New client information and paperwork
Please note: this paperwork should only be completed once you and a specific therapist have agreed to work together. Please visit our website and go to the "therapists" tab and reach out to a specific therapist if you have not done so already.
Mantra Mental Health, LLC does not discriminate based on age, gender, sexuality, race, ethnicity, religion, national origin, language, education, married status, body size, political affiliation, philosophical values, (a)sexual orientation, (a)gender identity/expression, fashion self-expression or creative abilities, mental or physical abilities, social-economic status, genetic and family history, HIV or STD status, medication status, veteran status, or past mental health concerns.
Mantra Mental Health, LLC information
Main Office Phone Number: 614-984-4394
Fax number: 614-319-5618
Mailing Address: 4041 North High Street, Ste 300H, Columbus, Ohio 43214
Therapist contact info:
Sam Bergstein MSW, LISW (therapist and owner):
Telehealth link: https://doxy.me/sambergstein
Victoria Alexander MSW, LISW-S (therapist and independent contractor):
Telehealth link: https://www.therapyportal.com/p/mantramental/login/
Client Portal: https://www.therapyportal.com/
Scheduling and billing:
Please email your therapist if you need to reschedule your appointment. You can also use the client portal (above) to cancel appointments.
Please direct billing questions to your therapist
Payment, accepted insurances, and fees (please note that fees and accepted insurances may be changed or adjusted, if your insurance changes or you lose your insurance, please discuss fees and insurance changes with your therapist immediately).
There are some restrictions on our ability to take some plans and some out-of-state plans. There are also some plans that specific therapists are unable to take at this time. Please email your therapist to verify that they are able to take your specific plan.
Please check with your insurance to identify if there are restrictions on which providers you can see with your insurance if you are unsure.
Please check with your therapist to be sure they take your insurance at the beginning of treatment as well as when you change insurance companies and/or insurance plans within the same company.
Unless you opt to not use your insurance, you must provide us with your primary insurance and secondary if you have a secondary plan (as well as any other plans that should be billed per your primary insurance). If you're unsure which insurance plan is primary or secondary, please contact your insurance company prior to treatment. If you do not provide us with accurate insurance information, it may result in improper billing. Claims may be paid in the short term but your insurance company will revoke the payment weeks or months after the claim originally was filed if the proper hierarchy of insurance plans were not provided (primary, secondary, etc). In this case, you will be responsible for the full fee of the session.
If you are unsure about the details of your insurance copay or deductible, it is a good idea to check with them before your first appointment so you do not have any unexpected fees. Once you have agreed for us to bill your insurance and once we have sent a claim for your session to insurance, it is typically non-reversible. Although we will attempt to understand your insurance requirements and fees, it is your responsibility to ask your insurance about expected fees for routine outpatient behavioral health services if you are concerned about finances and/or if you do not know the details of your insurance. Insurance companies require “CPT” (service codes). The codes that may be used for your sessions may include but are not be limited to: 90791, 90837, 90834, 90832, 90791-GT, 90837-GT, 90834-GT, and 90832-GT. It may be helpful to have these codes handy when calling your insurance company. You will want to have both your provider name (Either Samantha Bergstein or Victoria Alexander) as well as our business name (Mantra Mental Health, LLC) handy when you call your insurance.
Some insurance plans cover an entire session, however, this is not always the case. You may have a copay or coinsurance for your session which can range from but is not limited to $3.00-$50.00. This rate is set by your insurance plan and is non-negotiable. You may also have to pay the full fee of the session if you have not met your deductible which may range from but is not limited to $68.00-$180.00 per session. By agreeing to use your insurance, you agree to pay any and all fees set forth by your insurance company. You also agree to pay for services rendered not covered by insurance.
Notify your therapist immediately if your insurance provider or coverage changes. By engaging in services, you indicate an understanding that if your insurance has changed, there is a possibility that fees may have changed as well and that you may owe more or less based on your new insurance provider.
We will not rebill sessions as "private pay" once a session has been completed.
We will not rebill "private pay" sessions to your insurance once a session has been completed.
Starting March 1, 2021, Mantra Mental Health, LLC implemented same-day payments for services. This means that we will require to have a card on file to charge after each session. This payment will go through as soon as directly after your appointment but may take as long as a week to go through. If there are holidays or your therapist takes a vacation, it may delay the charging of your card. This charge will be based on what we know of your current deductible, copay, and fees your insurance has indicated up to this point. If your insurance ends up covering sessions that have been charged, (for example, if you met your deductible near the time of our session, we may not have this information from your insurance company yet) you will be issued a refund. This policy is in alignment with overall best practices and recommendations from professionals in the field for many reasons including consistency and avoiding accruing a large balance.
It is important for you to have a valid card on file. If there is an issue with charging your card on file, you will be asked to provide an additional payment method or pay via Square invoice and save your card on Square to be charged in the future. If payment is not received 24 hours before your next appointment, your next appointment and appointments after that may be canceled until payment is received.
We will be sending you a separate link to join the client portal and complete a credit card authorization form on the client portal. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until canceled. This card will be used for copays, no-show fees, late cancellation fees, and other amounts you may owe. Please note, it is required to have a card on file with us unless you have Medicaid.
