Outpatient Services Contract
Welcome to our practice. This document contains important information about our professionalservices and business policies. Please read it carefully and jot down any questions you might have sothat we can discuss them at our next meeting. When you sign this document, it will represent anagreement between you and me.
Psychotherapy is not easily described in general statements. It varies depending on the personalities ofthe psychologist and client and the particular problems you bring forward. There are many diHerentmethods I may use to deal with the problems that you hope to address. Psychotherapy is not like amedical doctor visit. Instead, it calls for a very active eHort on your part. In order for the therapy to bemost successful, you will have to work on things we talk about both during our sessions and at home.
Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspectsof 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 peoplewho go through it. Therapy often leads to better relationships, solutions to specific problems, andsignificant reductions in feelings of distress. But there are no guarantees of what you will experience.
Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, I will beable to offer you some first impressions of what our work will include. You should evaluate thisinformation along with your own opinions of whether you feel comfortable working with me. Therapyinvolves a large commitment of time, money, and energy, so you should be very careful about thetherapist you select. If you have questions about my procedures, we should discuss them wheneverthey arise. If your doubts persist, I will be happy to help you set up a meeting with another mentalhealth professional for a second opinion.
I normally conduct an evaluation that will last from 2 to 4 sessions. During this time, we can both decidewhether I am the best person to provide the services you need in order to meet your treatment goals. Ifpsychotherapy is begun, I will usually schedule one 45-55-minute session (one appointment hour of 45-55 minutes duration) per week at a time we agree on, although some sessions may be longer or morefrequent. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide24 hours advance notice of cancellation (unless we both agree that you were unable to attend due tocircumstances beyond your control). Full payment for services will need to made prior to anotherappointment being scheduled. If it is possible, I will try to find another time to reschedule the missedappointment.
My hourly fee is $140 for individual therapy, couples, and family therapy. In addition to weeklyappointments, I charge the hourly fee of $140 for other professional services you may need, though Iwill break down the hourly cost if I work for periods of less than one hour. Other services include reportwriting, telephone conversations lasting longer than 15 minutes, attendance at meetings with otherprofessionals you have authorized, preparation of records or treatment summaries, and the time spentperforming any other service you may request of me. If you become involved in legal proceedings thatrequire my participation, you will be expected to pay for my professional time even if I am called totestify by another party. (Because of the difficulty of legal involvement, I charge $250 per hour forpreparation, travel, and attendance at any legal proceeding.)
Payment for legal Services
If you become involved in legal proceedings that requires our participation, you will be expected to payfor our professional time even if we are called to testify by another party. The fee will be $250 per hourfor preparation and attendance at any legal proceeding. Hotel and travel fees are charged in addition tohourly rates. A retainer fee of $1500.00 is required for clients that need the Clinician to appear/testifyin court.
Billing and Payments
You will be expected to pay for each session at the time it is held, unless we agree otherwise or unlessyou have insurance coverage that requires another arrangement. Payment schedules for otherprofessional services will be agreed to when they are requested. (In circumstances of unusual financialhardship, I may be willing to negotiate a fee adjustment or payment installment plan.)
If your account has not been paid for more than 60 days and arrangements for payment have not beenagreed upon, I have the option of using legal means to secure the payment. This may involve hiring acollection agency or going through small claims court. If such legal action is necessary, its costs will beincluded in the claim. In most collection situations, the only information I release regarding a client’streatment is his/her name, the nature of services provided, and the amount due. I also work with athird party billing associate who assists me with keeping track of billing statements and insurancereimbursement. I may provide information to her such as your insurance information, DOB, socialsecurity number, and other information necessary for her to handle billing. Though the third party billeris ethically bound to keep information received confidential, I have no control over what is done withthis information after I submit it.
In order for us to set realistic treatment goals and priorities, it is important to evaluate what resourcesyou have available to pay for your treatment. If you have a health insurance policy, it will usuallyprovide some coverage for mental health treatment. Either I or a third party billing associate affiliatedwith my practice will fill out forms and provide you with whatever assistance possible to help youreceive the benefits to what you are entitled; however, you (not your insurance company) areresponsible for full payment of my fees. It is very important that you find out exactly what mentalhealth services your insurance policy covers.
You should carefully read the section in your insurance coverage booklet that describes mental healthservices. If you have questions about the coverage, call your plan administrator. Either I or a third partybilling associate affiliated with my practice will provide you with whatever information we can based onour experience and will be happy to help you in understanding the information you receive from yourinsurance company. If it is necessary to clear confusion, I or a third party billing associate affiliated withmy practice will be willing to call the company on your behalf.
