White Cloud Therapeutic Services, LLC
322 Monticello Ave.
Williamsburg, VA 23185
Whitecloudtherapy.com | email@example.com | tel: 757-503-7917 | fax: 855-823-3243
CLIENT SERVICE AGREEMENT/Consent to Therapy
Welcome to White Cloud Therapeutic Services. This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.
Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in therapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. White Cloud Therapeutic Services and your individual therapist has corresponding responsibilities to you. These rights and responsibilities are described in the following sections.
Therapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness, and helplessness, because the process of therapy often requires discussing the unpleasant aspects of your life. However, therapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But there are no guarantees about what will happen. Therapy requires a very active effort on your part. To be most successful, you will have to work on things you discuss with your therapist outside of sessions.
The first 1-2 sessions will involve a comprehensive evaluation of your needs. By the end of the evaluation, we will be able to offer you some initial impressions of what our work might include. At that point, we will discuss your treatment goals and create an initial treatment plan. You should evaluate this information and make your own assessment about whether you feel comfortable working with us. If you have questions about our procedures, we should discuss them whenever they arise. If your doubts persist, we will be happy to help you set up a meeting with another mental health professional for a second opinion.
APPOINTMENTS and FEES
Appointments will ordinarily be 50-60 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, we ask that you provide us with at least 24-hour notice. If you miss a session without canceling, our policy is to charge a $45 no-show fee. If you cancel with less than 24-hour notice, our policy is to collect a $35 late cancellation fee (unless you and your therapist both agree that you were unable to attend due to circumstances beyond your control). It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the portion of the fee as described above. In addition, you are responsible for coming to your sessions on time; if you are late, your appointment will still need to end on time. After 3 no-shows (excusing extenuating circumstances) we will no longer be able to hold your scheduled appointment time.
All copays, deductibles, and fees are due at the time of your appointment and will be charged to your card on file unless other arrangements have been made.
SOCIAL MEDIA AND TELECOMMUNICATION
Due to the importance of your confidentiality and the importance of minimizing dual relationships, our therapists do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc.). Adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of the therapeutic relationship. If you have questions about this, please bring them up when you meet with your therapist, and we can talk more about it.
We cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, we will do so. Please contact our Office Manager, Nakeela Richmond, to cancel or reschedule appointments (email: firstname.lastname@example.org, call or text: 757-503-7917). While we try to return messages in a timely manner, we cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.
The standard fee for the initial intake is $200.00 and each subsequent session is $150.00 for individual therapy and $150 for couples and family therapy. You are responsible for paying all fees at the time of your session. Fees will be charged to your credit or debit card on file unless prior arrangements have been made. Alternate payment arrangements must be made with the Clinical Director, Dr. Joseph A. Garcia, LCP. Payments must be made by cash, check, debit, or credit card. Missed or cancelled appointment fees will be automatically charged to your debit or credit card on file. Any checks returned to our office are subject to an additional fee of up to $25.00 to cover the bank fee that we incur. If you refuse to pay your debt, we reserve the right to use an attorney or collection agency to secure payment.
In addition to weekly appointments, it is our practice to charge $150.00/hour on a prorated basis for other professional services that you may require such as report writing, letters written, telephone conversations that last longer than 15 minutes, attendance at meetings or consultations which you have requested, or the time required to perform any other service which you may request. If you anticipate becoming involved in a court case, please discuss this fully with your individual therapist before you waive your right to confidentiality. If your case requires our participation, you will be expected to pay for the professional time required even if another party compels us to testify.
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. With your permission, our billing service will assist you to the extent possible in filing claims and ascertaining information about your coverage, but you are responsible for knowing your coverage and for letting us know if/when your coverage changes. By signing this agreement, you consent to us sharing information with our insurance biller, Nakeela Richmond, and further consent to her contacting you as well as your insurance provider with any billing questions.