If your HSA/Credit/Debit card expires or is declined, you will be asked to provide a new credit card for us to charge. You may also be asked to immediately pay a Square invoice. Failure to do so may result in the cancellation of future sessions until a new card is provided and the balance is paid.
Please note HSA/Credit/Debit information is stored in our secure, HIPAA compliant portal. It is our duty to take measures to protect your private health and payment information and we take this duty very seriously. If you’d prefer to send your credit card info through the mail we can send you a form to print yourself, fill out, and send to us but this must be received by your next appointment time.
You are expected to pay any invoices for services at the time of invoice. Exceptions to this expectation must be discussed and agreed upon ahead of time (before the session). Failure to pay invoices at the time of invoice without clear communication about the reason for doing so may result in the cancellation of future appointments and possible termination of services. Please your therapist If you have concerns about an invoice. Invoices are non-negotiable. It is part of my contract with your insurance company and code of ethics that I collect fees for services. Failure for me to do so is unethical and a breach of my contract with the company.
We will be asking for you to upload a photo or copy of your insurance card to the portal annually as well as if your insurance changes at any point throughout the year.
"Self-pay" refers to paying for services without the use of insurance.
$180 per 50-60 minute session
$210 for the "Intake" appointment (first appointment).
The fee for a late cancellation (canceling less than 24 hours before a telehealth session and less than 72 hours for an in-person session) is $50 unless you have Medicaid.
You will be charged the full fee of your session for a “no show” (not showing to telehealth or in-person sessions as scheduled and not calling ahead of time to cancel. Your session is considered a no-show if you're 15 or more minutes late to your session) unless you have Medicaid.
A session that is interrupted and lasts 17 minutes or less for standard sessions and 16 minutes or less for new client intakes may be considered a late cancellation and you will be charged the $50 cancellation fee unless you have Medicaid.
Although there is a window for cancellation that will prevent you from having to pay the late cancellation or “no-show” fee, if you are frequently canceling appointments this can impact the ability for us to make therapeutic progress and also may make it difficult for other clients who need to be seen be scheduled in a timely manner. Thus, if the 24-hour or 72-hour cancellation policy is used very frequently, it may be required for us to problem-solve in order to reduce overall cancellations. Excessive cancellations, even within the 24-hour period, may result in termination of services if a solution cannot be reached.
If you “no show” (don’t show for your appointment and don’t call or email me to notify me that you cannot make your appointment), all appointments after this date may be canceled and will need to be rescheduled. It cannot be guaranteed that your original appointment time will still be available. Please notify your therapist as soon as possible if you are unable to make an appointment.
Although Medicaid clients are not charged a $50 dollar fee for late cancellations or the full fee for “no-shows” as earlier stated, frequent (3 or more) missed appointments or “late cancellations” may result in termination of services.
The cancellation policy applies to your first session.
A “Sliding scale” self-pay fee (temporarily reduced fee based on income) may be available but must be discussed prior to the first session. This is typically a temporary arrangement.
Your therapist may or may not offer a sliding scale. Please ask your specific therapist if this is an option.
Please note, this option is typically based on income, socioeconomic factors, current circumstances, is typically considered a short-term option, and cannot be guaranteed due to the limited number of clients that this is able to be offered to. Additionally, sliding scale fees may or may not be able to be billed through insurance and may not be able to go towards your deductible.
By signing this document you confirm that you read through, understand, and agree to the following: Mantra Mental Health is not a mental health crisis resource. This means, outside of appointment times, your therapist cannot guarantee that they can be reached. Thus, if you are thinking about killing yourself or hurting someone else, you should use a crisis resource (See below). It also means that your therapist may not get your message or emails immediately and will attempt to return your calls or emails within 48 hours on business days and/or days that your therapist typically works. Your therapist will not be accessible during planned vacations, holidays, etc.
CRISIS & AFTER HOURS 24/7 RESOURCES
911- Please call 911 in the event of a mental health emergency/immediate threat to safety inflicted by self or others
Mental health (panic, depression, anxiety, suicidal thoughts, etc)
Nationwide Children’s Hospital (Ages 17 and Under) 614-722-1800
NetCare Access (Ages 18 and Older)
614-276-CARE (2273) or 888-276-CARE (2273)
National Suicide Prevention Lifeline (All ages) 1-800-273-TALK (8255) or text “HELLO” to 741741
Crisis Text Line (All ages) Text “4hope” to 741-741
NIMH Depression & Panic Disorder Hotline 1-800-421-4211
Veterans Crisis Line 1-800-273-8255 or text 838255 HIV/AIDS
CDC National HIV & AIDS Hotline 1-800-342-2437
National Eating Disorder Association Hotline
1-800-931-2237 or text “NEDA” to 741741
Trans Lifeline 877-565-8860
Trevor Lifeline (LGBTQ+) 1-866-488-7386 or text “START” to 678678
LGBTQIA+ Violence Hotline (all ages) 773-871-2273
Substance use and other compulsive behaviors
Compulsive Gambling Hotline 1-800-522-4700
Alcoholics Anonymous Local Central Office (24h) 614-253-8501
Narcotics Anonymous Local Office (24h) 614-251-1122
The Recovery Village (Addictions and Alcohol Hotline) 844-244-3171
Relapse Prevention Hotline 1-800-RELAPSE (7352773)
Domestic Violence, Community Violence, and Sexual Assault
Sexual Assault Response Network of Central Ohio (SARNCO) 24-hr Rape Helpline (All ages) 614-267-7020
CHOICES for Victims of Domestic Violence (All ages) 614-224-4663
U.S. National Domestic Violence Hotline (all ages, English and Spanish) 1-800-799-7233
BRAVO Buckeye Region Anti-Violence org (all ages) 24/7 reporting 866-862-7286 Abuse, neglect, and youth respite
Huckleberry House youth crisis line (17 or under) 614-294-5553
STAR House homeless youth drop-in center (ages 14-24) 614-826-5868
National Runaway Safeline (Youth Runaway) 1-800-786-2929
Franklin County Children’s Services (to report neglect or abuse) 614-229-7000
Adult Protective Services (ages 65+) 614-525-4348
Treatment is confidential generally, examples of exceptions include, but are not limited to the following:
· You threaten to harm yourself or someone else.
