Practice Policies and HIPAA Information

Client Information Form

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Information for Clients
Updated 2/6/19


Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us.

What is psychotherapy?

Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, 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.

What are the benefits and risks of psychotherapy?

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 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 no guarantees of what you will experience.

How do we get started?

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. 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. I normally conduct an evaluation that will last from 2 to 4 sessions. 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.

What if I have questions about my procedures?

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, or to provide you with a referral to another therapist who may be a better fit for you.

Information About Sessions

How frequently do we meet, and for how long?

I usually schedule one 45-50-minute session per week at a time we agree on, although we may agree to have longer or shorter sessions and to meet more or less frequently. I am available on weekdays and some evenings. I do not have any weekend appointments.

Can we have sessions via telephone or video-conference?

Although it is optimal for therapy to take place face-to-face in my office, at times, it may be appropriate to have sessions using telephone or video-conference. However, note that phone sessions are not usually covered by insurance, and video sessions, if covered, may be reimbursed at lower rates.

Communication with Me

How do I communicate with you?

I can be contacted via phone or via email. I am usually not immediately available by telephone or able to respond immediately to email. When I am unavailable, my telephone is answered by my voicemail, which I monitor frequently. Messages left on my voicemail are confidential and private. If it is urgent, you can send an email, but please also leave a phone message.

Please note that any communication via email is not secure and your privacy may not be protected. Please let me know if you prefer that I not communicate with you via email of if I limit email communication to scheduling, billing, and/or other issues. I will reply to email within 48 hours to the best of my ability. Email is not an appropriate means for communication regarding therapeutic issues that are best discussed during sessions.

I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of times when you will be available. In emergencies, 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 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.

What if I am in a crisis or have an emergency need for help?

If you need immediate assistance, you should call 911 or go to the Urgent Care Center of your local hospital.

Consultation with Other Clinicians

When and why would I want to communicate with other clinicians?

You may decide to give me permission to consult with other clinicians whom you meet with individually (e.g.,a psychiatrist, internist, etc.), to your couple’s therapist, and/or to your spouse’s individual therapist.

Each clinician has unique knowledge and perspective. In sharing information the practitioners who help you can learn from one another so as to be better able to support you in your healing and growth. We can also clarify if we may be giving you different guidance that might create confusion. When that occurs, we can discuss these differences and work to develop a more integrated plan to help you.

When and why would it not be advisable for me to speak with other clinicians?

You need to know that anything you share with me is private and confidential. If there is some information that you need to keep private, you may ask me not to share those details, or you may need me not to communicate with those practitioners.

Do I need to give you permission to speak with other clinicians?

For me to speak with other clinicians, you will need to give me written permission. Without that written permission, I am not permitted – legally or ethically – to discuss my work with you. You can access the Authorization for Release of Information Form.

What will be the fee for your time in consulting with other clinicians?

I do not charge for brief consultation with other clinicians, up to 5 minutes in length. For longer consultations, I charge based on my hourly fee of $270/hour.

Fees and Insurance

What are your fees for sessions?

The fee for a 45-50 minute session is $225. Longer/shorter sessions are pro-rated proportionally. Please let me know if you want to limit sessions to 45-50 minutes.

What is your cancellation policy?

If you need to cancel an appointment, please let me know as soon as possible. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide a minimum of 48 hours advance notice of cancellation, unless I am able to reschedule the time.

How do I make a payment?

You are responsible for payment of fees at the time of each session. I accept all credit cards except American Express. You can also make payment via Venmo. You will be expected to pay for each session at the time it is held, unless we agree to a different plan. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment.

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. If such legal action is necessary, its costs will be included in the claim. 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.

What are your fees for other services - correspondence, consultation with other clinicians, reports?

I charge an hourly fee of $270/hour for other professional services you may need. 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 5 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 become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $350 per hour for preparation and attendance at any legal proceeding.

Can I use my health insurance?

If you have a health insurance policy, you may be able to get reimbursement for the costs of therapy if you have coverage for out-of-network, outpatient 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 responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers.

I do not participate in any managed care networks and am not a Medicare or MassHealth provider. You are unlikely to be able to obtain reimbursement for my services if you are limited to meeting with providers in your insurance network. There are some circumstances in which insurors do pay for treatment with an out-of-network provider when there is no qualified provider in the network. In doing so, you will need to make a special request to your insuror. If you are interested in pursuing this possibility, I will be glad to discuss the process of applying for authorization for out-of-network treatment, help clarify if that is an option for you, and work with you to complete this process.

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. 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 healthcare, 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 a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end.

If you need to have a provider who is covered by your insurance, I will help you find a referral to an appropriate clinician who participates in your insurance network.

You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). 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.

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 our sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above.

Will my insurance reimburse me for telephone & video sessions?
Insurors do not generally reimburse for phone sessions. Reimbursement policies for video sessions vary with different insurance companies and policies. Refer to the Teletherapy Guide for Clients for more information. Check with your insuror to clarify reimbursement policies and any special procedures that need to be followed to obtain reimbursement.
What records do you keep? And can I have access to my records?

The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of your records, or I can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents. Patients will be charged an appropriate fee for any professional time spent in responding to information requests.

If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from parents that they agree to give up access to your records. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. I will also provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss.


Is my communication with you confidential?

In general, the privacy of all communication between a patient and a psychologist is protected by law, and I can only release information about our work to others with your written permission. If I am meeting with a couple, I will not release any information without prior permission from both partners, unless required to do so legally.

What are the limits to confidentiality?
In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it.

There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a patient’s treatment. For example, if I believe that a child, elderly person, or disabled person is being abused, I may be required to file a report with the appropriate state agency.

If I believe that a patient is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If the patient 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.

These situations have rarely occurred in my practice. If a similar situation occurs, I will make every effort to fully discuss it with you before taking any action.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems. If you have questions about the limits of confidentiality, it is important that you discuss with me any concerns you have prior to sharing potentially sensitive information. I will be happy to discuss these issues with you if you need specific advice, but formal legal advice may be needed because the laws governing confidentiality are quite complex, and I am not an attorney.

I may occasionally find it helpful to consult other professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The consultant is 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.

For more detailed information about confidentiality and limits to confidentiality, refer to Notice of Policies and Practices to Protect the Privacy of Your Health Information.

What are your policies regarding the privacy of couples?

Please read my No Secrets Policy for Couples and Families for more information regarding couples’ privacy.