Outpatient Services Contract
Welcome to our Practice! Our contract contains important information about our professional services and business policies.
InMindOut Emotional Wellness Center offers the following services Consultations, Individual Therapy, Couples Therapy, Family Therapy, Group Therapy, Youth Therapy, Cognitive Behavioral Therapy (CBT), Dialectal Behavior Therapy (DBT), EMDR Therapy, Chemical Dependency for Drug and Alcohol Therapy, Psychological Testing, Video Sessions, Phone Sessions, Biofeedback, and Neurofeedback.
Please make sure to review each section of our contract prior to being seen in our facility and initial the bottom of each page of the contract before signing the last page. If the client has any questions about our contract, please share with the front office staff so that our Practice Administrator can assist the client with any additional information that the client may need.
InMindOut Emotional Wellness Center TeleHealth
Telehealth refers to psychotherapy services that occur via phone, email, or synchronous videoconferencing. All of our interactions will fall under this term. When using technology there is always therisk of security issues, as well as technical issues (phone not charged, computer or software notworking, etc.).
You have the right to learn about alternative methods of treatment. We will discuss these with youduring our work together. TeleHealth services are not appropriate for all clients. Generally, those who areexperiencing suicidal ideation or altered mental status are not appropriate. Should telehealth services not be a good fit for you, We will assist you in finding alternative options.
InMindOut will develop an individualized plan on how best to address technical issues that mayarise and will take steps to facilitate the security of interactions with your therapist. In addition to theidentified risks, there are several benefits that come from using technology. For instance, it allowstherapists to connect with people who may otherwise not be able to access services, there is anopportunity for more flexibility in scheduling, and convenience in being able to connect from a space ofyour choosing. In order to protect your confidentiality and to facilitate the security of your information asmuch as possible, here is a list of recommendations:Engage in sessions in a private location where you cannot be heard by othersUse a private phoneDo not record any sessionsPassword protect any technology you will be interacting with your therapist onAlways log out or hang up once sessions are complete
Email is the main form of contact that will be used outside of the consultation and sessions. Please notethat email is not secure, so communication should be limited to scheduling questions and providingresources.
Payment for InMindOut TeleHelath ServicesPayments for services are only accepted via credit or debit card. For your convenience payments will need to be made prior to the start of the TeleHealth session. For our safety and our protection your card information is not kept or recorded.
Clinicians and Service Providers at InMindOut Emotional Wellness Center
InMindOut Emotional Wellness Center has clinicians with the following licensures: Dr. Heather Ingram Licensed Psychologist (PsyD) along with Licensed Professional Counselors (LPC), Licensed Marriage and Family Therapists (LMFT), National Certified Counselors (NCC), Certified Clinical Trauma Professionals (CCTP), Certified Sex Offender Treatment Specialists (CSOTS), Licensed Clinical Social Workers (LCSW), Licensed Sex Offender Therapy Providers (LSOTP), Licensed Chemical Dependency Counselors (LCDC) to service multiple client needs.
InMindOut Emotional Wellness Center is committed to the education and training of early career practitioners in mental health. In addition to our counselors and therapists we also utilize Postdoctoral Fellows, Practicum Students, and Interns.
Postdoctoral Fellows are individuals holding a doctoral degree and are engaged in a temporary period of mentored research and/ or training to acquire the professional skills needed to peruse a career as a psychologist in independent practice.
Practicum students and interns are individuals who are pursuing their degree in clinical or counseling psychology and the individual is under the direct supervision of Doctor Heather Ingram PsyD.
The Postdoctoral Fellows, Practicum students, and Interns are under the direct supervision of Dr. Heather Ingram PsyD. The supervision includes a review of cases, assessments, and other relevant information to ensure ethical and competent delivery by the Postdoctoral Fellows, Practicum Students, and Interns. By signing this contract, the client acknowledges that the client is aware of the training level of our testing specialist(s) and agree to be seen by them for Research Study Therapy, Biofeedback, Nuerofeedback and Psychological testing.