· If you disclose known abuse or neglect of a dependent (abuse of a child, a disabled individual, an elder, or an animal).
· If you are a minor and there is information that is needed to share with your caregiver to keep you safe and healthy. Generally, both parents have a right to obtain your treatment records (see the minor section later).
· Your insurance provider may request information to complete an insurance claim.
· For in-person sessions, health officials may request information about dates or times you have been in the office for COVID-19/contact tracing purposes.
· The unlikely event that a court or administrative agency issues a subpoena signed by a judge or the appropriate person at any agency to acquire your health records.
· Please check the practice’s Notice of Privacy Practices for more information on exceptions and client
Services may be terminated for the following reasons:
· Verbal or physical threats towards staff or other individuals in the building (this includes over the phone, video, or in-home sessions).
· Non-compliance with treatment or extended periods without involvement in services. Your case will be closed approximately 60 days after our last session unless we have otherwise discussed a planned break from therapy beforehand. If you do not return to therapy within the discussed timeframe, your case will be closed approximately 60 days after that timeframe has passed. Please note that if you disengage in services for 60 or more days and would like to return, you may be required to wait 3 or more weeks for a session depending on availability in your therapist's schedule.
· Non-compliance with important recommendations surrounding other services you may need.
· Three or more missed appointments without sufficient notice (see “Cancellation Policy” section above) may result in termination from services.
· You have not paid outstanding balances as expected 3 or more times or after 3 or more discussions about the concerns. If you fail to pay, the practice reserves the right to send your balance due to collection. In that event, only the minimum amount of information necessary to do that will be disclosed. It is our ethical and legal obligation to require payment for services once services have been rendered. This includes all copays and fees set forth by your insurance provider.
If you or the client (if the client is a minor or a ward of a guardian) become involved in legal proceedings that require my participation you will be expected to pay for all of my professional time, even if I am called to testify by another party. I will ask that a retainer be paid of half of the expected fees at least one week prior to providing these services, and the second half of expected fees and any additional fees that may have been accrued be paid within one week after services are delivered. Any unused amounts will be refunded. My professional time for legal proceedings may include preparation, document review or letter preparation, phone consultation with other professionals or you, record copying fees, and travel time to and from proceedings, testifying, and time that I wait in court prior to or after I may be called to testify. Due to the time-consuming and often difficult nature of legal involvement, I charge $200.00 per hour. You will also be responsible for any legal fees that I may incur in connection with the legal proceeding, which may include responding to subpoenas.
The laws and standards of my profession require that I keep Protected Health Information about you in your client file. Your client file may include information about your reasons for seeking therapy, a description of the ways in which your problems affect your life, your diagnosis, the goals for treatment, your progress toward those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, any payment records, and copies of any reports that have been sent to anyone. You may examine and/or receive a copy of all of your records that I have prepared in connection with your treatment if you request them in writing unless I determine for clearly stated treatment reasons that disclosure of the records to you is likely to have an adverse effect on you, and in that event, under Ohio law, I may exercise the option of turning the records over to another mental health therapist designated by you, unless otherwise required by federal law. Because these are professional records that can be misinterpreted and/or upsetting to untrained readers, I, therefore, recommend that you initially review them with me or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge fees set under Ohio and federal laws for copying and sending records. These fees may change every year, so I will let you know what the charge is at the time that a records request is made. If you desire to have the information sent to you electronically, if I maintain the information in an electronic format, I will provide the information in that format if you agree to accept the potential risks involved in sending the information that way.
As your therapist, I will keep a set of psychotherapy notes which are for my own use and which are designed to assist me in providing you with the best treatment. These notes are kept separate from the rest of your records. In order for psychotherapy notes to be released to third parties, you must sign a separate authorization in addition to one for the rest of your records
If you are under 18 years of age, please be aware that the law generally provides your parents the right to examine your treatment records, unless blocked by court order or if I feel that the release of your records to your parents might have an adverse effect on you, in which case under Ohio law they can name another mental health therapist that I will have to turn them over to, unless otherwise required by federal law. Before giving parents any information I will discuss the matter with you, if possible, and do my best to handle any objections you may have. Except in unusual circumstances, I like to make both parents aware of and involved in the treatment. In addition, if one parent brings in a child and the therapy only involves the child, under Ohio law since generally, both parents have access to the child’s records unless that access is blocked by court order, anything that either parent says in the sessions is available to both parents. Legal documents need to be provided in cases where custody, visitation, shared parenting, guardianship, or other matters which are covered by court documents are involved before I see a minor for treatment. Minors 14 years of age and older should be aware that they have an option to see me on a limited basis without their parents’ knowledge, except where there is a compelling need for disclosure based on a substantial probability of harm to the minor or to other persons, and if the minor is notified of my intent to inform the minor’s parent, or guardian. Only the minor is responsible for paying for services under this option.
