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Office Policies & Agreement for Psychotherapy Services
Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and write down any questions you might have so we can discuss them at our next meeting. When you sign this document, it will 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 bring forward. 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. At the same time, 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 not guarantees of what you will experience. Our first few sessions will involve an evaluation of your needs during which I will gather personal information form you about your background and goals for therapy, and assess whether I can be of benefit to you. By the end of the evaluation period, I will be able to offer my working understanding of your issues and some initial impressions of what out work will include 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. If you have questions about my procedures, we should discuss them whenever they arise. Termination and Follow-Up Deciding when to stop our work together is meant to be a mutual process. Before we stop, we will discuss how you will know if or when to come back or whether a regularly scheduled "check-in" might work best for you. If it is not possible for you to phase out of therapy, I recommend that we have closure on the therapy process with at least one-two termination sessions If during our work together, you or I feel that our work is not effective in helping you reach your therapeutic goals, I am obliged to discuss this with you. If appropriate, we will terminate treatment and I will give you referrals that may be of help to you. Appointments Appointments are ordinarily 45 minutes in duration, once per week, and at a time we agree on. Some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. You are responsible for coming to your appointment on time. If you are late, I will still need to end our appointment on time. Cancellations and Lateness If you need to cancel or reschedule a session, I require you to provide at least 48 hours notice. Since scheduling of an appointment involves the reservation of time specifically for you, appointments cancelled or rescheduled with less than 48 hours notice will be charged a late cancellation fee of $100 (unless we both agree that you were unable to attend due to an exceptional circumstance beyond your control, i.e. sudden medical emergency). This also applies to clients using insurance because I cannot bill your insurance for late cancellations or missed sessions. If you are running late for your appointment, please phone or email me as soon as you can to let me know you will be late. If you are late for your session, we will still end at our regular time so that I have time to prepare for my next appointments and I can be on time for them. Emails, Phone Calls, and Emergencies Email: For routine administrative matters such as checking appointment times or changing them, you may email me at [email protected]. I usually respond within the first 24 hours, with the exception of weekends and holidays. Phone Calls: For clinical matters, please leave a message for me at 510-701-5317. I check my messages daily. I encourage you to leave a detailed message including some good times that you can be reached. If I am planning on being out of town, I will inform you as soon as possible. Emergencies: If an emergency situation arises, please indicate it clearly in your message to me. If your situation is an acute emergency and you need to talk to someone right away, please call 911 or go to the nearest emergency room. Please note that phone calls and emails are not meant to be used to discuss lengthy issues, and time that is spent on your behalf outside of session time will be charged on a prorated basis beyond 10 minutes. Professional Fees My standard fee is $140 per 45 minute session. Prorated fees are offered for extended sessions at the same rate (i.e. $210 for 75 minute session). The fee is to be paid at the start of each session unless other arrangements have been made. Payments may be made by cash, check, or credit card. A fee of $50 will be charged if a check bounces and the full amount of the cost of the session will be included. *Please note if you are client through Psychiatric Alternatives & Wellness Center payment will be collected through their system. In addition to therapy appointments, I charge this same amount for other professional services you may need. I will prorate 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, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. If you become involved in legal proceedings that require my participation, you will be expected to pay for the professional time even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $150 per hour for preparation and record review. If I am deposed or called to testify in court, my fee is $300 per hour and a deposit of four hours of billing ($1,200) will be due prior to the start of my involvement in legal proceedings. Time that is billed will start when I arrive at court or in a law office and will end when I am done being deposed or my attendance at any legal proceeding is finished. If travel is required to any court proceedings, billing will start once I get in the car. Sliding scale: I do reserve some openings for reduced-fee patients. To receive these sliding scale fees, you must present proof of income through recent pay stubs or tax forms that substantiate financial hardship. Fees are subject to change at counselor’s discretion. Collections: If your account has not been paid for more than 30 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 release regarding a patient’s treatment is his/her name, the nature of services provided and the amount due. Insurance Reimbursement If you have a health insurance policy, it will usually provide some coverage for mental health treatment. With your permission, I will assist you to the extent possible in filing claims and ascertaining information about your coverage; 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 and to let me know if/when your coverage changes. In addition, if you plan to use your insurance, authorization from the insurance company may be required before they will cover psychotherapy fees. If you did not obtain authorization prior to our