GENERAL PSYCHOTHERAPY/PSYCHOLOGICAL ASSESSMENT INFORMATION

I do hereby seek and consent to take part in the treatment and/or Psychological Evaluation with Dr. Oren Schwartz If the patient is a minor, I hereby give my consent as a parent/legal guardian for my child to participate in Psychotherapy and/or complete Psychological Evaluation by Dr. Oren Schwartz. I understand that it is my sole responsibility to notify my child’s other parent of these Psychological Services. I also understand that no promises have been made to me as to the results of treatment, evaluation or of any other procedures provided by this clinician, as treatment benefits, while likely, cannot be guaranteed. I understand that services provided to me, and any future implications or consequences, are the sole responsibility of the Independent Contractor.

I have the right to inquire fully about the credentials, education, and experience of my clinician or my child's clinician, and to have my questions answered to my satisfaction. I am aware that I may discontinue services with this clinician at any time. My only obligation will be to pay all outstanding fees for the services I have already received. I understand that under certain circumstances I may lose other services or may face other consequences if I stop treatment (for example, if my treatment has been Court-ordered, my discontinuing treatment may have an adverse effect on the outcome of the Court proceeding). 

THERAPY PAYMENT INFORMATION

The initial appointment for Psychotherapy is a diagnostic intake session with a fee of $200. The standard fee for Psychotherapy is $200 for a full 50-minute session, which will be billed at the conclusion of each session. Other payment options will be explored by request.

TESTING PAYMENT INFORMATION

The fee for a full psychological evaluation is $2,000. $200 will be due after the initial session with the remainder of the fee being due prior to the first testing session. Other payment options will be explored by request. 

CANCELLATION POLICY

I know that I must call to cancel an appointment at least 24 hours before the time of the appointment. If I do not cancel or do not show for my appointment, I will be charged the agreed upon fee for that service. I understand that if I do not pay for the services I receive, those services may be discontinued.

INSURANCE INFORMATION
If the you utilize a health insurance policy, Oren Schwartz PsyD PA will complete the necessary forms and provide the client with documentation to assist him/her in receiving benefits to which you are entitled. However, you are responsible for full payment of my fees. While Oren Schwartz PsyD PA will provide you with an intiail evaluation of benefits, please review your insurance coverage booklet that describes mental health services.  If you have questions about the coverage, call your plan administrator.    

Please be aware that many insurance companies require that a clinical diagnosis and in some cases other clinical documentation be provided. You will be informed of and provided with any documentation provided to an insurance company. You understand thats, by using insurance, and signing this form, Oren Schwartz PsyD PA is authorized to release such information to your insurance company.

CONFIDENTIALITY 

Historically, mental health services have been associated with absolute confidentiality between the family and clinician. Currently, Federal and Florida laws and regulations and professional ethics require clinicians to maintain complete confidentiality of information and communications revealed in the course of treatment. In these cases, the clinician cannot release any information about my family without my expressed and informed permission. There are some exceptional circumstances where clinicians are required or permitted to communicate information about mental health services to persons outside the family. I am aware that an agent of my insurance company, billing service or other third-party payer may be given information about the type(s), cost(s), date(s), and providers of any services or treatments I receive. Other exceptions include the following situations:

• The client presents a clear and present danger to himself or herself and refuses to accept appropriate treatment.

• The client communicates to the clinician an imminent threat of physical violence against a clearly identified or reasonably identifiable victim, or the clinician has a reasonable basis to believe there is a clear and present danger of physical violence against such a victim.

• The client introduces his or her mental condition as a defense in a legal proceeding.

• In child custody or adoption cases, the judge determines that the clinician has information bearing significantly on the client's ability to provide suitable care or custody and this information bears significantly on the welfare of the child.

• The client initiates legal action against the clinician, and client information is necessary or relevant to the clinician's defense.

• The clinician has grounds to believe a child under the age of 18, an elderly person (over age 60), or a handicapped adult, has been or is at risk of being abused or neglected.

• A Judge orders a clinician to release client information. With a properly signed Release of Information, I understand that Treatment Summary letters may be provided in lieu of releasing the complete psychological records to a requesting party.

I have discussed responsibility for payment for treatment and I assume financial responsibility for myself and/or my family members for all psychological services rendered; including psychotherapy, psychological testing, and other psychological services. I understand that if I am using an insurance plan, payment by an insurance company cannot be guaranteed. I understand that I am responsible to meet my insurance deductible and co-payments, in addition to payment for any services not covered by my insurance carrier. If my insurance carrier refuses to make payment, I accept responsibility for prompt payment for any treatment and services rendered to myself and/or my family. Independent Contractors reserve the right to release necessary and relevant information to a collection agency regarding overdue balances or fees owed for services provided.

If an emergency arises after working hours and in the event that I cannot contact my clinician, I will call 911 or go to the nearest emergency room if I believe I am a danger to myself or others, or my child may be a danger to him/herself or others.

My signature below shows that I have read, understand and agree with all of the statements within this Consent for Treatment. A photocopy of this agreement will be considered valid as an original.