Incapacity or Death of Therapist
In the event that I am incapacitated or die, it will be necessary for another therapist to take possession of your file and records. By signing this form you consent to allow another licensed mental health professional whom I designate to take possession of your file and records, provide you with copies upon request, or deliver them to a therapist of your choice.
Disclosing Information to Family Members, Relatives, or Close Friends
By signing this document you agree to allow me, if you are incapacitated, in an emergency situation or are not available, to contact a family member, a relative, a close friend, or any other person you identify, and disclose your personal health information that directly relates to that person’s involvement in your healthcare. This information will be disclosed as necessary only if I determine that it is in your best interest based on my professional judgment.
Email, Texting, and Electronic Communications
I do not like to use e-mail, texting, or electronic communications unless we both agree that is appropriate. If you decide you want do not want to utilize any form of electronic communication, please let me know. By contacting me via email, text, or other electronic communications you acknowledge that there are confidentiality risks inherent in such communications if they are unencrypted and you agree to accept those risks. Please note that due to COVID19 and me conducting all sessions via telehealth, it may be difficult or impossible to hold sessions without some electronic communication. If this is an issue for you, we can discuss referral options to an alternate provider who may provide in-person sessions at this time.
By signing this document you agree that you understand the risks involved in unencrypted electronic communications and agree to accept such risks in communications from either me to you or you to me that involve scheduling and/or therapy.
What to Expect from Mantra Mental Health
· Your first 1-2 sessions will consist of a diagnostic assessment which involves discussion of symptoms, family and social history, goals for therapy, and medical background. It is important for us to get to know each other and for your therapist to know this history before diving into deep therapeutic work.
· We understand some subjects may be difficult to discuss in the first few sessions. Some questions that your therapist may ask are important for your therapist to understand your life, are a part of a “diagnostic assessment” which is required by insurance companies and is considered best practice overall, and some questions are essential to ensure safety. Please note that if there are any topics including but not limited to those surrounding your family history, trauma history, or identity that you are not comfortable exploring in the first sessions, this will not impact your ability to be seen by using your insurance so please let your therapist know if you are not comfortable answering certain questions. We will however ask that you prepare yourself to answer questions surrounding safety (thoughts of self-harm, suicidal thoughts, or homicidal thoughts) and ask that you let your therapist know if you are struggling with drugs, alcohol, or eating disorders.
· Sessions typically run between 45-55 minutes. Your therapist will keep track of time but please note that sessions between 55-120+ minutes are a possibility but must be agreed upon when scheduling the appointment. Sessions over 60 minutes may require additional fees which will likely not be covered by your insurance. If we happen to go over our time by a few minutes, we will not charge extra but if it happens often we will need to come up with a plan.
· Therapy is a team effort. We will work together to develop goals and identify needs for treatment. Please note that it may take time to prepare for specific types of therapy including EMDR and general trauma treatment depending on symptoms, safety concerns, your window of tolerance for stress, and general level of functioning.
· Your therapist’s goal is to best meet your needs and provide services catered to your specific symptoms, goals, and needs for therapy. Please note that engagement in therapy services does not guarantee a specific outcome. Therapy is a combined effort of the therapist and client (you), so quality change or improvement in symptoms may require some work on your part.
· Know that requests for letters such as those for emotional support animals or gender-affirming medical care have specific requirements and ethical limitations. Your therapist is not permitted to provide recommendations or letters outside of their scope of practice and training. Please discuss this with your therapist if this is a specific letter is a primary goal of yours.
· Letter requests, except for gender-affirming care letter requests, may require an additional fee of up to $100.00 which will not be covered by your insurance coverage.
· Letter requests, if within therapists’ scope of practice, will be met in a timely manner but you are required to give your therapist at least 30 days to complete a letter. This process may be quicker but is greatly dependent on your therapist’s workload, other clients’ needs, and the therapist’s personal needs.
We understand that sometimes you may seek a specific type of therapy based on a recommendation, past experiences, or research you have done. By engaging with this therapist, you acknowledge that there is always a possibility that the type of therapy you seek may not be the most appropriate or best method to address your concerns. You also understand that engaging in therapy with this provider does not guarantee a specific outcome.
Mantra Mental Health strives to use holistic, integrative, evidence-based practices in order to deliver the best possible services for you.
With this said, your therapist's methods may include a combination of various types of therapy. For example, if you request "DBT therapy", this can be accommodated but it is likely that most sessions will involve a combination of different methods in addition to DBT.
Please refer to our website for more information on therapeutic approaches.
