I generally provide all of my new clients with a copy of this document at the first session. After reading and discussing these policies, I ask each client to sign a copy of the document and I provide each client a copy of this agreement.
Outpatient Services Contract
to my practice. This document contains
important information about my professional services and business
policies. Please read it carefully and
jot down any questions to you might have so that we can discuss them at our
next meeting. Once you sign this, it
will constitute a binding agreement between us.
is not easily described in general statements.
It varies depending on the personality of both the therapist and the
patient and the particular problems that the patient brings. There are a number of different approaches
that can be utilized to address the problems you hope to address. It is not like visiting a medical doctor in
that it requires a very active effort on your part. In order to be most successful, you will have
to work both during our sessions and at home.
has both benefits and risks. Risks
sometimes include experiencing uncomfortable levels of feelings like sadness,
guilt, anxiety, anger and frustration, loneliness and helplessness. Psychotherapy often requires recalling
unpleasant aspects of your history.
Psychotherapy has also been shown to have benefits for people who
undertake it. It often leads to a
significant reduction of feelings of distress, and better relationships and
resolutions of specific problems. But
there are no guarantees about what will happen.
By the end of the evaluation, I will be able to offer you
some initial impressions of what our work will include and an initial treatment
plan, if you decide to continue. You
should evaluate this information along with your own assessment about 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 to secure an
appropriate consultation with another mental health professional.
My normal practice is to conduct an evaluation that will
last from two to four sessions. During
this time, we can both decide whether I am the best person to provide the
services that you need in order to meet your treatment objectives. If psychotherapy is initiated, I will usually
schedule one 50-minute session (one appointment hour of 50 minutes duration)
per week at a mutually agreed time, although sometimes sessions will be longer
or more frequent. Once this appointment
hour is scheduled you will be expected to pay for it unless you provide 24
hours advance notice of cancellation or unless we both agree that you were
unable to attend due to circumstances that were beyond your control. If this is the case, I will try to find
another time to reschedule your appointment.
My hourly fee is $175.
In addition to weekly appointments, it is my practice to charge this
amount on a prorated basis for other professional services you may require such
as report writing, telephone conversations that last more than 5 minutes,
attendance at meetings or consultations with other professionals which you have
authorized, preparation of records or treatment summaries or the time required
to perform any other service which you may request of me. In unusual circumstances, you may become
involved in litigation that may require my participation. You will be expected to pay for the
professional time required even if I am compelled to testify by another
party. Because of the complexity and
difficulty of legal involvement, I charge $250 per hour for preparation for and
attendance at any legal proceedings with a minimum charge of four hours.
Billing and Payments
You will be expected to pay for each session at the time
it is held, unless we agree otherwise or you have insurance coverage that
requires another arrangement. For
patients with insurance coverage, most typically you will be expected to pay
the co-pay or amount not covered by insurance (this can range from $10 to $175
per session). If you have no insurance and
have a significant financial hardship, I will be willing to discuss
some discount of my fees. Unless we make
some specific arrangement, you are responsible for payment of $175 at the time
of each session. My lowest discount is
to $140 per session. If you are unable
to afford my fees I will provide you with names of other providers that you
might be able to see. Payments can be
made by cash, check, or credit card (MasterCard or Visa).
In order for us to set realistic treatment goals and
priorities, it is important to evaluate what resources are available to pay for
your treatment. If you have a health
benefits policy, it will usually provide some coverage for mental health
treatment. I will provide you with
whatever assistance I can in facilitating you receipt of the benefits to which
you are entitled including filling out forms as appropriate. However, you, and not your insurance company,
are responsible for full payment of the fee that we have agreed to. Therefore, 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, you should call your
plan and inquire. Of course, I will
provide you with whatever information I can based on my experience and will be
happy to try to assist you in deciphering the information you receive from your
Insurance benefits have become increasingly complex and
it has made it difficult to understand how much mental health coverage is
available. Managed health care plans and
HMOs and PPOs often require you seeing a particular provider and require
advance authorization before they will provide reimbursement. I participate in no such plans. These plans are often oriented to a
short-term treatment approach designed to resolve specific problems that
interfere with one’s usual level of functioning. Many of these plans also require or encourage
the use of medications. In my
experience, while quite a lot can be accomplished in short-term therapy, many
clients feel that more services are necessary after insurance benefits
expire. If you choose to continue
receiving services from me after the benefits have ended, you will be expected
to provide the full fee at the time of service.