Psychotherapy is not easily described in general terms; the definition may vary depending on the personality of the therapist and the client’s concerns. The clinicians at InMindOut Emotional Wellness Center often use different methods to address the concerns that a client may have. Our office employs therapists that offer treatment specific methods for clients dealing with Anxiety, Depression, Mood Disorders, PTSD, Life Transitions, Self Esteem, Behavioral Disorders, Dual – Diagnosis, LGBTQIA Gender Dysphoria, Grief and loss, ODD and Phobias.
Psychotherapy is not like a medical doctor’s visit; instead, it calls for active effort and application of the treatment plans provided by the therapist for the client.
For the therapy to be successful, the client will have to work on the methods discussed in the session at home and outside of the therapy session.
Psychotherapy has many benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings. The feelings can include 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 reduction in feelings of distress. The experience will vary with each client and no guarantees can be made.
Biofeedback and Neurofeedback
Biofeedback therapy is a process in which an individual learns to monitor and regulate the mind and body. Our Biofeedback and Neurofeedback program is designed to promote mental/emotional health, physical health, and overall well-being. Initially, this is done with the assistance of a clinician and special equipment. This equipment includes sensors that monitor respiration, heart rate, skin temperature, muscle tension, and brain waves. The objective is for the client to learn how to monitor and regulate on their own without equipment.
Neurofeedback is a method of regulating your brain wave activity. In Neurofeedback we take an electroencephalogram (EEG), observe the data and determine whether or not your brain activity is in optimal ranges. An EEG is a recording of electrical waves of activity that occur in the brain, and across its surface. Using this information, you can make direct changes to your EEG patterns moving your brain activity into more optimal ranges which can enhance your emotional and mental health.
Common effects of biofeedback treatment include improved self-regulation of arousal level, stress reduction, increased attention, concentration, decreased impulsivity, and some relief from feelings of anxiety and depression. Clients with a history of seizures are seen on a case-by case basis. Some types of biofeedback training may result in the client experiencing a state of reflection and creativity that is accompanied by temporary drowsiness. If clients have a diagnosis of seizure, in rare cases Nuerofeedback can trigger seizure activity.
Psychological Testing is defined as a brief, initial evaluation of a client's psychological state and current risk factors including diagnosis, current safety risk, and safety plan.
If a client is looking for any of the following types of testing, we can help:
General medical procedures including Bariatric surgery screen
If the case is complex, a referral for additional testing may be required. If so, the therapist will notate this in the recommendations section of the report and review with the client during the feedback session.
Client Session and Clinician Preferences
Clinicians normally conduct an evaluation that will last from 2 to 4 sessions. During this time, the client and the clinician can both decide whether the current clinician is the best person to provide the services the client needs to meet treatment goals. If psychotherapy has begun, your clinician will usually schedule one 45-55-minute session per week at an agreed upon time. At any time after the initial session the client can request a new clinician for any reason. The client should notify the front office staff and any future appointments can be adjusted at that time. Each clinician will be made aware of the change and the client will continue treatment with the newly assigned therapist. Research suggests that most clients receive the most benefit from therapy if they attend at least 13 sessions. This is our recommendation.
Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information.
Please read and review it carefully.
The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. For Psychotherapists this requires little change from the practice of confidentiality that has been required of our profession prior to HIPAA. In general, the HIPAA Act gives you, the client or patient, significant new rights to understand and control how your health care information is used. We are required by law to maintain the privacy of your protected heath information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.
Uninsured Client fees
The hourly out-of-pocket (OOP)/uninsured costs for individual, couples, and family therapy are $150.00 for the initial session and $140.00 for follow-up sessions.
Insured Client Fees
The cost for individual, couples, and family therapy sessions covered by major behavioral health insurance coverage may vary due to client deductible amounts, co-insurance amounts, and allowable amounts.
In addition to weekly appointments, InMindOut Emotional Wellness Center collects payments and fees for services provided by Therapists that are not covered by the client insurance. The services listed below are billed individually to the client at an Out-of-Pocket cost.