Virtual (telehealth/telebehavioral health) sessions
We are still holding most sessions via secure video due to COVID-19. All new clients will begin with telehealth-only sessions through the assessment period. Please discuss concerns with your therapist if using a video platform is not possible. It is best practice and safest for us to hold video sessions rather than phone sessions if possible as there is importance in our visual cues and understanding of your surroundings to ensure the safest and most effective session. we do understand that there are some barriers to using video for sessions so if this is a problem, we can troubleshoot the issue together.
What is telehealth?
Telebehavioral health (telehealth) includes the practice of the diagnosis, treatment, education, goal setting, accountability, referral to resources, problem-solving, skills training, and help with decision making through the use of internet-based video conferencing or phone calls. The benefits of telebehavioral health include greater flexibility by geographical location, reduction of travel to a physical office, and participation from your own home environment.
Instructions for video/telehealth sessions:
Please use the telehealth link that your therapist provides to you before your first session.
Please try your best to be on time for your session.
There is always a chance your therapist may be a couple of minutes behind if the client before you has complex needs, if there are technology issues, etc. We appreciate your patience with this.
Troubleshooting with telehealth—the connection or video are not working.
· Make sure all other video apps or websites are closed on your device.
· Connect to Wi-Fi or an ethernet cable if possible.
· Close any streaming services and unneeded tabs.
· Call your therapist if you are still unable to connect.
Acknowledgment of Informed Consent to Telehealth Services
1. By signing this document, you understand that as a client of Mantra Mental Health, LLC you understand it is possible that at some point in my treatment, some or all of your services will be provided via Telehealth, as described below. You understand and agree to the following with respect to the use of Mantra Mental Health, LLC's Telehealth services:
2. You understand that Telehealth is health/mental health services provided by Mantra Mental Health, LLC via interactive audio and video technology while the provider is at a different location than me. Telehealth will be provided by your Mantra Mental Health, LLC therapist: Samantha Bergstein MSW, LISW; or Victoria Alexander MSW, LISW-S
3. You understand that these Telehealth services may involve the communication of health information, orally and visually, to health care practitioners. Specifically, you understand that Telehealth services include, but are not limited to consultation, treatment, and transfer of health data using interactive audio and video.
4. The laws that protect the confidentiality of your health information apply to these services the same as in-person services. As such, you, the client, understand that the information disclosed during any Telehealth session is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality.
5. You understand that there are risks and consequences of using these services including, but not limited to, the possibility that, despite Mantra Mental Health, LLC's reasonable efforts, the transmission of my health information could be disrupted or distorted by technical failures and/or the transmission of my health information could be intercepted or accessed by unauthorized persons and you agree to accept these risks. You agree that Telehealth is appropriate for your circumstances despite these risks. You understand that when you receive Telehealth services from a location other than at Mantra Mental Health, LLC, your own device and Internet connectivity may impact the quality of the services and that The Mantra Mental Health, LLC does not have control over your end of the transmission.
6. You understand that Telehealth services may not be the same as in-person services, where non-verbal communication (body signals) are readily available to both provider and client. You also understand that issues with technology such as poor internet connection and sound issues may impact the quality of your session. Mantra Mental Health, LLC's Telehealth provider will further discuss this limitation with you should you receive Telehealth services. You also understand that, if your provider believes you would be better served by another form of therapeutic services (e.g., in-person services or a specific type of therapy not offered by Mantra Mental Health, LLC) you will be referred to a professional who can provide such services in your area.
7. If our Telehealth session abruptly terminates, the Mantra Mental Health, LLC provider will immediately call you at the number(s) provided at the time of intake. Together we will either attempt to regain the contact via Telehealth technology or, if unable to do so, we will either reschedule or finish the service via telephone, if appropriate.
8. Only agreed-upon participants will be present in the room of the clinician and the client during the telebehavioral health session. It is important to be in a quiet, private space that is free of distractions (including computers, additional phones, or other devices) during the session.
9. Nobody will record the session without the permission of the other person(s).
10. Sessions will not occur while any of the participants are driving.
11. You understand that in order to have telehealth sessions, you must be in Ohio. If you will be out of the state, it is your responsibility to reschedule our appointment.
12. If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in telebehavioral health sessions.
13. We need a safety plan that includes at least one emergency contact and the closest ER to your location, in the event of a crisis situation.
14. It is important to be on time. If you need to cancel or change your tele-appointment, you must notify the clinician in advance by phone or email. Please give your therapist at least 24 hours notice by email or phone to cancel telehealth sessions.
Other client responsibilities and considerations:
· Attend scheduled appointments as discussed. Log into the virtual portal or answer the phone or have your telehealth session set up on your computer at or before appointment time for telehealth sessions.
· Just as with in-person sessions, you should treat your scheduled telehealth appointment as a solidly planned commitment. Please inform your therapist as soon as possible via email or phone call if you need to cancel or reschedule your appointment.
· Inform your therapist of any changes in contact information and emergency contact information. It is very important for your safety and for us to be able to do our job ethically that we have up-to-date contact information for you and for your emergency contact.
· Inform your therapist prior to the first session if you are seeking therapy based on a court order and if your therapist will be expected to report to the court, probation officers, or other entities. We cannot provide recommendations on guardianships, visitation, or custody issues, nor on disability applications.
