INFORMED CONSENT & OFFICE POLICIES

This document contains important information about my professional services and business policies. Please read it carefully. When you sign this document, it will represent an agreement between us.

THERAPEUTIC SERVICES

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by signing at the end of the intake form you fill out.

Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to address. There are many different methods I may use to deal with those problems. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.

Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But, there are no guarantees as to what you will experience.

Our first few sessions will involve an evaluation of your needs. After the first two to three I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and, if so, I will give you referrals to other practitioners whom I believe are better suited to help you.

Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional.

MEETINGS

After the first session,, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If we agree to begin psychotherapy, I typically schedule one 50-minute session (one appointment hour of 50 minutes duration) per week, at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to attend unless you provide 24 hours advance notice of cancellation. If it is possible, I will try to find another time to reschedule the appointment. Please see late cancelations/no-show policy for more information.

RATES & INSURANCE

The following fees are self-pay rates for services. If I am an in-network provider for your insurance plan, rates are determined per contract for each plan. If your insurance company does not pay the full amount of this rate based on your coverage benefits, you will be responsible for the remainder of the rate. Fees are increased $10 a year in September.

45 minute therapy session (38-52 minutes): $160

60 minute therapy session (53 - 60 minutes): $175

60 minute intake session (53-60 minutes): $185

Legal Proceedings: $300 per hour (including travel, preparation, and attendance paid in full prior to court appearance)

Phone consultations with patients or other care providers for more than 15 minutes: $45 per additional 15 minute increment

Preparation of documents (treatment summaries, letters, forms) = $45 per 15 minute increment (15 minute minimum)

Returned Check Fee = $20

BILLING AND PAYMENTS

You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. By saving your credit card(s) on the online practice software you agree to be charged for session payments and/or for late cancellations/no show fees once accrued. You can change your credit card/HSA card on file as needed. Payment schedules for other professional services will be agreed to when such services are requested.

If your account has not been paid for more than 60 days 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. In most collection situations, the only information I will release regarding a patient’s treatment is his/her name, the dates, times, and nature of services provided, and the amount due.

INSURANCE REIMBURSEMENT

In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If necessary, I am willing to call the insurance company on your behalf to obtain clarification.

Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. Though a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will try to assist you in finding another provider who will help you continue your psychotherapy.

You should also be aware that most insurance companies require that I provide them with your clinical diagnosis. Sometimes I have to provide additional clinical information, such as treatment plans, progress notes or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any records I submit, if you request it. You understand that, by using your insurance, you authorize me to release such information to your insurance company. I will try to keep that information limited to the minimum necessary.

Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above unless prohibited by the insurance contract.

NO - SHOWS and LATE CANCELLATIONS:

Please provide at least 24 HOURS ADVANE NOTICE OF THERAPY SESSION CANCELLATIONS or you will be subject to a charge unless we both agree that circumstances were out of your control. This is necessary because a time commitment is made to you and is held exclusively for you. If it is possible, I will try to find another time to reschedule the appointment that same week.

1st Occurrence late cancellation/no-show for therapy: no charge

2nd Occurrence late cancellation/no-show for therapy: half session charge

3rd Occurrence late cancellation/no-show for therapy: full session charge

If you begin to cancel appointments regularly or no-show more than 2 consecutive times, we will need to discuss your ability to commit to therapy and consider discontinuing services depending on the circumstances.

COMMUNICATIONS POLICY

Telephone Accessibility:

I am often not immediately available by telephone due to being in session with a client. I am usually in my office between 9 AM and 5 PM on Monday through Thursday. When I am unavailable, please leave a message on my voice mail that I monitor frequently. I will make every effort to return your call on the same day you make it, if requested, or within 48 hours when I am in the office, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. If I am absent from the office for an extended time, I will attempt to inform you ahead of time or my voice message will state when I plan to return. I am not available to speak about clinical matters during non-office hours.

There could be circumstances (i.e., illness, emergencies, weather conditions) when I need to unexpectedly cancel appointments with you. If this occurs, I will try to reach you the best I can to reschedule your appointment. I will also put a message in my voicemail stating the terms of my absence.

I will inform you of the time I am away as far ahead as possible and we will arrange Telehealth.

In the case of an emergency:

If you are unable to reach me and feel that you cannot wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. You can also go directly to emergency departments.