CLIENT INFORMATION AND CONSENT FOR SERVICES Welcome to my practice. I am a licensed psychologist in the state of Georgia, license number PSY001911. This document contains important information about my professional services and business policies. Please read it carefully and note any questions you might have so that we can discuss them at our meeting. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and new client rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information at the end of this session. Although these documents are long and sometimes complex, it is very important that you read them carefully. Please read carefully and note any questions you might have so that we can discuss them at our meeting. When you sign this document, it will also represent an agreement between us.
PSYCHOLOGICAL SERVICES Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and client, and the particular problems you are experiencing. There are many different methods I may use to deal with the problems that you hope to address. 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. Since 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 many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience.
Our first session or two will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you my initial impressions of whether I believe that I can be helpful to you and what our work and treatment plan would consist of, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. 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 for a second opinion.
APPOINTMENTS I normally conduct an initial evaluation that will last 50 to 75 minutes. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If psychotherapy is begun, I will usually schedule one appointment hour of 50 minutes duration per week at a time we agree on, although sessions may be more or less frequent depending on your treatment needs. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation unless we both agree that you were unable to attend due to circumstances beyond your control. No shows are subject to a $35 service fee. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. If it is possible, I will try to find another time to reschedule the appointment.
PROFESSIONAL FEES My standard hourly fee is $125. In addition to weekly appointments, I charge this amount for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 10 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party.
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. Payment schedules for other professional services will be agreed to when they 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 which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a client’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim.
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 ultimately the party responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers.
You should carefully read the section in your insurance coverage booklet that describes mental health services. 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 it is necessary to clear confusion, I will be willing to call the company on your behalf.
Due to the rising costs of health care, insurance benefits have increasingly become more complex. “Managed Health Care” plans such as HMOs and PPOs 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. While much can be accomplished in short-term therapy, some clients 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 do my best to find another provider who will help you continue your psychotherapy.
You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. 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 report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier.
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 your sessions. It is important to remember that you usually have the right to pay for my services yourself to avoid the problems described above.
CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. I utilize a cell phone with a voice mail system and check for messages regularly during normal business hours of days on which I work. Messages left on weekends or holidays will be returned the following business day. Occasionally, messages get lost or are not received, so if you have not received an expected return call, you will need to call again. If you are difficult to reach, please inform me of some times when you will be available.
EMERGENCIES The practice of private outpatient psychotherapy with adults makes the assumption that clients are functioning, self-responsible individuals with legitimate pain and legitimate needs. Private outpatient psychotherapy cannot, by its structure, assume responsibility for day-to-day functioning of its clients in the same way agencies and institutions can. Yet, at times some clients may have legitimate needs that require special attention. With this philosophy in mind, I attempt to operate my practice in a way that is responsible to your needs, encouraging of your autonomy, and respectful of my limits. Therefore, I am not ordinarily available for therapy or crisis calls that occur outside of scheduled appointments. During weekdays, I will make every effort to return phone calls within 24 hours, and weekend calls will be returned by Monday or the first business day after a holiday weekend, barring personal emergency, or planned out-of-town absences. If you feel that you cannot wait for me to return your call, please contact your family physician or the emergency room at the nearest hospital and ask for the psychologist or psychiatrist on call. If I am going to be unavailable for an extended period of time, I will let you know in advance and will, if requested, provide you with the name of a trusted colleague whom you can contact during my absence.
LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client 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 HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows:
• Consultation: I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information).
• Collections: Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.
• Imminent Harm to Self: If a client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection.
There are some situations where I am permitted or required to disclose information without either your consent or Authorization:
• Litigation: If you are involved in a court proceeding and a request is made for information concerning my professional services, such information is protected by the psychologist-client privilege law. I cannot provide any information without your written authorization, or a court order. 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.
• Agency Request: If a government agency is requesting the information for health oversight activities, I may be required to provide it for them.
• Self-defense: If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself.
• Workers Compensation: If a client files a worker’s compensation claim, and I am providing treatment related to the claim, I must, upon appropriate request, furnish copies of all medical reports and bills.
There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice. 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.
• Child Abuse: If I have reason to believe that a child has been abused, the law requires that I file a report with the appropriate governmental agency, usually the Department of Human Resources. Once such a report is filed, I may be required to provide additional information.
• Elder Abuse: If I have reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means, or has been neglected or exploited, I must report to an agency designated by the Department of Human Resources. Once such a report is filed, I may be required to provide additional information.
• Imminent Harm to Others: If I determine that a client presents a serious danger of violence to another, I may be required to take protective actions. These actions may include notifying the potential victim, and/or contacting the police, and/or seeking hospitalization for the client.
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. If you request, I will provide you with a copy of the APA ethical principles and code of conduct and/or relevant portions of the applicable State laws governing these issues.
PROFESSIONAL RECORDS The laws and standards of my profession require that I keep treatment records. Your Clinical Record may include information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, contents of our conversations, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself or others or makes reference to another person (unless such other person is a health care provider) and I believe that access is reasonably likely to cause substantial harm to such other person, you or your legal representative 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 that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most situations, I am allowed to charge a copying fee of $0.15 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form.
CLIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you.
COUPLES & COLLATERALS When a couple contracts with me to provide relationship therapy, I view the couple as the client. As a result, both individuals have access to the Clinical Record and I will need both individual's authorization to release the Record to anyone else. Occasionally when working with an individual, it may be useful to have a session with the individual's partner and in this situation, the individual is viewed as the client and the partner is viewed as a collateral. Collaterals do not have access to the Clinical Record. I will clarify this relationship in our first meeting.
MINORS & PARENTS Clients under 18 years of age who are not emancipated and their parents should be aware that the law allows parents to examine their child’s treatment records unless I believe that doing so would endanger the child or we agree otherwise. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is generally my policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, I will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.
YOUR AGREEMENT I understand that the results of therapy can be variable, and that the attainment of a positive outcome is dependent upon the effort expended by both myself and my therapist. I have read and understand all of this information, including my rights as a client. My signature below indicates that I agree to all of the above policies and procedures and I have received a copy of this agreement and the HIPPA notice described above.