· Give a minimum of 24-hours notice when unable to attend a scheduled telehealth session and 72-hours notice for in-person sessions. You can call your therapist, email, or reschedule through the client portal. This cancellation policy applies to your first session.
· If you consent to text and/or email communications, you will be sent a reminder about 24 hours before your appointment. It is also your responsibility to track your sessions. If you receive the text and it seems the appointment time is not accurate or not what you wrote down, please contact us immediately by email so we are able to troubleshoot and reschedule if needed.
· We are not able to see you if you are not physically in the state of Ohio. Please reschedule your telehealth appointment at least 24 hours ahead of time if you will not be in Ohio during our appointment time.
· Inform your therapist prior to the first session if you are seeking therapy based on a court order and if your therapist will be needed to report to the court, probation officers, or other entities. These issues may or may not fall in your therapist’s scope of practice so please let them know as soon as possible.
· If a minor or ward of a guardian is involved and there are court orders on custody/visitation or guardianship, you agree to provide that information prior to the minor or ward receiving services.
· Know that requests for letters such as those for emotional support animals or gender-affirming medical care have specific requirements and ethical limitations. I am not permitted to provide recommendations or letters outside of my scope of practice and training. Please discuss this with as soon as possible your therapist if this is a primary goal of yours.
· Letter requests, except for gender-affirming care letter requests, may require an additional fee of up to $100.00 which will not be covered by your insurance coverage.
· Letter requests, if within therapists’ scope of practice, will be met in a timely manner but you are required to give your therapist at least 30 days to complete a letter. This process may be quicker but greatly depends on the therapist’s workload, other clients’ needs, and the therapist’s personal needs.
· You have the right to request your records and request that your records are sent to other providers. Please note there may be a minimum fee of $15.00 in fees associated with acquiring or sending records including but not limited to copying, postage, faxing fees, and labor/time. Requests for records will be met in a timely manner through please know that this can be a time-consuming process and it may take time for your therapist to compile these. Your therapist’s goal is to best
meet your needs and provide services catered to your specific symptoms, goals, and needs for therapy. Please note that engagement in therapy services does not guarantee a specific outcome. Therapy is a combined effort of the therapist and client (you), so quality change or improvement in symptoms may require some work on your part. Results are typically not immediate, depending on the presenting issues you seek therapy for, long-term engagement in therapy may be necessary to achieve your desired outcome.
Although we may typically hold only individual sessions (just you and your therapist), there may be times it may be therapeutically appropriate to have another person in session (such as a spouse, parent, friend, etc.). Please let me know beforehand if you would like to have another person attend our session so we can discuss the circumstances, how this may be helpful, if it is ethically appropriate and in your therapist’s scope of practice, and so you are able to provide consent to have another individual in session (as our sessions are considered protected health information by HIPAA). If you do not notify your therapist beforehand, the therapist is not able to prepare and ensure that they are following ethical guidelines thus you will be asked to schedule a separate session including this individual and hold a current session without this individual present.
Notice of Policies and Practices to Protect the Privacy of Your Health Information for Mantra Mental Health, LLC / Samantha Bergstein, MA, MSW, LISW 4041 North High St., Ste. 300H, Columbus, OH 43214 / Ph: 614.984.4394
THIS NOTICE DESCRIBES HOW MENTAL HEALTH AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Uses and Disclosures for Treatment, Payment, and Health Care Operations
“I” refers to the Mantra Mental Health LLC owner Samantha Bergstein and your Mantra Mental Health, LLC therapist if your assigned therapist is not Samantha Bergstein but is another contracted therapist within the practice.
I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes in most instances without your consent under HIPAA, but I will obtain consent in another form for disclosing PHI for other reasons, including disclosing PHI outside of my practice, except as otherwise outlined in this Policy. In all instances, I will only disclose the minimum necessary information in order to accomplish the intended purpose. To help clarify these terms, here are some definitions:
“PHI” refers to information in your health record that could identify you.
“Treatment” is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another therapist.
“Payment” is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage, which would include an audit. Please note, insurance/healthcare reimbursement may not cover the entirety of your session cost.
“Health Care Operations” are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
“Use” applies only to activities within my practice, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
“Disclosure” applies to activities outside of my practice, such as releasing, transferring, or providing access to information about you to other parties.
Uses and Disclosures Requiring Authorization
I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances, when I am asked for information for purposes outside of treatment, payment, and health care operations, I will obtain an authorization from you before releasing this information, including uses and disclosures of PHI for marketing purposes, and disclosures that constitute a sale of PHI. Examples of disclosures requiring an authorization include disclosures to your partner, your spouse, your children, except in some limited instances where they are involved in your health care, in which case I will obtain your consent first. Any disclosure involving psychotherapy notes, if I maintain them, will require your signed authorization, unless I am otherwise allowed or required by law to release them. You may revoke an authorization for future disclosures, but this will not be effective for past disclosures which you have authorized.
