SERVICE AGREEMENT
PSYCHOLOGICAL SERVICES
Psychotherapy is not easily described in general statements. How the process unfolds depends upon the personalities and styles of the psychologist and client, the particular problems being experienced and the desired goals or outcomes. I may use a variety of different methods or interventions to address your problems or issues. In addition to your sessions, treatment may involve self-help groups, medication, books or articles to read, group therapies or homework assignments. Successful treatment will require active participation on your part, both within sessions and between sessions (i.e., thinking about what we have discussed and/or experimenting with new behaviors).
Psychotherapy can have both benefits and risks. At the core, therapy is a dialogue between psychologist and client that focuses on concerns that you would like to understand or manage better. As such, therapy often involves discussing unpleasant aspects of your life and you may experience uncomfortable feelings like sadness, guilt, frustration, loneliness, helplessness or anger. On the other hand, psychotherapy has also been shown to have many benefits: It often leads to improved relationships, solutions to specific problems and significant reductions in feelings of distress or confusion. But there are no guarantees of what your experience or outcome will be.
If you ever feel our work is not proceeding in a way that is productive for you, I invite you to speak with me about it. I am providing a service to you and you have the right to ask for what you want and need. I am not wedded to any particular approach as much as I am finding what works for you.
MEETINGS/FINANCIAL RESPONSIBILITIES
Our initial evaluation will help us both decide if I am the best person to provide the treatment you need in order to achieve your goals. If we agree to continue to work together, we will usually schedule weekly 45 – 50 minute sessions. I will be as flexible as my schedule permits in scheduling your appointments.
It is important to note that insurance companies do not provide reimbursement for cancelled or missed sessions, therefore the following must apply: Once an appointment has been scheduled, you will be expected to keep the appointment unless you provide 36 hours advanced notice of cancellation. Failure to provide adequate notice will result in your being responsible to pay $75.00 for the first missed session. After that, you will be responsible to pay my regular session fee of $150.00. If you are more than 15 minutes late for an appointment, you will be considered self-pay for the portion of the session that you missed.
I do understand that emergencies arise but I ask that you understand that this is my livelihood. You are my employer and employers pay their employees even if they (the employer) do not come to work. In addition, insurance companies do not provide reimbursement for services provided over the telephone or by email. For this reason, among others, I do not engage in these practices.
Consistent attendance is a requirement for effective treatment and to ensure that I am able to maintain a space in my schedule for you. A pattern of missed or cancelled sessions may result in a renegotiation of our service agreement or discharge from services. I may contact you to offer an earlier or later appointment time that I believe might be more convenient for you as they become available. You are under no obligation to accept any offer I make to reschedule your appointment.
Co-payments are due at the beginning of each session and are payable by cash or check. Sessions cannot take place without payment.
CONTACTING ME
I monitor my messaging system throughout the day and I make every effort to return your call/text in a timely manner, with the exception of holidays and weekends. However, due to my schedule, I cannot guarantee that messages will be returned within the same day. Please remember: If you decide to use or allow me to use them, texts and emails are not secured methods of communication.
I am NOT available 24 hours a day/7days a week and I cannot guarantee that I will be available in an emergency situation. If you are unable to reach me and you cannot wait for me to return your call, please contact Lenape Valley Acute Care Services at 215.785.9765 or go to your local emergency room. The emergency room that is closest to my office is St. Mary's Hospital at 1202 Langhorne-Newtown Road in Langhorne (215.710.2100) If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact if necessary, upon your request.
LIMITS ON CONFIDENTIALITY AND ETHICS
NOTICE OF PRIVACY PRACTICES
If there is a breach of your confidentiality, then I must inform you as well as Health and Human Services. A breach means that information has been released without authorization or without legal authority unless I (the covered entity) can show that there was a low risk that the PHI has been compromised because the unauthorized person did not view the PHI or it was de-identified.
If you are self-pay, then you may restrict the information sent to insurance companies.
Most uses and disclosures of psychotherapy notes and of protected health information for marketing purposes and the sale of protected health information require an authorization. Other uses and disclosures not described in the notice will be made only with your written authorization. You must sign an authorization (release of information form) for releases unless it is for purposes already mentioned in this Privacy Notice (such as mandated reporting of child abuse, reporting of elder abuse, reporting of impaired drivers, etc.).
You have the right to receive a copy of your Protected Health Information in an electronic format or (through a written authorization) designate a third party who may receive such information.
