is the Professional Will of
IN THE EVENT OF MY INCAPACITY OR DEATH, PLEASE CONTACT THE FOLLOWING
MEMBERS OF MY EMERGENCY RESPONSE TEAM:
Please keep this
in a secure and confidential location.
involves relationships with a high degree of confidentiality and trust,
and because patients often develop close attachments to therapists,
this professional will has been developed as a necessary accompaniment
to my practice. Patients may be sensitive to interruptions or a disruption
in their treatment. They may be strongly affected when a therapist
is sick or dies.
I hope that by
leaving the following instructions I can reduce the stress to my patients,
my colleagues, and my family. The colleagues designated in this document
have agreed to act as the members of my Emergency Response Team to
handle the responsibilities identified below. My spouse should be
asked to respond to questions and needs only as absolutely necessary.
Patients should be discouraged from attempting to contact my family
or from visiting me in the event that I have a debilitating illness.
Any expression of concern for me or my family should be received by
Emergency Response Team (ERT) colleagues. The members of the ERT should
use their clinical judgment about whether to pass information from
my patients to me or my family.
1. The members
of the ERT should inform my patients by telephone of my disability
or death, promptly cancel appointments, and offer consultation and/or
referrals to minimize any disruption to my patients.
2. In the event
of a serious illness or my death, I ask that my ERT colleagues consider
the following requests and suggestions. I also expect them to make
decisions as required based upon the particular situation, a patient's
individual needs, and the therapist's professional availability and
energy to act. Each member of the ERT has a copy of this "PROFESSIONAL
WILL." Additional copies are located in the file cabinet in my
office and in my safety deposit box.
3. If it makes
sense to have one member of the ERT act as a coordinator, the three
members should collectively decide who has the time, energy and interest
to take on such a role.
4. In order to
access clinical and financial information, obtain office and file
cabinet keys and passwords, I authorize the ERT to contact my wife.
No one other than the ERT is to have access to my clinical files.
numbers for all current patients can be found in the front of my datebook
in my leather briefcase. Current patient files are kept in my locked
office file cabinet. Past patient files are kept in my locked home
office file cabinet. Billing files are kept under password protection
in my computer in the folder labeled, "Patient Billing Files."
6. I strongly
prefer that any message left on a patient's answering machine be limited
to the request to return a phone call. A suggestion for an acceptable
message might be, "Hello... My name is_____________. ____________________
has asked me to contact you regarding your appointments with him.
Please call me at__________________________________."
7. It might be
a good idea for a note to be placed near the waiting room in the hallway
of my office. The note should state,
"_______________________________ is unavailable to meet today.
Please check your answering machine for a message." It may be
helpful to leave an additional note that asks callers to contact one
or more of the ERT members.
8. Answering machine
information. In the event of my illness or death, one of the members
of the ERT should obtain the key to my office, either from my wife
or the office manager, in order to make a new outgoing message on
my answering machine. The message should state, "You have reached
the message machine of _____________________________. (First name
only) is unavailable to keep his appointments this week. If you are
a current patient, you can expect a call shortly. At the tone, if
you leave a message, you will be contacted as soon as possible."
9. Please collect
messages and return calls from my answering machine promptly. In the
event of my death, it would be worthwhile to have the telephone company
generate a message for at least six months to refer callers to members
of the ERT.
In The Event
Of My Mental Incapacitation
10. If a chemical dependence, organic illness, or mental illness interferes
with my judgment to the degree that the well?being of my patients
may be in jeopardy, I further request that one or more members of
the ERT discuss this with me directly. The colleague(s) should request
that I discuss the situation with my therapist or my consultant. If
I refuse or postpone such consultation, I authorize the ERT to contact
my therapist or consultant directly.
11. If my therapist
or consultant deems it necessary to safeguard the wellbeing of my
patients, I authorize him or her to discuss the matter with me directly.
In the event that I disregard this advice and counsel, and if it seems
necessary to safeguard the wellbeing of my patients, I authorize either
my psychotherapist, my consultant or the ERT to contact the BBS.
12. In the event
of my sudden disability or death, patients should be told as much
or as little information as needed on a case by case basis in order
that they may process their feelings. Some may ask questions and others
may not. Respond with as much or as little information as you deem
Financial Records, Collections
13. Patient notes should be maintained or destroyed within legally
appropriate guidelines to protect patient confidentiality. In the
event that my patient notes are to be destroyed, I request that they
be shredded before disposal.
amounts owed to me or my estate are unlikely, given that patients
pay me at the time of each session. However, occasionally a patient
will be late with a single session or pay a week or two in advance.
The ERT is urged to respond to these patients using sound clinical
15. I have no
desire or need for either a public or private memorial. However, I
have no objection to one being given in the event friends, relatives,
or patients are inclined to grieve together. I have no objections
to patients attending a public memorial service, but in all regards,
I wish my family's privacy to be respected.
16. For additional information, please contact:
- My Therapist:
- My consultant:
- My office
landlord: (telephone number)
17. My professional
Liability Insurance is through______. The policy is in the locked
file cabinet labeled, "Professional Subjects" in the folder
titled, "Malpractice Insurance." To protect my estate from
the unlikely event of an action arising following my death, the insurance
company should be contacted. If additional coverage is necessary,
my policy should be amended and paid through my professional checking
18. In all actions
taken by the ERT, I request that the ERT recognize the need to protect
the confidentiality of all patients and request that no unnecessary
or unauthorized disclosures about patients be made without their expressed
In advance, I convey my regret for any problems this request might
cause. In the absence of specific guidelines, the ERT is asked to
use their best clinical judgment. I have chosen my friends and colleagues
with great care. I trust your judgment and feel grateful that you
have agreed to carry out my wishes. Thank you.
Notary date________________________________ date: