CLIENT SERVICES AGREEMENT
Effective October 1, 2015
Welcome to my practice. This document contains important information about my professional services and business policies. Although this document is long and sometimes complex, it is very important that you read it carefully before our next session. We can discuss any questions you have about our procedures at that time. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have taken action in reliance on it; if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you are experiencing. There are many different methods I may use to help you reach the goals you have set for our work. Psychotherapy calls for an active effort on your part both during our sessions and in your daily life.
Psychotherapy can have benefits and risks. Since therapy often involves discussing difficult 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. However, there are no guarantees of what you will experience.
Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, 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. 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. Therapy involves a large commitment of time, money, and energy. It is important that you feel you can work effectively with the therapist you select. Once psychotherapy begins, I will usually schedule one 45 or 60-minute session (one appointment hour of 45-60 minutes duration) per week at a time we agree on, although the duration and frequency of sessions may vary. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation. 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.
If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to provide names of other therapists.
We conduct formal assessments of many different types, including Psychological, Psycho-Educational, and Neuropsychological evaluations. While the specific goals for the evaluations are set by the client or the client's representative(s), the general goal is to gather information about strengths and weaknesses in intellectual, cognitive, academic, and social/emotional functioning and then to apply that knowledge to better understand the challenges and obstacles faced by the client. Our assessments usually begin with an intake appointment to gather developmental and family history, as well as information about current functioning to best tailor the focus of the evaluation. The client then meets with the evaluator for 8 to 12 hours, divided into sessions of a developmentally appropriate length. We strongly recommend that sessions for school-aged children be conducted in the mornings, when they are likely to have the most energy and ability to focus. After the evaluator has scored and considered the test results, an interpretive session is arranged to discuss them and to make recommendations. When children are assessed, the interpretive session occurs with their parents or guardian. We encourage a separate, brief session with the child, so that they learn about the results in general, broad terms, and understand the recommendations that have been made to their parents and teachers. Following the interpretive session and full payment of the assessment fee, a comprehensive report of the evaluation is prepared.
My fees for evaluations and for therapy sessions of different lengths of time are listed on the back of the Information Form, which you will be asked to complete and sign. In addition, I charge 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 billable services include letter writing, telephone conversations, email time, consulting with other professionals and insurance companies 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. Because of the difficulty of legal involvement, I charge per hour for preparation and transportation. In-court time is double my regular fee.
Due to my work schedule, I am often not immediately available by telephone. Even when I am in my office, I probably will not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by voice mail. I will try to return your call, particularly if urgent, within one business day. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and feel that you can't wait for me to return your call, contact your family physician or the nearest hospital emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact if necessary.
If you would like to contact me by email or text, you will be asked to sign permission for electronic communication. We ask that you do so because email is less secure than voice mail and, while we strive to protect your communications, we cannot guarantee that they will be kept private.
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. This Authorization will remain in effect for a length of time you determine. You may revoke the Authorization at any time, unless I have taken action in reliance on it. However, there are some disclosures that do not require your Authorization, as follows:
- You should be aware that I practice with other mental health professionals and that I employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member.
- I also have contracts with businesses such as bookkeepers, accountants and computer These businesses agree to maintain the confidentiality of data except as specifically allowed in the contract or otherwise required by law.
- 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 provide any information without your (or your legal representative's) 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.
- If a government agency is requesting the information for health oversight activities, I may be required to provide it for them.
- If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.
- If a patient files a worker's compensation claim, I must, upon appropriate request, provide a copy of the patient's record to the D.C. Office of Hearings and Adjudications, the patient's employer or insurer.
There are some situations in which I am legally obligated to take actions, because I believe these actions are necessary to protect others from harm. In this process, I may have to reveal some information about a patient's treatment. These situations are unusual in my practice. If such a situation arises, I will make every effort to discuss it fully with you before taking any action and I will limit my disclosure to what is necessary.
