Financial Agreement

I, {nameOfRepresentative}, on behalf of myself/or {nameOfPatient} request service from Kanaris Psychological Services, P.C. and understand that I am responsible for the payment of these services. I agree to keep my account current. I understand that all payments or co-payments are due at the time of the session. I also understand and agree to pay for any fees that my insurance company will not pay regardless of the reasons for the denial of payment. I understand that any cancelled appointment without advanced 24 hours notice is subject to a $30 cancellation fee. If I fail to show up for my scheduled appointment and give no prior notice, I agree to pay the full fee for the missed session.

Emergencies and Messages:
In case of emergency, clearly, inform the secretary that it is an emergency. Your therapist or another covering therapist will be contacted and will call you back as soon as possible. Messages may be left with the secretary, the answering services, or on the answering machine. Be sure to leave your name, phone number, and a BRIEF message. The therapist will return your call ASAP. Recognize that if you leave an emergency message on the answering machine it may be quite some time before you are called back. In the event of a delayed call back, you are advised to call 911 or go to the nearest hospital emergency room.

Confidentiality Statement:
I understand that information about psychotherapy is almost always kept confidential by the therapist and will not be revealed to others without my written consent. There are a few possible exceptions. Some of these are:

1. The therapist is required by law to report suspected child abuse or neglect to the authorities.
2. In the event that you tell the therapist that you intend to harm another person, the therapist may be required to take steps to warn or protect that person by informing that person, the police or other health care providers. Similarly, if you indicate an intent to harm yourself or if your life or health is determined by the therapist to be in immediate danger, the therapist may take steps to try to protect you, including telling others such as a relative, police or other health care providers.
3. The therapist is mandated to report to the authorities patients who are at imminent risk of harming themselves or others for the purpose of those authorities checking to see whether such patients are owners of firearms and if they are, or apply to be, then limiting and possibly removing their ability to possess them.
4. If you are involved in certain court or litigation proceedings, the therapist may be required by law to reveal information about your treatment. These situations include, but are not limited to, child custody, and visitation disputes, cases in which a patient's psychological condition is at issue. lawsuits, or formal complaints against the therapist, civil commitment hearings and court ordered treatment.
5. If your health insurance or managed care plan will be reimbursing you or paying the therapist directly, it will require you to waive confidentiality and require the therapist to provide them with detailed information about your condition and treatment. In the event you are part of a managed care system, you recognize that treatment parameters may be dictated by the managed care company. You recognize that coverage for treatment may be terminated by the managed care company. You recognize that should additional sessions beyond those provided by the plan be necessary, they are your responsibility. 
6. It is agreed and understood that if a couple is in treatment, and one member of the couple requests a release of records, then the second member of the couple must also sign a release.
7. It is agreed and understood that if a child is in treatment, and one custodial parent or guardian requests a release of the records, then the second custodial parent or guardian must also sign a release.
8. The therapist may need to consult with other therapist about your treatment, but in doing so would not reveal your name or other identifying information about you without your consent. Furthermore, when the therapist is away or unavailable, another therapist who is covering may answer calls and will, therefore, need to have some information about your treatment. In some emergency situations, information necessary for treatment by another professional may be revealed so that emergency treatment may be provided.
9. Should there be a need for your therapist to give a deposition or to provide testimony in court, there is a set fee of $6,000.00 per day, or part thereof.
10. Should there be a request for your therapist to speak to your legal representative, you recognize that all records may be released to your representatives with your written permission. You will be responsible for all copying and postal costs. Additional treatment summary reports will be charged at $250 per report.
11. If your account with the therapist becomes overdue and you do not work out a payment plan, the therapist will have to reveal a limited amount of information about your treatment in taking legal measure to be paid.
12. You recognize that although the aim of psychotherapy is to ultimately feel and function better than the state that led to seeking services, you may experience a worsening after an individual session or may experience initial decline from current functioning levels.
13. You agree and understand that there is no guarantee or warranty regarding the success of psychotherapy. Although the therapist will endeavor to do his best, the success of psychotherapy is also dependent upon the efforts of those in treatment.

In all situations described above, I understand the therapist will try, whenever possible, to discuss the situation with me before any confidential information is revealed and will reveal only the least amount of information necessary.

 

I HAVE READ THE ABOVE GUIDELINES, FINANCIAL AND INFORMED CONSENT AND CONFIDENTIALITY STATEMENTS, UNDERSTAND AND AGREE TO THEM AS WRITTEN. 

Prior to starting videoconferencing services, I understand, and agree to the following:

• There are potential benefits and risks of video-conferencing (e.g. limits to patient confidentiality) that differ from in-person sessions
• Confidentiality still applies for telepsychology services and nobody will record the session without permission.
• We agree to use the video-conferencing platform selected for our virtual sessions, and the psychologist will explain how to use it.
• You need to use a webcam or smartphone during the session.
• It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session.
• It is important to use a secure internet connection rather than public/free Wi-Fi.
• It is important to be on time. If you need to cancel or change your tele-appointment, you must notify the psychologist in advance by phone or email.
• We need a back-up plan (e.g. phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems.
• 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.
• If you are not an adult, we need the permission of your parent or legal guardiang (and their contact information) for you to participate in telepsychology sessions.
• You should confirm with your insurance company that the video sessions will be reimbursed; if they are not reimbursed, you are responsible for full payment.
• As your psychologist, I may determine that due to certain circumstances, telepsychology is no longer appropriate. You will then be given a referal to mental health professionals that conduct sessions in-person.

Dr. Kanaris understands that privacy and confidentiality are essential when specializing in the sensitive and personal areas of sex therapy, couples treatment, and infidelity. Dr. Kanaris is not in network in any health plans. If you have, and choose to use, out of network benefits, at your request our office will provide you with a bill for you to submit to your insurance company. The health plan could ask to review care or ask for the therapist's session notes. I have the right to refuse the treatment review or the release of notes, but I understand if I do refuse the insurance plan may not reimburse for those sessions. Dr. Kanaris is not a provider for my health plan, and thus does not guarantee reimbursement or that the documentation kept will meet health plan requirements.

Dr. Kanaris is sensitive to the cost of treatment and he will work with you to establish a pace and frequency of sessions that can balance the clinical need with managing the expense. Most commonly, treatments begin weekly and switch to alternate weeks as progress and momentum develop. Some cases then become monthly until termination of treatment. The pace is established collaboratively through an ongoing dialogue in session with Dr. Kanaris.

The total length of treatment cannot reasonably nor reliably be predicted at the start of treatment. You will get a sense of the length of treatment as you assess progress as treatment unfolds. This will best be determined by active and ongoing dialogue with Dr. Kanaris during treatment sessions.