PROFESSIONAL RECORDS
You should be aware that I keep records pertaining to all of our contacts, both in-person and by telephone, email, and text. Your clinical records include information gathered from the original intake, your reasons for seeking therapy, a description of how these problems have impacted your life, your symptoms and diagnosis, your medical and social history, the goals that we set for treatment, consultation notes, your progress towards goals, any past treatment records I obtain from past or current medical or mental health treaters and any reports that I have sent to anyone.
MINORS & PARENTS
Clients under 18 years of age who are not emancipated and their parents/guardians should be aware that the law may allow parents/guardians to examine their child's treatment records. While privacy in psychotherapy is very important, particularly with teenagers, parental/guardian involvement is also essential to successful treatment. Therefore it is usually my policy to request an agreement from any client that is between the ages of 14 to 17 and his/her parents/guardians allowing me to share general information about treatment progress and their child's attendance at scheduled sessions. Any other communication will require the minor's authorization, unless I believe that the minor is in danger or is a danger to someone else, in which case I will notify the parents/guardians of my concern. Before giving parents/guardians any information, I will discuss the matter with the client, if possible, and do my best to manage any objections s/he may have.
TRAINING
I have a Doctorate in Clinical Psychology which I earned from the University of Rhode Island in 2003. I have been licensed as a psychologist in Pennsylvannia since 2004. I have worked mostly in outpatient settings but I also have experience with in-patient mental health treatment, in crisis centers and educational settings. I started my private practice in 2006.
PSYCHOLOGICAL SERVICES
Psychotherapy is not easily described in general statements. How the process unfolds depends upon the personalities and styles of the psychologist and client, the particular problems being experienced and the desired goals or outcomes. I may use a variety of different methods or interventions to address your problems or issues. In addition to your sessions, treatment may involve self-help groups, medication, books or articles to read, group therapies or homework assignments. Successful treatment will require active participation on your part, both within sessions and between sessions (i.e., thinking about what we have discussed and/or experimenting with new behaviors).
Psychotherapy can have both benefits and risks. At the core, therapy is a dialogue between psychologist and client that focuses on concerns that you would like to understand or manage better. As such, therapy often involves discussing unpleasant aspects of your life and you may experience uncomfortable feelings like sadness, guilt, frustration, loneliness, helplessness or anger. On the other hand, psychotherapy has also been shown to have many benefits: It often leads to improved relationships, solutions to specific problems and significant reductions in feelings of distress or confusion. But there are no guarantees of what your experience or outcome will be.
If you ever feel our work is not proceeding in a way that is productive for you, I invite you to speak with me about it. I am providing a service to you and you have the right to ask for what you want and need. I am not wedded to any particular approach as much as I am finding what works for you.
MEETINGS/FINANCIAL RESPONSIBILITIES
Our initial evaluation will help us both decide if I am the best person to provide the treatment you need in order to achieve your goals. If we agree to continue to work together, we will usually schedule weekly 45 – 50 minute sessions. I will be as flexible as my schedule permits in scheduling your appointments.
It is important to note that insurance companies do not provide reimbursement for cancelled or missed sessions, therefore the following must apply: Once an appointment has been scheduled, you will be expected to keep the appointment unless you provide 36 hours advanced notice of cancellation. Failure to provide adequate notice will result in your being responsible to pay $75.00 for the first missed session. After that, you will be responsible to pay my regular session fee of $150.00. If you are more than 15 minutes late for an appointment, you will be considered self-pay for the portion of the session that you missed.
I do understand that emergencies arise but I ask that you understand that this is my livelihood. You are my employer and employers pay their employees even if they (the employer) do not come to work. In addition, insurance companies do not provide reimbursement for services provided over the telephone or by email. For this reason, among others, I do not engage in these practices.
Consistent attendance is a requirement for effective treatment and to ensure that I am able to maintain a space in my schedule for you. A pattern of missed or cancelled sessions may result in a renegotiation of our service agreement or discharge from services. I may contact you to offer an earlier or later appointment time that I believe might be more convenient for you as they become available. You are under no obligation to accept any offer I make to reschedule your appointment.
Co-payments are due at the beginning of each session and are payable by cash or check. Sessions cannot take place without payment.
CONTACTING ME
I monitor my messaging system throughout the day and I make every effort to return your call/text in a timely manner, with the exception of holidays and weekends. However, due to my schedule, I cannot guarantee that messages will be returned within the same day. Please remember: If you decide to use or allow me to use them, texts and emails are not secured methods of communication.