meeting(s) and it is required, you may be responsible for full payment of the fee. Many policies leave a percentage of the fee to be covered by the patient. Either amount is to be paid at the time of the visit by check or cash. In addition, some insurance companies also have a deductible, which is an out-of-pocket amount that must be paid by the patient before the insurance companies are willing to begin paying any amount for services. Out-of-network: If I am not a participating provider for your insurance plan, I will supply you with a receipt of payment for services, which you can submit to your insurance company for reimbursement. Please note that not all insurance companies reimburse for out-of-network providers. If you prefer to use a participating provider, I will refer you to a colleague. Please remember that you are ultimately responsible for payment. Fees you pay for therapy services that are not reimbursed by insurance may be deductible as medical expenses if you itemize deductions on your tax return. As described below in the section Health Insurance and Confidentiality of Records, be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Confidentiality The information disclosed by you in psychotherapy is generally confidential and will not be released to any third party without your written authorization, except when required or permitted by law. I will make every effort to keep your personal information private. Most of the provisions explaining when the law requires disclosure are described in the enclosed Notice of Privacy Practices. When Disclosure Is Required by Law Disclosure is required when there is a reasonable suspicion of child, dependent or elder abuse or neglect and when a client presents a danger to self, to others, to property, or is gravely disabled. If you participate in psychotherapy with me in compliance with a court order, I am required to release information to the relevant court, social service, or probation departments. When Disclosure May Be Required Disclosure may be required in a legal proceeding. For example, if you are involved in a legal proceeding initiated by you or filed against you, disclosure may be necessary. If you place your mental status at issue in litigation that you initiate, the defendant may have the right to obtain your psychotherapy records and/or your psychologist’s testimony. In couple or relationship therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. I will use our clinical judgment when revealing such information. If you have not paid your bill for treatment for a period of time, your name, payment record and last known address may be sent to a collection agency or small claims court. I will advise you in advance if I do so. In all cases including those described above, I will limit the release of information to the minimum possible and/or what is necessary by law Consultation I may occasionally find it helpful to consult other professionals about my clients but disguise identifying information when doing so. Please indicate to me if you wish to place restrictions on consultation, teaching, or writing related to your case. Health Insurance and Confidentiality of Records Your health insurance carrier may require disclosure of confidential information in order to process claims. Only the minimum necessary information will be communicated to your insurance carrier, including diagnosis, the date and length of our appointments, and what services were provided. Often the billing statement and your company's claim form are sufficient. Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases) that will become part of the insurance company files. While insurance companies claim to keep this information confidential, I have no control over the information once it leaves my office. Please be aware that submitting a mental health invoice for reimbursement carries some risk to confidentiality, privacy, or future eligibility to obtain health or life insurance. By signing this Agreement, you agree that I can provide requested information to your carrier if you plan to pay with insurance. Confidentiality and Technology There is always the possibility that unauthorized person may attempt to discover your personal information, particularly when we are communicating through e-mail, phone, fax, or using other electronic forms of communication. I will take every precaution to safeguard you information but I cannot guarantee that unauthorized access to electronic communications will not occur. Please be advised to take your own precautions when using technology to communication with me. Also, please do not contact me via email or faxes for emergencies. Email: I have your email address on file, though I will typically contact you by telephone as this helps assure a greater degree of confidentiality. In some cases I may contact you via email if I have difficulty reaching you by telephone, if I deem it more efficient to contact you via email related to non-clinical matters such as appointment time, or if you tell me that is your preferred contact method. You also have the right to refuse to provide your email address, or to decline using email as a form of contact between you and me. Record Keeping Records are kept to ensure a direction to your sessions and continuity in service. They will not be shared except with respect to the limits to confidentiality discussed in the Confidentiality section. Both California state law and the standards of my profession require that I keep treatment records for at least 7 years. Unless otherwise agreed to be necessary, I retain clinical records only as long as is mandated by California State law. If you have concerns regarding your treatment records, please discuss them with me. As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when I determine through my professional judgment that releasing such information might be harmful in some way. In such a case, I will provide the records to an appropriate and legitimate mental health professional of your choice. That said, upon your request and if it is appropriate, I will release information to any agency/individual you specify unless any of the above exclusions apply. As mentioned above, when more than one client is involved in treatment, I will release records only with signed authorizations from all the adults who can legally authorize a release. |