Additional Services Types and Fees
The following additional services are offered at InMindOut Emotional Wellness Center for an additional fee.
Insurance does not cover parental guidance sessions. The out-of-pocket cost for this session
Is $80.00. We also offer Report writing, Therapist attendance at meetings with authorized professionals outside of InMindOut Emotional Wellness Center, Medical Records Processing, ESA letters, EAP letters, SSI letters, Disability Claim letters, School letters, Physician/ PCP letters, completing FMLA documents and preparation, and the billable time spent performing any other service that will facilitate a client need.
Legal Appearances and Fees
The charge for legal appearances is $250.00 per hour for preparation, travel, and attendance at any legal proceeding. If a client is involved in any legal proceedings that require a clinician to appear, the client will be expected to pay for the professional time even if the clinician is called to testify by another party. Hotel and travel fees are charged in addition to hourly rates. A retainer fee of $1500.00 is required for clients that will need the clinician to appear/testify in court.
The hourly fee for Neurofeedback and Biofeedback services is $99.00 per hour. The initial evaluation for this service type is 2 hours and subsequent sessions are billed at 1 hour.
The out-of-pocket cost for general psychological testing is $960.00. Costs for insured clients may vary pending insurance approval process or denial.
Notification of Missed Appointments
If cancellation is necessary, we require that you call at least 24 Hours in advance. Appointments are in high demand, and your advanced notice will allow another client access to that appointment time.
If you need to cancel your appointment, please call us at 830-730-6090 prior to your scheduled appointment time. If necessary, you may leave a detailed voicemail message for the front office staff to cancel your appointment.
A no-call-no-show (NCNS) is when a client misses an appointment without cancelling or calling within 24 hours of their appointment time. A late cancel is when a client calls on the day of the appointment to cancel. In either case, we will charge the client a $140.00 missed appointment fee.
Please be advised after 3 NCNS or more than 3 cancellations within 3 months, reoccurring appointments will no longer be permitted, however, same-day call-in appointments would be accepted, if available.
When you book your appointment, you are holding a space on our calendar that is no longer available to our other clients. In order to be respectful of your fellow clients, please call InMindOut Emotional Wellness Center as soon as you know you will not be able to make your appointment.
Billing and Payments
You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. (In circumstances of unusual financial hardship, InMindOut Emotional Wellness Center may be willing to negotiate a fee adjustment or payment installment plan.) This requires speaking to our billing department and submitting additional paperwork as requested to determine eligibility.
If your account has not been paid for, for more than 60 days and arrangements for payment have not been agreed upon, InMindOut Emotional Wellness Center has the option of using legal means to secure the payment. This may involve hiring a collection agency or going through a
small claims court. If such legal action is necessary, its costs will be included in the claim submitted to the entity chosen. In most collection situations, the only information released regarding a client's treatment is his/her name, the nature of services provided, and the amount due. InMindOut Emotional Wellness Center also works with third-party billing associates who assist with keeping track of billing statements and insurance reimbursement. InMindOut Emotional Wellness Center may provide information to a third-party billing associate such as your insurance information, DOB, social security number, and other information necessary for the third-party billing associate to handle billing. Though the third-party biller is ethically bound to keep information received confidential, InMindOut Emotional Wellness Center has no control over what is done with this information after it is submitted.
Payments may be collected over the phone with credit cards. Payments for service are due at time of service or prior. For phone payments, a client’s credit card information is not written down or saved for the protection of the client; nor will InMindOut Emotional Wellness Center save a client’s payment information for future use.
To set realistic treatment goals and priorities, it is important to evaluate your available resources to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. Either InMindOut Emotional Wellness Center or a third party billing associate affiliated with the practice will fill out forms and provide you with whatever assistance possible to help you receive the benefits to what you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. Ultimately You must find out exactly what mental health services your insurance policy covers.
