General Information for New Clients
This agreement has been designed to clearly outline the services and structure of the therapy I provide, as well as answer any initial questions you may have. Please read thoroughly and feel free to ask any questions pertaining to myself or the nature of this agreement. Please sign and return the signature page at the back and keep this packet for your files.
1. The therapy appointments consist of weekly meetings (unless otherwise negotiated), usually scheduled in the same weekly time slot, beginning on the hour and lasting for 45 minutes. It is advised that you arrive on time because the sessions end promptly at 10 minutes before the hour.
2. The fee is $145 for each session after, unless otherwise negotiated. It is preferred that payment be made in the beginning of each session, usually the time of the meeting that other business is addressed (ie. vacation announcements, insurance issues, insurance copays, etc.). I typically raise my fee every few years to stay on par with the cost of living
3. If in between meetings you need to reach me, I am available through my voice mail, email or text. I usually check my messages several times per day, less on the weekends, and try to return messages within 24 hours. In a life threatening emergency or if you need immediate attention, you can receive assistance by calling 911 or going to your local emergency room.
4. I am bound by the law to keep all that is discussed in these meetings in the strictest confidence. I am also bound to forgo confidentiality if an individual is at risk of doing lethal harm to oneself, someone else or if the courts subpoena my records. In addition, I am bound to report any incidence of neglect or abuse of children, the elderly or the disabled.
5. Please be aware that if you are using insurance I have to provide the insurance company with information about our meetings (frequency and diagnosis code). Diagnosis explains the reason for your visit (i.e. anxiety, depression, adjustment issues, ptsd, etc). You are welcome to know what I share with them.
6. I require at least 24 hours advance notice for cancellations, otherwise you will be charged a late cancellation fee of $100.00. If you are using insurance, be aware that I cannot bill them for a missed session, so you will be responsible for this fee. If cannot make an appointment, I am willing to offer an occasional phone session in place of the scheduled session. This can be useful during inclement weather. Please note that I cannot bill insurance for a phone session, so you would be charged the late fee rate.
7. I usually take a few weeks of vacation each year. You will be given at least 1 month notice about these. In my absence, a colleague will be available for a session should the need arise. I would also prefer at least 2 weeks notification when you are planning to take vacation.
8. I periodically consult with colleagues to assist me in my work, and to offer advice and ideas. It is with them that I may share some information about your personal situation, leaving out any details that would identify you specifically. Again this is done to uphold confidentiality.
9. At times in therapy, you may feel uncomfortable or experience difficult emotions. This is common as a part of the therapy process. I encourage you to ask questions or raise concerns, whether it be about the course of your therapy, fees, scheduling or anything else that may arise. I have found that clients gain the most from their treatment when they freely speak with me about their reactions and responses to our work.
revised 05/20
NOTICE OF PRIVACY PRACTICES (HIPAA)
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW TO GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
1. MY PLEDGE REGARDING MEDICAL INFORMATION
The privacy of your medical information is important to me. I understand that your medical information is personal and I am committed to protecting it. I create a record of the care and services you receive at my office. I need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways I may use and share medical information about you. I also describe your rights and certain duties I have regarding the use and disclosure of medical information.
2. MY LEGAL DUTY
Law Requires me to:
1. Keep your medical information private.
2. Give you this notice describing my legal duties, privacy practices, and your rights regarding your medical information.
3. Follow the terms of the notice that is now in effect.
I have the Right to:
1. Change our privacy practices and the terms of this notice at any time, provided that the changes are permitted by law.
2. Make the changes in our privacy practices and the new terms of our notice effective for all medical information that I keep, including information previously created or received before the changes.
Notice of Change to Privacy Practices:
1. Before I make an important change to my privacy practices, I will change this notice and make the new notice available upon request.
3. USE AND DISCLOSURE OF YOUR MEDICAL RECORDS
The following section describes different ways that I use and disclose medical information. Not every use or disclosure will be listed. However, I have listed all of the different ways I am permitted to use and disclose medical information. I will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by notifying me.
FOR TREATMENT: I may use medical information about you, to provide you with medical treatment or services. I may disclose medical information about you to doctors, nurses, technicians, medical students, or other people who are taking care of you. I may also share medical information about you with your other health care providers to assist them in treating you.
FOR PAYMENT: I may use and disclose your medical information for payment purposes.
FOR HEALTH CARE OPERATIONS: I may use and disclose your medical information for my health care operations. This might include measuring and improving quality, evaluating the performance of employees, conducting training programs, and getting the accreditation, certificates, licenses and credentials I need to serve you.