Uses and Disclosures Requiring Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization as allowed by law, including under the following circumstances:
Serious Threat to Health or Safety: If I believe that you pose a clear and substantial risk of imminent serious harm, or a clear and present danger, to yourself or another person I may disclose your relevant confidential information to public authorities, the potential victim, other professionals, and/or your family in order to protect against such harm. If you communicate to me an explicit threat of inflicting imminent and serious physical harm or causing the death of one or more clearly identifiable victims, and I believe you have the intent and ability to carry out the threat, then I may take one or more of the following actions in a timely manner:
· take steps to hospitalize you on an emergency basis
· establish and undertake a treatment plan calculated to eliminate the possibility that you will carry out the threat, and initiate arrangements for a second opinion risk assessment with another mental health professional
· communicate to a law enforcement agency and, if feasible, to the potential victim(s), or victim's parent or guardian if a minor, all of the following information: a) the nature of the threat, b) your identity, and c) the identity of the potential victim(s). I will inform you about these notices and obtain your written consent if I deem it appropriate under the circumstances.
Felony Reporting: I am allowed to report any felony that you report to me that has been or is being committed.
For Health Oversight Activities: I may use and disclose PHI if a government agency is requesting the information for health oversight activities. Some examples could be audits, investigations, or licensure and disciplinary activities conducted by agencies required by law to take specified actions to monitor health care providers or reporting information to control disease, injury, or disability.
For Specific Governmental Functions: I may disclose PHI of military personnel and veterans in certain situations, to correctional facilities in certain situations, and for national security reasons, such as for the protection of the President.
For Lawsuits and Other Legal Proceedings: If you are involved in a court proceeding and a request is made for information concerning your evaluation, diagnosis, or treatment, such information is protected by law. I cannot provide any information without your (or your personal or legal representative’s) written authorization, or court order, or at times an administrative subpoena unless the information was prepared for a third party. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.
Worker’s Compensation: If you file a worker’s compensation claim, I may be required to give your mental health information to relevant parties and officials.
Abuse, Neglect, and Domestic Violence: If I know or have reason to suspect that a child under 18 years of age or a developmentally disabled adult or child, or animal has suffered or faces a threat of suffering any physical or mental wound, injury, disability, or condition of a nature that reasonably indicates abuse or neglect, the law requires that I file a report with the appropriate government agency.
Once such a report is filed, I may be required to provide additional information. If I have reasonable cause to believe that a developmentally disabled adult, or an elderly adult in an independent living setting or in a nursing home is being abused, neglected, or exploited, the law requires that I report such belief to the appropriate governmental agency. Once such a report is filed, I may be required to provide additional information. If I know or have reasonable cause to believe that a patient or client has been the victim of domestic violence, I must note that knowledge or belief and the basis for it in the patient’s or client’s records
To Coroners and Medical Examiners: I may disclose PHI to coroners and medical examiners to assist in the identification of a deceased person and to determine a cause of death.
For Law Enforcement: I may release health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons, or similar process, subject to all applicable legal requirements.
Required by Law. I will disclose health information about you when required to do so by federal, state, or local law.
Public Health Risks. I may disclose health information about you for public health reasons in order to prevent or control disease, injury, or disability; or report births, deaths, non-accidental physical injuries, reactions to medications, or problems with products.
Information Not Personally Identifiable. I may use or disclose health information about you in a way that does not personally identify you or reveal who you are.
Other uses and disclosures will require your signed authorization unless the use or disclosure is allowed or required by law.
Patient's Rights and Therapist Duties
Right to Request Restrictions and Disclosures–You have the right to request restrictions on certain uses and disclosures of protected health information about you for treatment, payment, or health care operations.
However, I am not required to agree to a restriction you request, except under certain limited circumstances, and will notify you if that is the case. One right that I may not deny is your right to request that no information be sent to your health care plan if payment in full is made for the health care service. If you select this option then you must request it ahead of time and payment must be received in full each time a service is going to be provided. I will then not send any information to the health care plan for that session unless I am required by law to release this information.
Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. If your request is reasonable, then I will honor it.
Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record, except under some limited circumstances. If I maintain the information in an electronic format you may obtain it in that format. This does not apply to information created for use in a civil, criminal, or administrative action or proceeding. I may charge you reasonable amounts for copies, mailing or associated supplies under most circumstances. Under certain stances where I feel, for clearly stated treatment reasons, the disclosure of your record might have an adverse effect on you, I will provide your records to another mental health therapist of your choice.
Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request but will note that you made the request. Upon your request, I will discuss with you the details of the amendment process.
Right to an Accounting – With certain exceptions, you generally have the right to receive an accounting of disclosures of PHI, not including disclosures for treatment, payment, or health care operations for paper records on file for the past six years and for an accounting of disclosures made involving electronic records, including disclosures for treatment, payment or health care operations, for a period of six years. At your request, I will discuss with you the details of the accounting process.
Right to a Paper Copy – You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically. You will not be automatically provided a paper copy unless requested.
I am required by law to maintain the privacy of PHI, to provide you with this notice of my legal duties and privacy practices with respect to PHI, and to abide by the terms of this notice.
I reserve the right to change the privacy policies and practices described in this notice and to make those changes effective for all of the PHI I maintain.
If I revise my policies and procedures, which I reserve the right to do, I will make available a copy of the revised Notice to you on my website or on the client portal, if I maintain one, and one will always be available at my office. You can always request that a paper copy be sent to you by mail.