I am NOT available 24 hours a day/7days a week and I cannot guarantee that I will be available in an emergency situation. If you are unable to reach me and you cannot wait for me to return your call, please contact Lenape Valley Acute Care Services at 215.785.9765 or go to your local emergency room. The emergency room that is closest to my office is St. Mary's Hospital at 1202 Langhorne-Newtown Road in Langhorne (215.710.2100) If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact if necessary, upon your request.
LIMITS ON CONFIDENTIALITY AND ETHICS
- I strive to maintain the highest ethical standards in my work.
- I maintain written records of each session in a locked file cabinet.
- Your insurance company has the right to view your records. If you were initially asked to provide my biller with your insurance information, my biller will also have access to selected medical information about you required for billing purposes. You agree to this when you use your insurance benefits.
- If your insurer has a managed care component, I must submit written or oral reports to the managed care company in order for you to be able to use your insurance. The report includes information about your symptoms, diagnosis, treatment goals, stresses in your life and the progress you are making toward meeting your goals.
- If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-client privilege law. I cannot provide any information without your written consent or a court order. I have no legal protection to maintain confidentiality if a judge orders me to produce your records and limited protection if I am subpoenaed to testify in court.
- If a complaint or lawsuit is filed against me by a client, I may be required to disclose relevant information regarding my work with them in order to defend myself.
- I am required by law to report instances of child or vulnerable adult abuse and/or neglect. I am also required by law to report instances of sexual abuse of adults by other psychologists.
- I am required by the ethics of my profession to breach confidentiality when I am concerned that someone's (yours or someone else's) life may be in danger. Protective actions may include initiating hospitalization, informing the intended victim or the police about the threat or notifying family members or others who can protect the client. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary.
- I engage in regular supervision with a consultant and occasionally consult with other mental health or medical professionals. In these situations, I protect my clients' confidentiality by omitting identifying details (i.e., names, exact age, residence). The other professionals are also legally bound to keep this information confidential.
- Members of your family do not have access to information about your treatment without your written permission. This protection in somewhat limited for my adolescent clients. (Please see Minors & Parents section below for more details.)
NOTICE OF PRIVACY PRACTICES
If there is a breach of your confidentiality, then I must inform you as well as Health and Human Services. A breach means that information has been released without authorization or without legal authority unless I (the covered entity) can show that there was a low risk that the PHI has been compromised because the unauthorized person did not view the PHI or it was de-identified.
If you are self-pay, then you may restrict the information sent to insurance companies.
Most uses and disclosures of psychotherapy notes and of protected health information for marketing purposes and the sale of protected health information require an authorization. Other uses and disclosures not described in the notice will be made only with your written authorization. You must sign an authorization (release of information form) for releases unless it is for purposes already mentioned in this Privacy Notice (such as mandated reporting of child abuse, reporting of elder abuse, reporting of impaired drivers, etc.).
You have the right to receive a copy of your Protected Health Information in an electronic format or (through a written authorization) designate a third party who may receive such information.
PROFESSIONAL RECORDS
You should be aware that I keep records pertaining to all of our contacts, both in-person and by telephone, email, and text. Your clinical records include information gathered from the original intake, your reasons for seeking therapy, a description of how these problems have impacted your life, your symptoms and diagnosis, your medical and social history, the goals that we set for treatment, consultation notes, your progress towards goals, any past treatment records I obtain from past or current medical or mental health treaters and any reports that I have sent to anyone.
MINORS & PARENTS
Clients under 18 years of age who are not emancipated and their parents/guardians should be aware that the law may allow parents/guardians to examine their child's treatment records. While privacy in psychotherapy is very important, particularly with teenagers, parental/guardian involvement is also essential to successful treatment. Therefore it is usually my policy to request an agreement from any client that is between the ages of 14 to 17 and his/her parents/guardians allowing me to share general information about treatment progress and their child's attendance at scheduled sessions. Any other communication will require the minor's authorization, unless I believe that the minor is in danger or is a danger to someone else, in which case I will notify the parents/guardians of my concern. Before giving parents/guardians any information, I will discuss the matter with the client, if possible, and do my best to manage any objections s/he may have.
TRAINING
I have a Doctorate in Clinical Psychology which I earned from the University of Rhode Island in 2003. I have been licensed as a psychologist in Pennsylvannia since 2004. I have worked mostly in outpatient settings but I also have experience with in-patient mental health treatment, in crisis centers and educational settings. I started my private practice in 2006.
| Service Agreement |
| Practice Operations/Policies |
