OFFICE POLICIES AND GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICES

This form provides you (patient) with information that is additional to that detailed in the notice of privacy practices and it is subject to HIPAA preemptive analysis.

Confidentiality

All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client’s) written permission, except where disclosure is required by law. Most of the provisions explaining when the law requires disclosure were described to you in the notice of privacy practices that you received with this form.

When disclosure is required by law

Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent, or elder abuse or neglect; and where a client presents a danger to self, to others, to property, or is gravely disabled (for more details see also notice of privacy practices form).

When disclosure may be required

Disclosure may be required pursuant to a legal proceeding. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by insert name of psychotherapist. In couple and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. The psychotherapist will use clinical judgment when revealing such information. The psychotherapist will not release records to any outside party unless so authorized to do so by all adult family members who were part of the treatment.

Emergencies

If there is an emergency during our work together, or in the future after termination, where the psychotherapist becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, she will do whatever she can within the limits of the law to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, s/he may also contact the police, hospital, or the person whose name you have provided on the biographical sheet.

Health Insurance and Confidentiality of Records

Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. If you so instruct the psychotherapist only the minimum necessary information will be communicated to the carrier. Unless authorized by you explicitly, the psychotherapy notes will not be disclosed to your insurance carrier. The psychotherapist has no control or knowledge over what insurance companies do with the information s/he submits or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy, or to future eligibility to obtain health or life insurance. The risk stems from the fact that mental health information is entered into insurance companies’ computers and soon will also be reported to the Congress-approved National Medical Data Bank. Accessibility to companies’ computers or to the National Medical Data Bank database is always in question, as computers are inherently vulnerable to break-ins and unauthorized access. Medical data have been reported to have been sold, stolen, or accessed by enforcement agencies; therefore, you are in a vulnerable position.

Confidentiality of e-mail, cell phone, and fax communication

It is very important to be aware that e-mail and cell phone (also cordless phones) communication can be relatively easily accessed by unauthorized people and, hence, the privacy and confidentiality of such communication can be easily compromised. E-mails, in particular, are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e-mails that go through them. Faxes can be sent erroneously to the wrong address. Please notify the psychotherapist at the beginning of treatment if you decide to avoid or limit in any way the use of any or all of the abovementioned communication devices. Please do not use e-mail or faxes in emergency situations.

Litigation Limitation

Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters that may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to, divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) nor your attorney, nor anyone else acting on your behalf will call on the psychotherapist to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.

Consultation

The psychotherapist consults regularly with other professionals regarding her clients; however, the client’s name or other identifying information is never mentioned. The client’s identity remains completely anonymous, and confidentiality is fully maintained. Considering all of the above exclusions, if it is still appropriate, upon your request, the psychotherapist will release information to any agency/person you specify unless the psychotherapist concludes that releasing such information might be harmful in any way.

Telephone and emergency procedures

If you need to contact the psychotherapist between sessions, please leave a message on the answering machine (813) 360-0949 and your call will be returned as soon as possible. The psychotherapist checks her messages a few times a day (but never during the nighttime), unless she is out of town. The psychotherapist checks the messages less frequently on weekends and holidays. If an emergency situation arises, please indicate it clearly in your message. If you need to talk to someone right away, you can call the 24-hour crisis line (988) or the Police (911).

Payments and insurance reimbursement

Clients are expected to pay the standard fee of $120 per 53 - minute session at the end of each session unless other arrangements have been made. Telephone conversations, site visits, report writing and reading, consultation with other professionals, release of information, reading records, longer sessions, travel time, and so forth, will be charged at the same rate, unless indicated and agreed otherwise. Please notify the psychotherapist if any problem arises during the course of therapy regarding your ability to make timely payments. Not all issues/conditions/problems that are the focus of psychotherapy are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage. A regular credit card will be taken over the phone before the first therapy session. 50% of the no show fee will be charged to the credit card to hold the first appointment or use towards a future missed session. If no session is missed, you will receive a full reimbursement for the amount held.

The process of therapy/evaluation

Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. The psychotherapist will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in your experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, and so forth, or experiencing anxiety, depression, insomnia, and so forth. The psychotherapist may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, the psychotherapist is likely to draw on various psychological approaches according, in part, to the problem that is being treated and his/her assessment of what will best benefit you. These approaches include behavioral, cognitive-behavioral, psychodynamic, existential, system/family, developmental (adult, child, family), or psychoeducational.

Discussion of treatment plan

Within a reasonable period of time after the initiation of treatment, the psychotherapist will discuss with you (client) her working understanding of the problem, treatment plan, therapeutic objectives, and view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, the psychotherapist’s expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits. If you could benefit from any treatment that the psychotherapist does not provide, he has an ethical obligation to assist you in obtaining those treatments.

Termination

As set forth above, after the first couple of meetings, the psychotherapist will assess if she can be of benefit to you. The psychotherapist does not accept clients who, in her opinion, she cannot provide the needed service to. In such a case, she will give you a number of providers that you can contact. If at any point during psychotherapy, the psychotherapist assesses that she is not effective in helping you reach the therapeutic goals, she is obliged to discuss it with you and, if appropriate, to terminate treatment. In such a case, she would give you a number of providers that may be of help to you. If you request it and authorize it in writing, the psychotherapist will talk to the psychotherapist of your choice in order to help with the transition. If at any time you want another professional’s opinion or wish to consult with another therapist, the psychotherapist will assist you in finding someone qualified, and, if she has your written consent, she will provide her or him with the essential information needed. You have the right to terminate therapy at any time. If you choose to do so, the psychotherapist will offer to provide you with names of other qualified professionals whose services you might prefer. Dual relationships Not all dual relationships are unethical or avoidable. Therapy never involves sexual or any other dual relationship that impairs the psychotherapist’s objectivity, clinical judgment, or therapeutic effectiveness or can be exploitative in nature. the psychotherapist will assess carefully before entering into nonsexual and non-exploitative dual relationships with clients. The psychotherapist will never acknowledge working therapeutically with anyone without her written permission. Additionally, the psychotherapist will discuss with you, her client(s), the often-existing complexities, potential benefits, and difficulties that may be involved in such relationships. Dual or multiple relationships can enhance therapeutic effectiveness but can also detract from it and often it is impossible to know that ahead of time. It is your, the client’s, responsibility to communicate to the psychotherapist if the dual relationship becomes uncomfortable for you in any way. The psychotherapist will always listen carefully and respond accordingly to your feedback. The psychotherapist will discontinue the dual relationship if she finds it interfering with the effectiveness of the therapeutic process or the welfare of the client and, of course, you can do the same at any time.

Cancellation

Since scheduling of an appointment involves the reservation of time specifically for you, a minimum of 23.5 hour (1 day and a half) notice is required for rescheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification. Most insurance companies do not reimburse for missed sessions. A regular credit card number will be taken over the phone before the first session to hold the initial appointment and 50% of the no show fee will be deducted if you do not arrive. The same credit card will be used for future no shows or late cancellations. Video Surveillance I acknowledge that the facility, United Hands Counseling & Consulting, uses video surveillance in common areas as part of its quality assessment and improvement of activities and health care operations as defined by 45 CFR 164.501 and 164.506. I acknowledge and consent to the video recording, with the understanding that the images from such recording may be used only for facility health care operations and will not be disclosed except as required or permitted by law.

OFFICE POLICIES AND GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICES

I have read the above agreement and office policies and general information carefully. I understand them and agree to comply with them: