This
document contains important information about our professional services and
business policies. Please read it carefully
and jot down any questions that you might have so that we can discuss them at
our next meeting. Once you sign this, it
will constitute a binding agreement between us.
Psychotherapy is not easily described in general
statements. It varies depending on the
personality of both the therapist and the patient and the particular problems
that the patient brings. There are a
number of different approaches that can be utilized to address the problems you
hope to address. It is not like visiting
a medical doctor, in that it requires a very active effort on your part. In order to be most successful, you will have
to work both during our sessions and at home.
Psychotherapy has both benefits and risks. Risks sometimes include experiencing
uncomfortable levels of feelings like sadness, guilt, anxiety, anger and
frustration, loneliness and helplessness.
Psychotherapy often requires recalling unpleasant aspects of your
history. Psychotherapy has also been
shown to have benefits for people who undertake it. It often leads to a significant reduction of
feelings of distress, and better relationships and resolutions of specific
problems. But there are no guarantees
about what will happen.
By the end of the evaluation, your therapist will be
able to offer you some initial impressions of what the work will include and an
initial treatment plan, if you decide to continue. You should evaluate this information along
with your own assessment about whether you feel comfortable working with your
selected therapist. 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 your therapist’s procedures, please feel free to discuss
them whenever they arise. If your doubts
persist, we will be happy to help you to secure an appropriate consultation
with another mental health professional.
Our
normal practice is to conduct an evaluation that will last from 2 to 4
sessions. During this time, you and your
therapist can decide together whether he/she is the best person to provide the
services that you need in order to meet your treatment objectives. If psychotherapy is initiated, we will
usually schedule one forty-five to fifty-minute session (one appointment hour
of 45-50 minutes duration) per week at a mutually agreed time, although
sometimes sessions will be longer or more frequent. Once this appointment hour is scheduled, you will be expected to pay
the full $125.00 fee, unless you provide 24 hours advance notice of
cancellation [or unless we both agree that you were unable to attend due to
circumstances beyond your control].
The regular hourly rate for psychotherapy services
is $125.00 however, for clients without insurance or who are experiencing
financial hardship, we may be willing to prorate our fee at your request,
according to a predetermined sliding scale. The fee is determined upon
completion of the SLIDING SCALE FEE AGREEMENT.
In addition to weekly appointments, it is our practice to charge this
amount on a prorated basis for other professional services you may require such
as report writing,
telephone conversations that
last longer than 5 minutes, attendance at meetings or
consultations with other professionals which you have authorized, preparation
of records or treatment summaries or the time required to perform any other service
that you may request of your therapist.
In unusual circumstances, you may become involved in a litigation that
may require your therapist’s participation.
You will be expected to pay for the professional time even if your
therapist is compelled 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.
Payment schedules for other professional services will be agreed to at
the time these services are requested.
If you did not pay at the time of service and your
account is more than 60 days in arrears, a service charge of 1.5% of the
balance per month will be charged to your account. If your account is more than 60 days past due
and suitable arrangements for payment have not been agreed to, we have the
option of using legal means to secure payment, including collection agencies or
small claims court. If such legal action
is necessary, the costs of bringing that proceeding will be included in the
claim. In most cases, the only
information that is release about a client’s treatment would be the client’s
name, the nature of the services provided, and the amount due.
If
your therapist is an in-network provider with your mental health insurance
carrier, our office will submit claims for payment on your behalf. You are responsible for any co-payments,
co-insurance, and deductibles required by your health plan.
If
your therapist is not an in-network provider with your mental health insurance
carrier, our office will assist you by completing our portion of a claim
form. You are responsible for completing
your portion as well as mailing it to the insurance company and tracking your
reimbursement. We do not accept
assignment of benefits from insurance carriers whose panels we are not
affiliated with. Your therapist will
gladly discuss your proposed treatment with your insurance company if they call us and you provide us with
a signed release. We will not call to request authorizations. You are responsible for the full $125 fee
regardless of your insurance company’s reimbursement policies.
Your therapist is often not immediately available by
telephone. Anytime you need to speak to
your therapist, you may call our main line at 713-533-9811. During business hours you may either leave a
message with our office manager, or you may leave a voicemail message. If you call outside of business hours, you
will be able to leave a confidential voicemail message for your therapist. Listen carefully to the message to ensure you
are selecting the correct voicemail box for your therapist. Please note that non- emergency messages will
be returned the next business day, and urgent messages will result in your
therapist being paged. If you cannot
reach your therapist, and you feel that you cannot wait for your call to be
returned, you should call your family physician or the emergency room at the
nearest hospital and ask for the psychologist or psychiatrist on call. If your therapist will be unavailable for an
extended time, he/she will provide you with the name of a trusted colleague
whom you may contact if necessary.