Victims of Abuse, Neglect or Domestic Violence: I may disclose medical information to appropriate authorities if I reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. I may share your medical information if it is necessary to prevent a serious threat to your health safety or the health or safety of others. I may share medical information when necessary to help law enforcement officials capture a person who has admitted to being part of a crime or has escaped from legal custody.
Workers Compensation: I may disclose health information when authorized and necessary to comply with laws related to workers compensation or other similar programs.
Health Oversight Activities: I may disclose medical information to an agency proving health oversight for oversight activities authorized by law, including audits, civil, administrative, or criminal investigations or proceedings, inspections, licensure or disciplinary actions, or other authorized activities.
Law Enforcement: Under certain circumstances, I may disclose health information to law enforcement officials. These circumstances include reporting required by certain laws (such as the reporting of certain types of wounds), pursuant to certain subpoenas or court orders, reporting limited information concerning identification and location at the request of a law enforcement official, reports regarding suspected victims of crimes at the request of a law enforcement official, reporting death, crimes on our premises, and crimes in emergencies.
4. YOUR INDIVIDUAL RIGHTS - You have the right to:
1. Look at or get copies of your medical information. You may request that I provide copies in a format other than photocopies. I will use the format you request unless it is not practical for me to do so. You must make your request in writing. If you request copies, I will charge you the average copy cost per page and postage if you want the copies mailed to you.
2. Receive a list of all the times I share your medical information for purposes other than treatment, payment and health care operations and other exceptions.
3. Request that I place additional restrictions on my use or disclosure of your medical information. I am not required to agree to these additional restrictions, but if I do, I will abide by our agreement (except in the case of an emergency).
4. Request that I communicate with you about your medical information by different means or to different locations. This request must be made in writing.
5. Request that I change your medical information. I may deny your request if I did not create the information you want changed or for certain other reasons. If I deny your request, I will provide you a written explanation. You may respond with a statement of disagreement that will be added to the information you wanted changed. If I accept your request to change the information, I will make reasonable efforts to tell others, including people you name, of the change and to include the changes in any future sharing of that information.
6. If you have received this notice electronically, and wish to receive a paper copy, you have the right to do so by making a request in writing to the above office.
QUESTIONS AND COMPLAINTS
If you have any questions about this notice or if you think that I may have violated your privacy rights, please contact me. You may also submit a written complaint to the U.S. Department of Health and Human Services. I will not retaliate in any way if you choose to file a complaint.
This agreement has been designed to clearly outline the services and structure of the therapy I provide, as well as answer any initial questions you may have. Please read thoroughly and feel free to ask any questions pertaining to myself or the nature of this agreement. Please sign and return the signature page at the back and keep this packet for your files.
1. The therapy appointments consist of weekly meetings (unless otherwise negotiated), usually scheduled in the same weekly time slot, beginning on the hour and lasting for 45 minutes. It is advised that you arrive on time because the sessions end promptly at 10 minutes before the hour.
2. The fee is $145 for each session after, unless otherwise negotiated. It is preferred that payment be made in the beginning of each session, usually the time of the meeting that other business is addressed (ie. vacation announcements, insurance issues, insurance copays, etc.). I typically raise my fee every few years to stay on par with the cost of living
3. If in between meetings you need to reach me, I am available through my voice mail, email or text. I usually check my messages several times per day, less on the weekends, and try to return messages within 24 hours. In a life threatening emergency or if you need immediate attention, you can receive assistance by calling 911 or going to your local emergency room.
4. I am bound by the law to keep all that is discussed in these meetings in the strictest confidence. I am also bound to forgo confidentiality if an individual is at risk of doing lethal harm to oneself, someone else or if the courts subpoena my records. In addition, I am bound to report any incidence of neglect or abuse of children, the elderly or the disabled.
5. Please be aware that if you are using insurance I have to provide the insurance company with information about our meetings (frequency and diagnosis code). Diagnosis explains the reason for your visit (i.e. anxiety, depression, adjustment issues, ptsd, etc). You are welcome to know what I share with them.
6. I require at least 24 hours advance notice for cancellations, otherwise you will be charged a late cancellation fee of $100.00. If you are using insurance, be aware that I cannot bill them for a missed session, so you will be responsible for this fee. If cannot make an appointment, I am willing to offer an occasional phone session in place of the scheduled session. This can be useful during inclement weather. Please note that I cannot bill insurance for a phone session, so you would be charged the late fee rate.
7. I usually take a few weeks of vacation each year. You will be given at least 1 month notice about these. In my absence, a colleague will be available for a session should the need arise. I would also prefer at least 2 weeks notification when you are planning to take vacation.
8. I periodically consult with colleagues to assist me in my work, and to offer advice and ideas. It is with them that I may share some information about your personal situation, leaving out any details that would identify you specifically. Again this is done to uphold confidentiality.
9. At times in therapy, you may feel uncomfortable or experience difficult emotions. This is common as a part of the therapy process. I encourage you to ask questions or raise concerns, whether it be about the course of your therapy, fees, scheduling or anything else that may arise. I have found that clients gain the most from their treatment when they freely speak with me about their reactions and responses to our work.
revised 05/20
NOTICE OF PRIVACY PRACTICES (HIPAA)
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW TO GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
1. MY PLEDGE REGARDING MEDICAL INFORMATION
The privacy of your medical information is important to me. I understand that your medical information is personal and I am committed to protecting it. I create a record of the care and services you receive at my office. I need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways I may use and share medical information about you. I also describe your rights and certain duties I have regarding the use and disclosure of medical information.
2. MY LEGAL DUTY
Law Requires me to:
1. Keep your medical information private.
2. Give you this notice describing my legal duties, privacy practices, and your rights regarding your medical information.
3. Follow the terms of the notice that is now in effect.
I have the Right to:
1. Change our privacy practices and the terms of this notice at any time, provided that the changes are permitted by law.
2. Make the changes in our privacy practices and the new terms of our notice effective for all medical information that I keep, including information previously created or received before the changes.
Notice of Change to Privacy Practices:
1. Before I make an important change to my privacy practices, I will change this notice and make the new notice available upon request.
3. USE AND DISCLOSURE OF YOUR MEDICAL RECORDS
The following section describes different ways that I use and disclose medical information. Not every use or disclosure will be listed. However, I have listed all of the different ways I am permitted to use and disclose medical information. I will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by notifying me.
FOR TREATMENT: I may use medical information about you, to provide you with medical treatment or services. I may disclose medical information about you to doctors, nurses, technicians, medical students, or other people who are taking care of you. I may also share medical information about you with your other health care providers to assist them in treating you.
FOR PAYMENT: I may use and disclose your medical information for payment purposes.
FOR HEALTH CARE OPERATIONS: I may use and disclose your medical information for my health care operations. This might include measuring and improving quality, evaluating the performance of employees, conducting training programs, and getting the accreditation, certificates, licenses and credentials I need to serve you.
Victims of Abuse, Neglect or Domestic Violence: I may disclose medical information to appropriate authorities if I reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. I may share your medical information if it is necessary to prevent a serious threat to your health safety or the health or safety of others. I may share medical information when necessary to help law enforcement officials capture a person who has admitted to being part of a crime or has escaped from legal custody.
Workers Compensation: I may disclose health information when authorized and necessary to comply with laws related to workers compensation or other similar programs.
Health Oversight Activities: I may disclose medical information to an agency proving health oversight for oversight activities authorized by law, including audits, civil, administrative, or criminal investigations or proceedings, inspections, licensure or disciplinary actions, or other authorized activities.
Law Enforcement: Under certain circumstances, I may disclose health information to law enforcement officials. These circumstances include reporting required by certain laws (such as the reporting of certain types of wounds), pursuant to certain subpoenas or court orders, reporting limited information concerning identification and location at the request of a law enforcement official, reports regarding suspected victims of crimes at the request of a law enforcement official, reporting death, crimes on our premises, and crimes in emergencies.
4. YOUR INDIVIDUAL RIGHTS - You have the right to:
1. Look at or get copies of your medical information. You may request that I provide copies in a format other than photocopies. I will use the format you request unless it is not practical for me to do so. You must make your request in writing. If you request copies, I will charge you the average copy cost per page and postage if you want the copies mailed to you.
2. Receive a list of all the times I share your medical information for purposes other than treatment, payment and health care operations and other exceptions.
3. Request that I place additional restrictions on my use or disclosure of your medical information. I am not required to agree to these additional restrictions, but if I do, I will abide by our agreement (except in the case of an emergency).
4. Request that I communicate with you about your medical information by different means or to different locations. This request must be made in writing.
5. Request that I change your medical information. I may deny your request if I did not create the information you want changed or for certain other reasons. If I deny your request, I will provide you a written explanation. You may respond with a statement of disagreement that will be added to the information you wanted changed. If I accept your request to change the information, I will make reasonable efforts to tell others, including people you name, of the change and to include the changes in any future sharing of that information.
6. If you have received this notice electronically, and wish to receive a paper copy, you have the right to do so by making a request in writing to the above office.
QUESTIONS AND COMPLAINTS
If you have any questions about this notice or if you think that I may have violated your privacy rights, please contact me. You may also submit a written complaint to the U.S. Department of Health and Human Services. I will not retaliate in any way if you choose to file a complaint.