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 advance authorization, without which they may refuse to 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 patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow us to provide services to you once your benefits end. If this is the case, we will do our 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 us to provide them with a clinical diagnosis. (Diagnoses are technical terms that describe the nature of your problems and whether they are short-term or long-term problems. All diagnoses come from a book entitled the DSM-5. There is a copy in our office, and we will be glad to let you see it to learn more about your diagnosis, if applicable.). Sometimes we 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. Though all insurance companies claim to keep such information confidential, we have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. We will provide you with a copy of any report we submit if you request it. By signing this Agreement, you agree that we can provide requested information to your carrier if you plan to pay with insurance.
In addition, if you plan to use your insurance, authorization from the insurance company may be required before they will cover therapy fees. If you did not obtain authorization and it is required, you may be responsible for full payment of the fee. Many policies leave a percentage of the fee (which is called co-insurance) or a flat dollar amount (referred to as a co-payment) to be covered by the patient. Either amount is to be paid at the time of the visit by cash, check, or credit/debit card. In addition, some insurance companies also have a deductible, which is an out-of-pocket amount that must be paid by the patient before the insurance companies are willing to begin paying any amount for services. This will typically mean that you will be responsible to pay for initial sessions with us until your deductible has been met; the deductible amount may also need to be met at the start of each calendar year. Once we have all the information about your insurance coverage, we will discuss what we can reasonably expect to accomplish with the benefits that are available and what will happen if coverage ends before you feel ready to end your sessions. It is important to remember that you always have the right to pay for our services yourself to avoid the problems described above, unless prohibited by our provider contract.
If we are not a participating provider for your insurance plan, we will supply you with a receipt of payment for services, which you can submit to your insurance company for reimbursement. Please note that not all insurance companies reimburse for out-of-network providers. If you prefer to use a participating provider, I will refer you to a colleague. At your request, our biller can also take care of submitting these claims for you.
We are required to keep appropriate records of the psychological services that we provide. Your records are maintained in secure HIPAA compliant digital format. We keep brief records noting that you were here, your reasons for seeking therapy, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records we receive from other providers, copies of records we send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them with your therapist or have them forwarded to another mental health professional to discuss the contents. If we refuse your request for access to your records, you have a right to have our decision reviewed by another mental health professional, which we will discuss with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request.
Our policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled Notice of Privacy Practices. You have been provided with a copy of that document and we will discuss any of your issues or concerns related this during our first session. Please remember that you may reopen the conversation at any time during our work together.
PARENTS & MINORS
While privacy in therapy is crucial to successful progress, parental involvement can also be essential. It is our policy not to provide treatment to a child under age 13 unless s/he agrees that we can share whatever information we consider necessary with a parent. For children 14 and older, we request an agreement between the client and the parents allowing us to share general information about treatment progress and attendance, as well as a treatment summary upon completion of therapy. All other communication will require the child’s agreement, unless their therapist feels there is a safety concern (see also above section on Confidentiality for exceptions), in which case we will make every effort to notify the child of our intention to disclose information ahead of time and make every effort to handle any objections that are raised.
We are open from 9:00 am to 5:00 pm Monday through Friday (with a one-hour lunch break usually between 12:45 and 1:45). At these times, you may leave a message on our confidential voice mail, and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters. If, for any number of unseen reasons, you do not hear from us or we are unable to reach you, and you feel you cannot wait for a return call or if you feel unable to keep yourself safe, call 911 and ask to speak to the mental health worker on call or go to your Local Hospital Emergency Room.
We will make every attempt to inform you in advance of planned absences and provide you with the name and phone number of the mental health professional covering our practice.
EMERGENCY CONTACT PROCEDURES
If you feel you are experiencing a psychological emergency or you feel that you or someone else is unsafe, please call 911 immediately. If you are experiencing a non-life-threatening emergency, you may call our office and request that your therapist call you back. We cannot guarantee a time frame for call backs from therapists. If you feel you cannot wait for a call back, please call 911. Please note that all callbacks directly from your therapist will come from a blocked number.
If you are unhappy with what is happening in therapy, we hope you will talk with your therapist so that they can respond to your concerns. Such concerns will be taken seriously and handled with care and respect. You may also request that we refer you to another therapist and are free to end therapy at any time. You have the right to considerate, safe, and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about your therapist’s specific training and experience.
CONSENT TO THERAPY
Your signature below indicates that you have read this Agreement and the Notice of Privacy Practices and agree to their terms.
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