Both law and the standards of this profession
require that we keep appropriate treatment records. You are entitled to receive a copy of the
records at our discretion, but if you wish, your therapist can prepare an
appropriate summary. Because these are
professional records, they can be misinterpreted and/or can be upsetting. If you wish to see your records, we recommend
that you review them in your therapist’s presence so that you may discuss what
they contain. Clients will be charged an
appropriate fee for any preparation time required to comply with an information
request.
If you are under eighteen years of age, please be
aware that the law may provide your parents with the right to examine your
treatment records. It is our policy to
request an agreement from parents that they consent to give up access to your
records. If they agree, your therapist
will provide them only with general information on how your treatment is
proceeding unless he/she feels that there is a high risk that you will
seriously harm yourself or another, in which case, your parents will be
notified. Your parents will also be
provided a summary of your treatment when it is complete. Before giving them any information, your
therapist will discuss the matter with you and will do the best he/she can to
resolve any objections you may have about what has been prepared to discuss.
In general, the confidentiality of all
communications between a client and a licensed professional counselor is
protected by law, and your therapist can only release information about your
work to others with your written permission.
However, there are a number of exceptions.
In some judicial proceedings, you may have the right
to prevent information about your treatment being provided. However, in some circumstances, such as child
custody proceedings and proceedings in which your emotional condition is an
important element, a judge may require the testimony of your therapist if
he/she determines that resolution of the issues before him/her demands it.
There are some situations in which your therapist
would be legally required to take action to protect others from harm, even
though that requires revealing some information about a client’s treatment:
Should such situations occur, your therapist would
make every effort to fully discuss it with you before taking any action.
Your therapist may occasionally find it helpful to consult about a case with other professionals. In these consultations, he/she will make every effort to avoid revealing the identity of his/her client. The consultant is, of course, also legally bound to keep the information confidential. Unless you object, your therapist will not tell you about these consultations unless he/she feels that it is important to your work together.
While this written summary of exceptions to
confidentiality should prove helpful in informing you about potential problems,
it is important that you discuss any questions or concerns that you may have
with your therapist at your next meeting.
As you might suspect, the laws governing these issues are quite complex
and your therapist is not an attorney.
While he/she will be happy to discuss these issues with you, should you
need specific advice, formal legal consultation may be desirable. If you request, your therapist will provide
you with relevant portions or summaries of the applicable state laws governing
these issues.
_____________________________________________________________________________________
Client Name(s)
I,
______________________________________, have read and agree to the conditions
of this contract.
(Print full name(s). If client is a minor, name of parent or legal
guardian. For couples/family counseling,
names of all individuals.)
____________________________________________ _______________________________
Signature (If
client is a minor, signature of parent or legal guardian) Date
____________________________________________ _______________________________
Signature (For
couples/family counseling, signatures of all individuals.) Date
Check
one of the following statements:
____I am covered by mental health
insurance for which my selected therapist is an in-network provider. I understand that he/she will seek
reimbursement from my mental health insurance carrier and will track reimbursement. I hereby authorize the release of any
information necessary to process health insurance claims and assign payment of
such benefits to my selected therapist.
____I am covered by mental health
insurance for which my selected therapist is an out-of-network provider, will
be seeking reimbursement for services, and am requesting services at the
regular hourly rate. I understand that
my therapist or his/her office manager will complete the provider’s portion of
a health insurance claim form at least once every four visits and at my request
and will provide such form to me. If for
any reason I have not paid in full for services received, I hereby authorize
the release of any information necessary to process the necessary health
insurance claim and assign payment of such benefits to my selected
therapist.
____I
do not have insurance covering mental health treatment.
HOURLY RATE $ 125.00
I, _______________________________________,
understand that the hourly rate for psychotherapy services is $125.00. I agree to pay the above hourly rate for any
professional services performed (as outlined under PROFESSIONAL FEES on page 1
of the Client Services Contract) during the course of my treatment. If I have mental health insurance that will
cover my sessions, I agree to pay my portion of the expense as dictated by my
insurance policy and by the explanations of plan benefits.
_______________________________________ ________________________________
Client Signature (if minor, parent or legal guardian) Date