Psychologist-Client Contract

InMindOut Emotional Wellness Center, LLC
Psychologist-Client Contract


Outpatient Services Contract


Welcome to our practice. This document contains important information about our professional
services and business policies. 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 you and me.


Psychological Services


Psychotherapy is not easily described in general statements. It varies depending on the personalities of
the psychologist and client and the particular problems you bring forward. There are many diHerent
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 eHort 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.

Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects
of 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 people
who go through it. Therapy often leads to better relationships, solutions to specific problems, and
significant 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 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. If your doubts persist, I will be happy to help you set up a meeting with another mental
health professional for a second opinion.




I normally conduct an evaluation that will last from 2 to 4 sessions. During this time, we can both decide
whether I am the best person to provide the services you need in order to meet your treatment goals. If
psychotherapy 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 more
frequent. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide
24 hours advance notice of cancellation (unless we both agree that you were unable to attend due to
circumstances beyond your control). Full payment for services will need to made prior to another
appointment being scheduled. If it is possible, I will try to find another time to reschedule the missed


Professional Fees


My hourly fee is $140 for individual therapy, couples, and family therapy. In addition to weekly
appointments, I charge the hourly fee of $140 for other professional services you may need, though I
will break down the hourly cost if I work for periods of less than one hour. Other services include report
writing, telephone conversations lasting longer than 15 minutes, attendance at meetings with other
professionals you have authorized, preparation of records or treatment summaries, and the time spent
performing any other service you may request of me. If you become involved in legal proceedings that
require my participation, you will be expected to pay for my professional time even if I am called to
testify by another party. (Because of the difficulty of legal involvement, I charge $250 per hour for
preparation, 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 pay
for our professional time even if we are called to testify by another party. The fee will be $250 per hour
for preparation and attendance at any legal proceeding. Hotel and travel fees are charged in addition to
hourly rates. A retainer fee of $1500.00 is required for clients that need the Clinician to appear/testify
in court.


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, 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 been
agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a
collection agency or going through small claims court. If such legal action is necessary, its costs will be
included in the claim. In most collection situations, the only information I release regarding a client’s
treatment is his/her name, the nature of services provided, and the amount due. I also work with a
third party billing associate who assists me with keeping track of billing statements and insurance
reimbursement. I may provide information to her such as your insurance information, DOB, social
security number, and other information necessary for her to handle billing. Though the third party biller
is ethically bound to keep information received confidential, I have no control over what is done with
this information after I submit it.


Insurance Reimbursement


In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources
you have available to pay for your treatment. If you have a health insurance policy, it will usually
provide some coverage for mental health treatment. Either I or a third party billing associate affiliated
with my 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. It is very important that you 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. Either I or a third party
billing associate affiliated with my practice will provide you with whatever information we can based on
our experience and will be happy to help you in understanding the information you receive from your
insurance company. If it is necessary to clear confusion, I or a third party billing associate affiliated with
my 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 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 me to provide services to you
once your benefits end. If this is the case, I will do my best to find another provider who will help you
continue your psychotherapy.)

You should also be aware that most insurance companies require you to authorize me to provide them
with a clinical diagnosis. Sometimes I have to 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. I also work with a third party
affiliated with my practice to assist with billing. Though all insurance companies and third party billing
associates claim to keep such information confidential, I have no control over what they do with a copy
of any report I submit.

Once we have all of the information about your 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 you feel
ready to end our sessions. It is important to remember that you always have the right to pay for my
services yourself to avoid the problems described above (unless prohibited by contract).


Contacting Me


My office phone number is (830) 730-6090. I am often not immediately available by telephone. While
office hours are typically between 9 A.M. and 5 P.M. Monday-Thursday, I probably will often not be able
to be reached by phone when I am with a client. When I am unavailable, my telephone is answered by a
voicemail that we monitor frequently or by my secretary who knows where to reach me. I will make
every effort to return your call within 48 hours, with the exception of weekends and holidays. If you are
difficult 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 the
clinician/psychologist/psychiatrist on call. If I will be unavailable for an extended time, I will provide you
with the name of a colleague to contact, if necessary.


Professional Records


The laws and standard of my profession require that I keep treatment records. You are entitled to
receive a copy of your records, or I 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, I recommend that you review them in my presence to that we can discuss the
contents. (I am sometimes willing to conduct a review meeting without charge.) Clients will be charged
an 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 to
examine your treatment records. It is my policy to request an agreement from parents that they agree
to give up access to your records. If they agree, I will provide them only with general information about
our 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 treatment
when 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 the
end of your treatment, I will prepare a summary of our work together for your parents, and we will
discuss it before I send it to them.)




In general, the law protects the privacy of all communications between a client and psychologist, and I
can release information about our work to others only with your written permission. But 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 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 a
child (elderly person, person with disabilities) 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 another, I 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, I may be
obligated to seek hospitalization for him or her or to contact family members or others who can help
provide protection.

These situations have rarely occurred in my practice. If a similar situation occurs, I will make every effort
to fully discuss it with you before taking any action. I may occasionally find it helpful to consult other
professionals about a case. During a consultation, I make every effort to avoid revealing the identity of
my 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 about
potential problems, it is important that we discuss any questions or concerns that you may have at our
next meeting. I will be happy to discuss these issues with you if you need specific advice, but formal
legal advice may be needed because the laws governing confidentiality are quite complex, and I am not
an attorney. (If you request, I will provide you with relevant portions or summaries of the state laws
regarding these issues.)



Your Signature below indicates that you have read the information in this document and agree to abide
by 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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InMindOut Emotional Wellness Center
Signature Certificate
Document name: Psychologist-Client Contract
Unique Document ID: f7cb3d3f0ab090b5bda3873b59850f9f3ad0bd51
Timestamp Audit
October 17, 2017 8:54 am CDTPsychologist-Client Contract Uploaded by Amanda Bergeron Bergeron - IP