Due to the rising costs of health care, insurance benefits have increasingly become more complex. It issometimes difficult to determine exactly how much mental health coverage is available. Managedhealth care plans such as HMOs and PPOs often require authorization before they providereimbursement for mental health services. These plans are often limited to short-term treatmentapproaches designed to work out specific problems that interfere with a person’s usual level offunctioning. 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 servicesafter insurance benefits end. (Some managed care plans will not allow me to provide services to youonce your benefits end. If this is the case, I will do my best to find another provider who will help youcontinue your psychotherapy.)
You should also be aware that most insurance companies require you to authorize me to provide themwith a clinical diagnosis. Sometimes I have to provide additional clinical information such as treatmentplans or summaries, or copies of the entire record (in rare cases). This information will become part ofthe insurance company files and will probably be stored in a computer. I also work with a third partyaffiliated with my practice to assist with billing. Though all insurance companies and third party billingassociates claim to keep such information confidential, I have no control over what they do with a copyof any report I submit.
Once we have all of the information about your insurance coverage, we will discuss what we can expectto accomplish with the benefits that are available and what will happen if they run out before you feelready to end our sessions. It is important to remember that you always have the right to pay for myservices yourself to avoid the problems described above (unless prohibited by contract).
My office phone number is (830) 730-6090. I am often not immediately available by telephone. Whileoffice hours are typically between 9 A.M. and 5 P.M. Monday-Thursday, I probably will often not be ableto be reached by phone when I am with a client. When I am unavailable, my telephone is answered by avoicemail that we monitor frequently or by my secretary who knows where to reach me. I will makeevery effort to return your call within 48 hours, with the exception of weekends and holidays. If you aredifficult to reach, please inform me of times when you will be available. In emergency situations,contact your family physician or the nearest emergency room and ask for theclinician/psychologist/psychiatrist on call. If I will be unavailable for an extended time, I will provide youwith the name of a colleague to contact, if necessary.
The laws and standard of my profession require that I keep treatment records. You are entitled toreceive a copy of your records, or I can prepare a summary for you instead. Because these areprofeSSional records, they can be misinterpreted by and/or upsetting to untrained readers. If you wishto see your records, I recommend that you review them in my presence to that we can discuss thecontents. (I am sometimes willing to conduct a review meeting without charge.) Clients will be chargedan appropriate fee for any professional time spent in responding to information requests.
If you are under 18 years of age, please be aware that the law may provide your parents the right toexamine your treatment records. It is my policy to request an agreement from parents that they agreeto give up access to your records. If they agree, I will provide them only with general information aboutour 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 treatmentwhen 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 about what I am prepared to discuss. (At theend of your treatment, I will prepare a summary of our work together for your parents, and we willdiscuss it before I send it to them.)
In general, the law protects the privacy of all communications between a client and psychologist, and Ican release information about our work to others only with your written permission. But there are afew exceptions.
In most legal proceedings, you have the right to prevent me from providing any information about yourtreatment. In some proceedings involving child custody and those in which your emotional condition isan important issue, a judge may order my testimony if he or 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 achild (elderly person, person with disabilities) is being abused, I must file a report with the appropriatestate agency.
If I believe that a client is threatening serious bodily harm to another, I may be required to takeprotective actions. These actions may include notifying the potential victim, contacting the police, orseeking hospitalization for the client. If the client threatens to harm himself or herself, I may beobligated to seek hospitalization for him or her or to contact family members or others who can helpprovide protection.
These situations have rarely occurred in my practice. If a similar situation occurs, I will make every effortto fully discuss it with you before taking any action. I may occasionally find it helpful to consult otherprofessionals about a case. During a consultation, I make every effort to avoid revealing the identity ofmy client. 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 will that it is important to our work together.
While this written summary of exceptions to confidentiality should prove helpful in informing you aboutpotential problems, it is important that we discuss any questions or concerns that you may have at ournext meeting. I will be happy to discuss these issues with you if you need specific advice, but formallegal advice may be needed because the laws governing confidentiality are quite complex, and I am notan attorney. (If you request, I will provide you with relevant portions or summaries of the state lawsregarding these issues.)
Your Signature below indicates that you have read the information in this document and agree to abideby its terms during our professional relationship.
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: Psychologist-Client Contract
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