Client Information and Office Policy Statement
Thank you for choosing me as your treatment provider. This is an opportunity to acquaint you with information relevant to treatment, confidentiality and office policies. I will answer any questions you have regarding any of these policies.
II. Aims and Goals:
The major goal is to help. you or your child identify and cope more effectively with problems in daily living and to deal with inner conflicts which may disrupt your ability to function effectively.
This purpose is accomplished by:
1. Increasing personal awareness.
2. Increasing personal responsibility and acceptance to make changes necessary to attain your goals.
3. Identifying personal treatment goals.
4. Promoting wholeness through psychiatric treatment and/ or psychological and spiritual healing and growth.
You are responsible for providing necessary information to facilitate effective treatment.
You are expected to play an active role in your treatment, including working with me to outline your treatment goals and assess your progress. You may be asked to complete questionnaires or to do homework assignments. Your progress in therapy often depends much more on what you do between sessions than on what happens in the session.
Appointments are usually scheduled for 45-90 minutes Patients are generally seen weekly or more/less frequently as acuity dictates and we agree. You may discontinue treatment at any time. In the event of an emergency. please call the Behavioral Health Center 704 358 2700 go to the ER. In the event of a life threatening emergency dial 911.
Issues discussed in therapy are important and are generally legally protected as both confidential and "privileged." However. There are limits to the privilege.
These situations include:
1. Suspected abuse or neglect of a child, elderly person or disabled person.
2. When I believes you are in danger of harming yourself or another person or you are unable to care for yourself.
3. If you report that you intend to physically injure someone the law requires your therapist to inform that person as well as legal authorities.
4. If I am is ordered by a court to release information as part of a legal involvement in litigation. (company litigation.etc).
5. When your insurance company is involved,(e.g. in filing a claim, insurance audits. case review or appeals, etc.)
6. In natural disasters whereby protected records may become exposed.
7. When otherwise required by law. You may be asked to sign a Release of Information so that I may speak with other mental health professionals or family members.
V. Record Keeping:
A clinical chart is maintained describing your condition and your treatment and progress in treatment, dates of, fees for sessions, notes describing each therapy session and miscellaneous information. Your records will not be released without your written consent, unless in those situations as outlined in the confidentiality section above.
Medical Records are locked and kept on site.
Private Fees for a 50 minute session are 95 dollars. Longer sessions vary depending on the time spent I may make arrangements with you to charge you at a lower rate or a sliding fee if you do not have any insurance.
Payment is due prior to the session unless other arrangements have been made in writing. You are responsible for deductibles, co-insurance, and co-payments. All of this will vary depending on the nature of my relationship with your insurance company, and the quality of the insurance that you have. If I am a member provider of your insurance company, the fees above do not apply. Each insurance company sets a different fee schedule.
VIII. Cancellations and Missed Appointments:
You will be billed 90.00 dollars for sessions not canceled with 24 hour notice accept in the event of an emergency. Insurance companies do not reimburse for failed appointments. Additionally I may terminate our relationship or give away your spot if you miss an appointment without 24 hours notice.
You have a right to have your complaints heard and resolved in a timely manner. If you have a complaint about your treatment, policy please inform me immediately and discuss the situation. If you do not feel the complaint has been resolved, you may also inform your insurance carrier and file a complaint if you so choose.
X. Consent for Treatment
By signing below, you are stating that you have read and understood this 3-page statement and you have had your questions answered to your satisfaction. In addition, you are confirming that you received the HIPPA overview brochure.
I accept, understand and agree to abide by the contents and terms of this agreement and further, consent to participate in evaluation and for treatment. I understand that I may withdraw from treatment at any time.
Signature X__________________________ Date_______________________________________