Psycotherapist & Client services and consent agreement
Psychotherapy varies depending on the personalities of the therapist and client, and the particular goals the client would like to achieve. During the initial session, we will conduct an evaluation and determine if it is felt by both parties that a therapeutic relationship can be formed. By the end of our first few sessions, I can offer some impressions about what treatment approach might be most helpful in meeting your treatment goals. We can discuss any questions you have about my thoughts on how to best help you in therapy. If you feel that you would prefer to work with someone else or receive some other form of therapy, I will be happy to help you set up a meeting with another mental health professional.
You have the absolute right to the confidentiality of your therapy. I cannot and will not tell anyone else what you have told me, or even that you are in therapy with me without your prior written Authorization. The limitations to confidentiality are reviewed further below in this document.
If you elect to work and/or communicate with me by email, phone, or skype at some point in our work together, please be aware that these methods are not completely confidential. All emails are retained in the logs of your or my internet service provider. While under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrator(s) of the internet service provider. Any email I receive from you, and any responses that I send to you, will be printed out and kept in your treatment record.
Sessions are typically held for 50 minutes once or twice a week. Once you are scheduled for a regular therapy appointment, you will be expected to pay at that time for services rendered. I charge an $85 fee for all missed appointments or canceled appointments that do not meet my required 24 hour cancellation policy (for eg. If your appointment is at 9am on Monday, you will need to have canceled by 9am Sunday the day before, or else you will be charged the full fee of the session).
My fee for psychotherapy sessions are $160 for the initial assessment which lasts 60 minutes and $145 for follow up 50 minute sessions, unless we have an agreed upon sliding scale fee. In addition to weekly appointments, I charge for other professional services that you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services may include, report or letter writing or treatment summaries, and telephone conversations lasting longer than 15 minutes. Professional services outside my office will be charged $145 per hour including transit time to and from my office as well as transportation costs. Such services may include meetings with other professionals that you have authorized, meeting with clients while hospitalized, school meetings, etc.
If you need to reach me, please call me at 201 988 6181 or email me at firstname.lastname@example.org. I will always attempt to return your calls within 48 hours. I do not receive nor respond to text messages. In the event that you have a clinical emergency that needs immediate attention, call 911 or proceed to your nearest emergency room. It is also important to leave me a message on my voice mail notifying me of the emergency.
LIMITS ON CONFIDENTIALITY
The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by District of Columbia law. However, in the following situations, no authorization is required:
Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this agreement.
If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot disclose any information without a court order (subpoena). * If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information.
If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.
There are some situations in which I am legally obligated to take actions, which are mandated by HIPPA laws, and I may have to reveal some information about a patient's treatment. These situations are unusual in my practice:
If I have reasonable cause to believe that a child under 18 known to me in my professional capacity may be an abused child or a neglected child, the law requires that I file a report with the local office of the Department of Children and Family Services. Once such a report is filed, I may be required to provide additional information.
If I have reason to believe that an adult over the age of 60 is/ has been abused or neglected, the law requires that I file a report with the agency designated to receive such reports. Once such a report is filed, I may be required to provide additional information.
If you have made a specific threat or act of violence against another or if I believe that you present a clear, imminent risk of serious physical harm to another, I may be required to disclose information in order to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking your hospitalization.
If I believe that you present a clear, imminent risk of serious physical or mental injury or death to yourself, I may be required to disclose information in order to take protective actions. These actions may include seeking your hospitalization or contacting family members or others who can assist in protecting you.
If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed.
The laws and standards of my profession require that I keep Protected Health Information about you in your Clinical Record. You may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend should you decide to request them, that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents.
BILLING AND PAYMENTS
You will be expected to pay the full-amount each time we meet or the agreed upon payment plan. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan.
If your account has not been paid and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient's treatment is his/her name, the nature of services provided, and the amount due.
Please note, at this time I accept Cash or Check for payments, and there is a $20 fee for all bounced checks.
If you are planning to use your insurance benefits to help you pay for your treatment, it is important to understand that you, not your insurance, is responsible for the payment of my fees. If you are self paying, I will provide you with the statements from each session for you to submit your claim to the insurance company, should you use to choose your out of network benefits. If using your insurance, it is important to know that it can be difficult to determine exactly how much mental health coverage is available. Some plans only cover short-term treatment approaches that are designed to work out specific problems that interfere with a person’s usual level of functioning. It is typical for clients and therapists to feel that they need more services after insurance benefits end. If this becomes an issue for you, we can find ways to continue working together, and if this is not possible, I will do my best to help you find another provider to continue with your psychotherapy.
I am a preferred provider for Carefirst Blue Cross Blue Shield and accept direct reimbursement from the insurance provider. I make the best effort possible to review copay, benefit, and eligibility status prior to our first meeting; however, by signing this agreement you accept responsibility for all charges should your Blue Cross Blue Shield decline or reject payment. I will inform you of this as soon as I am aware of the claim rejection.
You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis and in some cases with additional clinical information such as treatment plans. I have no control over what insurance companies do with your information once is in their hands, and by signing this agreement, you authorize me to release any information to expedite insurance claims.