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. InMindOut Emotional Wellness Center or a third-party billing associate affiliated with the practice will provide the client with whatever information we can based on our experience and will be happy to help the client in understanding the information the client will receive from their insurance company. If it is necessary to clear confusion, InMindOut Emotional Wellness Center or a third-party billing associate affiliated with the practice will be willing to call the company on the client’s behalf.
Due to the rising costs of health care, 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 clients feel that they need more services after insurance benefits end. (Some managed care plans will not allow InMindOut Emotional Wellness Center to provide services to the client once benefits end. If this is the case, InMindOut Emotional Wellness Center will do their best to find another provider who will help the client continue psychotherapy.)
The client should also be aware that most insurance companies require the client to authorize InMindOut Emotional Wellness Center to provide them with a clinical diagnosis. Sometimes clinicians must 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.
Once we have all of the information about the client’s 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 the client feels ready to end the sessions. It is important to remember that the client always has the right to pay for services to avoid the problems described above (unless prohibited by contract).
Authorization of Benefits (AOB)
For prompt insurance claim submissions and bill processing the client authorizes the release of demographic information to be submitted on behalf of the client to bill and obtain reimbursement for treatment at InMindOut Emotional Wellness Center.
As an Uninsured/Insured client I authorize InMindOut Emotional Wellness Center to share my information with insurance companies and their associations, employee groups or EAP Programs, government agencies or their third-party payers and their agents/employees, adjusters and/or attorneys involved in my case. I authorize the sharing of this information to be sent electronically, by mail, fax or courier in order to effectively process my claims.
I authorize payment of medical / hospital benefits provided to me and submitted to my insurance company on my behalf to be paid directly to InMindOut Emotional Wellness Center.
I agree that a photocopy of this assignment shall be considered as effective and valid as the original.
By singing the client contract I confirm that I have viewed or had access to view the Client Bill of Rights posted in the lobby of InMindOut Emotional Wellness Center.
SMS or Voice Messaging
I authorize InMindOut Emotional Wellness Center to send appointment reminder text notifications. I understand that standard text message rates will apply.
Opting Out of SMS or Voice Messaging
A client can opt out of SMS text or voice messaging at any time by replying “STOP” to the text message appointment reminder.
Consent for Data provided to be used for Research and Data Collection Purposes
InMindOut Emotional Wellness Center is continuously searching for the most evidenced-based therapy practices to provide our clients. We are continuing to find ways to improve our knowledge and understanding of therapeutic approaches for our clients. One way to do this is to research the data collected from our clients who obtain services at our facility.
I understand that the information that I provided on intake forms, during the assessment, and on the testing, forms are to be used for research, training, education, advertising, and marketing purposes only.
I understand that my name, birth date, and any other identifying information will be kept confidential and will not be connected to data used for research or advertising and marketing purposes. I understand that I can terminate my consent to this agreement at any time.
Consent to Audio Recording by Therapist
InMindOut Emotional Wellness Center is committed to the education and training of psychologists in mental health. As such, we are continuing to find ways to improve our supervision and training. One way to do this is to audio record therapy sessions to assist in the supervision of psychologists and to ensure the best quality of services.
I understand that I can terminate my consent to this agreement/declination at any time.
Contacting InMindOut Emotional Wellness Center
The office phone number is (830) 730-6090. InMindOut Emotional Wellness Center is not always immediately available by telephone. While office hours are typically between 8 A.M. and 5 P.M. Monday-Friday (depending on location), InMindOut Emotional Wellness Center front office assistants at times may be unavailable if they are with another client. When InMindOut Emotional Wellness Center staff members are unavailable, the telephone is answered by a voicemail that we monitor frequently throughout the day. InMindOut Emotional Wellness Center will make every effort to return your call within 48 hours, except for weekends and holidays. In the event of an emergency contact your family physician or go to the nearest emergency room. Upon arrival at the emergency room be sure to ask for the therapist on call. If your clinician will be unavailable for an extended time, InMindOut Emotional Wellness Center will provide you with the name of a colleague to contact, if necessary.