In the event that I learn that there has been an impermissible use or disclosure of your unsecured PHI unless there is a low risk that your unsecured PHI has been compromised, I will notify you of this breach.
If you are concerned that I have violated your privacy rights, or you disagree with a decision I make about access to your records, you may file a complaint with me and I will consider how best to resolve your complaint. Contact me, the Privacy Officer, if you wish to file a complaint with me. In the event that you aren’t satisfied with my response to your complaint, or don’t want to first file a complaint with me, then you may send a written complaint to the Secretary of the U.S. Department of Health and Human Services in Washington, D.C., 200 Independence Avenue S.W., Washington, D.C. 20201, Ph: 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/compliants/.
There will be no retaliation against you for filing a complaint.
This notice is effective as of August 1, 2020
Privacy and Security Officer:
I, Samantha Bergstein, MSW LISW, act as my own and Mantra Mental Health, LLC’s Privacy and Security Officer. My contact information is listed at the beginning of this form. I have sought expert legal, ethical, and clinical guidance regarding Privacy and Security best practices.
Mantra Mental Health, LLC Service and Payment Agreement
By signing this form and setting appointments with Mantra Mental Health, LLC you indicate that you have read and agree to the above information and that:
· You agree to provide credit card information for Mantra Mental Health, LLC to hold on file securely (unless you have Medicaid) which will be used for copays, session fees, late cancellation fees, missed appointment fees, or any other payments you need to make.
· You understand that you are responsible for providing up-to-date and accurate insurance information and that a change in insurance plan could result in a full fee charge or change in payment expectations. Should your insurance coverage end or not provide coverage, you understand you will be responsible for the full cost of services.
· If paying with a check, you authorize Mantra Mental Health, LLC to deposit the check with Fifth Third Bank. If a check is rejected, you agree to pay a $35 returned check fee.
· You understand that if you choose to pursue services without your insurance, the fee is $150.00 per standard therapy session and $180 for the first (intake) session.
· You understand that Mantra Mental Health, LLC utilizes TherapyNotes CardPoint secure credit card processing and Square for invoices and card processing.
· You agree to be sent invoices via Square and understand that payment via Square may be requested.
· You understand that Mantra Mental Health, LLC uses the HIPAA-compliant electronic health record system, TherapyNotes.
· You agree to be contacted by cell phone, email, and TherapyNotes secure client portal. Text appointment reminders and texted links to join sessions may also be required. Please notify your therapist if you are not comfortable receiving text reminders.
· You understand that it is not permitted by the therapist’s ethical code of conduct to hold sessions while you are under the influence of drugs or alcohol, driving, or in another state unless prior approval is obtained.
· You agree to engage in Telehealth sessions via the Doxy.me, Psychology Today, Google Meet, or TherapyNotes video portal depending on which portal works best with our connection or which your therapist utilizes.
· You agree to provide an emergency contact and understand that this person may be contacted in the event that your therapist is worried about your well-being/mental health symptoms and is unable to contact you.
Acknowledgment of Informed Consent to Treatment
By signing this document, you agree that you voluntarily agree to receive mental health assessment, care, treatment, or services and authorize your Mantra Mental Health, LLC therapist to provide such care, treatment, or services as are considered necessary and advisable. You further authorize the submission of information to an insurance company or third-party payer, to obtain reimbursement unless otherwise discussed.
By signing this document, you agree that you understand and agree that you will participate in the planning of your care, treatment, or services and that you may stop such care, treatment or services that you receive through Mantra Mental Health, LLC at any time. You also understand that there are no guarantees that treatment will be successful.
By signing this document you agree that you Acknowledgment of Informed Consent to Treatment, you, the undersigned client, acknowledge that you have both read and understood all the terms and information contained herein and you agree to be bound by the provisions in this agreement. Ample opportunity has been offered to you to ask questions and seek clarification of anything unclear to you. If a minor or an adult with a court-appointed guardian is the client, you are signing on behalf of the minor or ward as the authorized parent/guardian. (Information on Minor rights will be shared with the minor or the ward as appropriate.)
By signing this document you agree that you acknowledge that you have received a copy of the Notice of privacy.
You agree that Mantra Mental Health, LLC may release information about your claim(s) to the Ohio Department of Insurance in connection with any insurance company’s failure to properly pay a claim in a timely manner as well as to the Ohio Department of Commerce, which requires certain reporting of unclaimed funds. In those instances, only the minimal, required, information will be supplied.
You agree that from time to time Mantra Mental Health, LLC owner and/or therapist may have the need to consult with their practice attorney regarding legal issues involving your care (this is an infrequent occurrence but does happen from time to time). The practicing attorney is bound by confidentiality rules also. In addition, the Mantra Mental Health LLC owner and/or therapist will reveal only the information that is needed to reveal to receive appropriate legal advice in connection with those contacts.
You understand that the Mantra Mental Health LLC owner and/or therapist may practice with other health professionals and that Mantra Mental Health, LLC may employ administrative staff. In most cases, Mantra Mental health, LLC will need to share protected information with these individuals for both clinical and administrative purposes, such as typing, scheduling, billing, and quality assurance and you agree that I may do that. If the Mantra Mental Health LLC owner and/or therapist does that, they will only release the information necessary in order<