- If I know or have reason to suspect that a child has been or is in immediate danger of being mentally or physically abused or neglected, the law requires that I file a report with the appropriate governmental agency, usually the Child Protective Services Division of the Department of Human Services. Once such a report is filed, I may be required to provide additional information.
- If I have substantial cause to believe that an adult patient is in need of protective services because of abuse, neglect or exploitation by someone, the law requires that I file a report with the appropriate governmental agency, usually the Department of Human Services. Once such a report is filed, I may be required to provide additional
- In an emergency, if I believe that a patient presents a substantial risk of imminent and serious injury to him/herself, I may be required to take protective actions, including notifying individuals who can protect the patient or initiating emergency
- If I believe that a patient presents a substantial risk of imminent and serious injury to another individual, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient.
In all other situations, I will ask you for an advance Authorization before disclosing any information about you. 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.
You should be aware that I keep information about you and our sessions. 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, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve a substantial risk of imminent psychological impairment or imminent serious physical danger to yourself and others, 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 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, postage, and handling fee. If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon request.
In addition, I may also keep a separate set of psychotherapy notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of psychotherapy notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they affect your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record and they also include information from others provided to me confidentially. These psychotherapy notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your Authorization as a condition of coverage or penalize you in any way for your refusal to provide it.
In testing, the report is the clinical record. The report summarizes the client's background
information, lists and describes the test results, and provides our conclusions and recommendations. We cannot release raw data or test protocols because of copyright laws and the confidentiality of test materials.
MINORS & PARENTS
Psychologists can provide psychotherapy to minors age 14 and above without parental consent if the psychologist determines that the minor is knowingly and voluntarily seeking the services and that provision of the services is clinically indicated for the minor's well being. These services can be provided for only 90 days, but can be continued if the psychologist redetermines that the services are still clinically indicated. Parents do not have access to records of this treatment. Patients under 18 years of age but who are over 14 and who are not emancipated and whose parents have consented to treatment should be aware that parents can review their records only with the written authorization of the patient. Children under 14, whose parents have consented to the treatment, should be aware that their parents can examine their treatment records unless I decide that such access is likely to injure the child, or we all agree otherwise. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, and because it is important for parents to have some information about their child's treatment, it is usually my policy to request an agreement of both the parents and child about what information parents will receive about their child's treatment. During treatment, I will provide parents only with general information about the progress of the child's treatment and/or his/her attendance at scheduled sessions. When requested, 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.
BILLING AND PAYMENTS
You will be billed for psychotherapy monthly and are expected to pay your bill by the 15th of the month following the month of service. For assessment, one half (50%) of the estimated testing fee is due on the first day of testing. The balance is due on the day of the interpretive conference unless other arrangements have been made. 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 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 patient's treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs can be included in the claim.
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 the necessary billing documentation for you to present to your insurance company to help you receive the benefits to which you are entitled. However, you (not your insurance company) are responsible for full payment of my fees, and we are not Preferred Providers for any insurance plan. It is very important that you find out exactly what mental health services your insurance policy covers. I will ask you to fill out an authorization so that I can provide information to your insurance company or HMO that will allow me to provide the information necessary to secure payment for the services I provide for you. This Authorization will be in effect for one year, but can be revoked at any time. However, if revoked, I will continue to have the right to forward information necessary to process claims for services already provided. It is important that the insurance company pays you and you then pay us. We will not accept payment from insurance companies.
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. It is sometimes difficult to determine exactly how much mental health coverage is available. "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 patients feel that they need more services after insurance benefits end.
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. Under the laws of the District of Columbia, the information that I can provide is limited to diagnostic information, including a treatment plan, the reasons for continuing treatment and the prognosis of how long the treatment will need to continue. If the insurance company determines that more information is necessary, the insurance company must appoint an independent reviewer and the additional information can only be disclosed to the reviewer. You should also be aware that some self-insured employee benefit plans are not subject to this law. 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.
Your signature on our intake form indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.