The laws and standards of our profession require that InMindOut Emotional Wellness Center keep treatment records. You are entitled to receive a copy of your records, or InMindOut Emotional Wellness Center can prepare a summary for you instead. Because these are professional records, they can be misinterpreted by and/or upsetting to untrained readers. If you wish to see your records, we recommend that you review them in your clinician's presence to that we can discuss the contents. Clients will be charged an appropriate fee for any professional time spent in responding to information requests.
The fees for medical records are as follows: $25.00 fee for the first 20 pages and $0.50 per additional page; a special request letter is a $75.00 fee.
Upon scheduling a minor, the front office will request the contact information of the biological parent(s) or any guardian(s) that may be a part of the at home care of the minor client. InMindOut Emotional Wellness Center front office staff will request any legal documentation for the client file between both biological parents if there was a separation or divorce. Examples of documents that may be requested include a divorce decree, custody agreement, parental agreements, etc. These documents are needed for the client chart so the clinicians can adhere to them while the client is in our facility.
If you are under 18 years of age, please be aware that the law may provide your parents with the right to examine your treatment records. It is InMindOut Emotional Wellness Center’s policy to request an agreement from parents that they agree to give up access to your records. If they agree, InMindOut Emotional Wellness Center will provide them only with general information about your work with your clinician, unless your clinician feels there is a high risk that you will seriously harm yourself or someone else. In this case, your clinician will notify them of their concern. InMindOut Emotional Wellness Center will also provide them with a summary of your treatment when it is complete if needed. Before giving your parents any information, your clinician will discuss the matter with you, if possible, and do their best to handle any objections you may have about what your clinician is prepared to discuss.
In general, the law protects the privacy of all communications between a client and therapist, and InMindOut Emotional Wellness Center can release information about clinical work to others only with the written permission from the client or client’s guardian.
There are some exceptions and they are as follows: In most legal proceedings, the client or the client’s guardian may have the right to prevent InMindOut Emotional Wellness Center from providing any information about treatment. In some proceedings involving child custody and those in which emotional condition is an important issue, a judge may order a clinician to testify if he or she determines that the issue may demand it.
There are also some situations in which InMindOut Emotional Wellness Center is legally obligated to act on the behalf of the client to protect others from harm. InMindOut Emotional Wellness Center may reveal some information about a client's treatment if needed. For example, if your clinician believes that a child, elderly person, or a person with a disability is being abused, he/she must file a report with the appropriate state agency.
Another exception is if your clinician believes that a client is threatening serious bodily harm to another, he/she may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client. If the client threatens to harm himself or herself, your clinician may be obligated to seek hospitalization the client. The measures may require the clinician to contact family members and/or others who can help provide protection. These situations are less common, but if a similar situation occurs, your clinician will make every effort to fully discuss it with you before taking any action.
If the client is being seen to evaluate fitness for occupation sometimes clinicians may consult other professionals regarding their cases. InMindOut Emotional Wellness Center clinicians will make every effort to avoid revealing the identity of their client during a consultation. For the privacy of the client, the consultant is also legally bound to keep the information confidential. Your clinician is not obligated to tell you what is discussed in the consultation unless it is important for treatment.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, we must discuss any questions or concerns that the client may have at the next meeting with your clinician. We will be happy to discuss these issues with the client specific advice is needed, but formal legal advice may be needed because the laws governing confidentiality are quite complex, and we are not attorneys.
Your signature below indicates that you have read the information in this document and agree to abide by its terms during your treatment at InMindOut Emotional Wellness Center. By signing this document, it will represent an agreement between the client and InMindOut Emotional Wellness Center.
Your signature below indicates that you have read the information in this document and agree to abide by its terms during your professional relationship with InMindOut Emotional Wellness Center, LLC.
If client is a minor, please have the parent or legal guardian sign this form.
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If you have questions about the contents of this document, you can email the document owner.
Document Name: Client Contract
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