You should also be aware that most insurance agreements
require you to authorize me to provide a clinical diagnosis, and sometimes
additional clinical information such as a treatment plan or summary, or in rare
cases, a copy of the entire record. This
information will become part of the insurance company files, and, in all
probability, some of it will be computerized.
All insurance companies claim to keep such information confidential, but
once it is in their hands, I have no control over what they do with it. In some cases they may share the information
with a national medical information data bank.
If you request it, I will provide you with a copy of any report that I
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 the insurance benefits 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 and avoid the complexities that are described above.
I am often not immediately available by telephone. While I am usually in my office Monday
through Thursday from 8 AM to 5 PM, I usually will not answer the phone when
I am with a client. My phone is always
answered by a confidential voice mail system to which only I have access. I monitor this frequently during the workweek
and occasionally check it on the weekends.
I try and return all calls during the week within several hours of
receiving the message. I am generally
not available for crisis counseling or emergencies and do not have my practice
structured to deal with patients in crisis.
I do not carry a pager and often will be unavailable for
emergencies. If you cannot reach me, and
you feel that you cannot wait for me to return your call, you should call your
family doctor or the emergency room at the local hospital where arrangements
can be made for you to meet with a psychologist or psychiatrist on call. You may also call 911 to arrange for
emergency services. If I am unavailable
for an extended time, I will provide you with the name of a trusted colleague
whom you can contact if necessary.
Both law and the standards of my profession require that
I keep appropriate treatment records.
You are entitled to receive a copy of the records or I can provide you
with a summary of the records. Because
these are professional records, they can be misinterpreted and/or
upsetting. If you wish to see your
records, I recommend that you review them in my presence so that we can discuss
what they contain. Clients will be
charged an appropriate fee for any preparation time that is required to comply
with an information request.
If you are under 18 years of age, please be aware that
the law provides your parents with certain rights to your treatment
records. While I generally request that
parents honor certain limits of confidentiality, and the law provides some
exceptions to a parent’s right to know, many situations can develop where your
parents or guardians will receive information about your treatment. If I plan to discuss anything with your
parents or guardians I will discuss this with you and generally have our
discussion with you present with your parents.
In general, law protects the confidentiality of all
communications between a client and a psychologist, and I can only release
information about our work to others with your written permission. However, there are a number of exceptions.
In virtually every judicial proceeding you have the right
to prevent me from providing any information about your treatment. However, in rare circumstances a judge can
require my testimony if he/she determines that resolutions of the issues before
him/her demands it.
There are some situations in which I am legally required
to take actions to protect others from harm, even though that requires
revealing some information about a client’s treatment.
If I believe that a child or an elderly or disabled
person 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 am required to take protective
actions, which may include notifying the potential victim, notifying the
police, or seeking appropriate hospitalization.
If a client threatens to harm him/herself, I may be required to
intervene. These situations have rarely
arisen in my practice. Should such a
situation occur, I will make every effort to fully discuss it with you before
taking any action.
While this written summary of exceptions to
confidentiality should prove helpful in informing you about potential limits,
it is important that we discuss any questions or concerns that you may have at
our next meeting. As you might suspect,
the laws governing these issues are complex.
While I am happy to discuss these issues with you, should you need
specific advice, formal legal consultation may be desirable. I will provide you with relevant portions or
summaries of the applicable state laws governing 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. You
acknowledge your responsibility for all fees and charges for treatment