this subdivision shall prevent collaboration among two or more licensees in a case or cases. However, no fee shall be charged for that collaboration, except when disclosure of the fee has been made in compliance with subdivision (n). §123110. INSPECTION AND COPYING; VERIFICATION OF IDENTITY; RETENTION AND QUALITY OF RECORDS; LIABILITY FOR DISCLOSURE; VIOLATIONS; PENALITIES (j) This section shall be construed as prohibiting a health care provider from withholding patient records or summaries of patient records because of an unpaid bill for health care services. Any health care provider who willfully withholds patient records or summaries of patient records because of an unpaid bill for health care services shall be subject to the sanctions specified in subdivision (i). For California Law on Fees in Supervision, go to: http://www.zurinstitute.com/ethics_of_supervision.html Bold words are not in the original documents. For more references, click here. For guidelines regarding fees in therapy, click here. For online course on Fees In Therapy for CE credit based partly on this article, click here. For online course on Record Keeping, click here. For online course on HIPAA for CE credit, click here.

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