INFORMED CONSENT AGREEMENT
Welcome to my practice. This document contains important information about professional services
and business policies offered. 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.
PSYCHOLOGICAL SERVICES
Psychotherapy is not easily described in general statements. It varies depending on the personalities
of the psychologist and client, and 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. 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.
Initial 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. 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. If you have questions about my procedures, we should discuss them whenever they arise.
MEETINGS
The Initial consultation and evaluation requires 2 to 4 sessions. During this time, we can decide if I
am the best person to provide the services you need, in order to meet your treatment goals. If
psychotherapy is begun, we will meet for one 45-minute or 60-minute session per week.
PROFESSIONAL FEES
If services are provided locally the fee structure is as follows: $200.00 for a 45-minute individual therapy session, $250.00
for a 60-minute marital/family session, $275 for 90 minute individual session and $70.00 for 90-minute group session. In addition to weekly appointments,
the hourly fee of $175.00 is charged for all other professional services, such as report writing,
telephone consultation, attendance at meetings with other professionals you have authorized, and
preparation of records or treatment summaries. The fee for legal procedures is $275 per hour for
preparation and attendance at any legal proceedings. Other more specialized services such as forensic consultation and risk assessments are priced based on services rendered. Organizational consultations are priced based in extent and depth of services provided.
Distance consultations are based on services rendered and determined at
the time
BILLING AND PAYMENT
Our office has a pay up front policy. All clients pay at the time services are rendered. At the end
of every month, you will receive a claim with all procedural codes to submit to your insurance
company. Once an appointment hour is scheduled, you are expected to pay for it unless you
provide 24 hours advance notice of cancellation. With 24 hour notice, there is opportunity to
reschedule as our schedules permit.
If your account has not been paid for more than 90 days and arrangements for payment have not
been agreed upon, legal measures are taken to secure payment. This may involve an attorney or a
collection agency. In most collection situations, the only information released is a client’s name, the
nature of services provided, and the amount due. All accounts 90 days past due will be subject to late
fees and all costs of collections.
*All accounts 30 days past due are subject to 1.5% interest fees.
INSURANCE
If you have a health insurance policy, it will usually provide some coverage for mental health
treatment. It is very important to find out exactly what mental health services your insurance policy
covers, i.e. number of sessions allowed yearly for individual and for family. Please carefully read the
section in your insurance coverage booklet that describes mental health services. If you have
questions about coverage, call your plan administrator.
Be aware that insurance companies require you to authorize me to provide them with a clinical
diagnosis. Occasionally, I have to provide additional information such as treatment plans or
summaries. This information will become part of the company files and will probably be stored in a
computer.
CONFIDENTIALITY
In general, law protects the privacy of all communications
between a patient and a psychologist, and I can only release information about
our work to others with your written permission. There are a few exceptions. 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 client’s treatment.
For example, if I believe that a child is being abused, I must file a report
with the appropriate state agency. If I believe that a client is threatening
serious bodily harm to himself or herself or to another, I am required to take
protective actions. These actions may include notifying the potential victim,
contacting family members to provide help, contacting the police, or seeking
hospitalization for the client. At times, our practice employs an office
assistant or manager who oversees the entire business aspect of our practice.
She has a great deal of experience in dealing appropriately with confidential
materials, such as case files, doctor’s notes, telephone messages, and other
information. It is important that we discuss any questions or concerns that you
may have at our next meeting. Your signature below indicates that you have read
the information in this document and agree to abide by its terms during our
professional relationship.
Signature of Patient Date _____________________________________
Signature of Provider Date
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