Thank you for beginning this journey. No matter what the response has been from your immediate friends, families, or inner critic, you are making a good decision. Therapy is an inviting place where every single part of you is welcome, even the parts that are uncomfortable to share. As licensed therapists, we are honored that you chose this process as your vehicle to healing. 

If this is your first time in therapy, welcome. Our guess is that getting started can be pretty scary — to talk to someone you do not know about things that make you uncomfortable, sad, angry, overjoyed, or embarrassed — but we would like to reassure you that this processis here to help you grow and heal. 

There are certain elements necessary in therapy in order to maintain a space of positivity, growth, and healing. Yet, you are not responsible for maintaining those elements. That is the job of the therapist — our job. We maintain a judgment-free space, a space that is challenging but comforting, and a process that is enlightening as well as retrospective. 

For those who have been to therapy before and are starting again, welcome back. Whether you’re trying a new therapist after a not-so-good counseling experience, or whether you’re returning because previous experiences have helped you foster a sense of trust in therapy and it's benefits, you are welcome here. We are glad that you have returned to therapy to continue your personal growth. We hope that your time in therapy will be as positive as previous therapeutic journeys, or that it will allow new growth that was stifled by a prior unhelpful experience. Returning to therapy after some time will likely mean revisiting work that you did before and figuring out together what your path is now. 

We ask that you bring your authentic and whole self to each session. We encourage you to allow yourself to experience any emotion or thought freely. For example, crying without needing to apologize and voicing your feelings with confidence. If you are not quite there yet, we hope you will allow us to help you reach that point. It is our genuine desire that every human that knocks on our door, journeys along their therapeutic path with a renewed sense of understanding and self-appreciation. 

This packet contains important information about my professional services and business policies. Please read it carefully and ask any questions that you might have so that they can be discussed at your initial sessions. Once you review and sign, this packet will constitute as the agreement between us. 

Thank you for your cooperation and patience in filing out this packet!

At the time of service, your Wavelength therapist will collaborate with you to schedule your next session. We adhere to a flexible scheduling pattern, recognizing that a weekly set appointment time may not be suitable for everyone.

If a set weekly appointment aligns with your preferences and schedule, we will make every effort to maintain that consistency. We value your time and strive to provide you with at least 24 hours' notice if we ever need to reschedule a session.

Please be aware that we do not schedule sessions on Saturdays. Sunday morning sessions may be available on an as-needed basis.

Daily, we are often not immediately available by telephone. Our telephones are usually answered by voicemail which we monitor frequently. We will make every effort to return your call on the same day with the exception of weekends and holidays. If you cannot reach your therapist, and you feel that you cannot wait for us to return your call, please call your primary care physician, 911, or go to the nearest emergency room and ask for the mental health professional on call.

• New Jersey: 211 is a free referral and information helpline that connects people to a wide range of health and human services including mental health, 24 hours a day, 7 days a week. Dial 211 from any phone.
• New York: NYC Well is 24/7, free, confidential, and available for all New Yorkers. If you are in crisis or would like emotional support, please call 1-888-NYC-WELL, text WELL to 65173.

Our office hours are from 8:00 AM to 8:00 PM, Monday through Thursday. On Friday, we are available between the hours of 8:00 AM and 5:00 PM. For non-emergency emails, calls, and/or text messages received after 7:00 PM from Monday to Thursday and after 3:00 PM on most Fridays, we aim to respond on the following business day.

Because Wavelength Psychotherapy, LLC therapists are not often immediately available by telephone, email and text messaging, may be a primary contact between you and your therapist.

I {namefirstlast} consent to receive text messages and/or e-mail from my Wavelength Psychotherapy, LLC assigned therapist, on my cell phone or other devices. I understand that text messages sent by my therapist may include appointment reminders, my meeting Zoom link and/or changes in previously scheduled appointments. My therapist may also reach out with guidance or to check-in about scheduling sessions moving forward.

I {namefirstlast} understand that Wavelength Psychotherapy, LLC does not charge its' clients for this service, but that standard text message rates may apply as provided my wireless plan.

I {namefirstlast} understand that I may revoke my request for further communications via text or e-mail at any time by notifying my therapist in writing. However, if I continue to communicate with my therapist via text or e-mail, my therapist and/or Wavelength Psychotherapy, LLC support staff can assume that my consent remains valid.

Lastly, because e-mail sent over the internet or text messages sent over the control channel without encryption are not secure, I {namefirstlast} understand the risks associated with e-mail and text messaging, including; without limitation, that e-mails and text messages could be intercepted by unknown third parties, e-mail content can be changed without the knowledge of the sender or receiver, backup copies of e-mail may still exist even after the sender and receiver have deleted the messages, and e-mail can contain harmful viruses and other programs.

Wavelength Psychotherapy, LLC recommends that I delete all text messages or e-mail as soon as possible after receiving them in order to help prevent any unauthorized exposure.

Due to the importance of your confidentiality and the importance of minimizing dual relationships, Wavelength Psychotherapy, LLC therapists DO NOT accept friend and/or contact requests from current or former clients on any social networking site (i.e. Facebook, Instagram, LinkedIn, etc).

We believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship.

If you have any questions regarding this matter, please feel free to raise them during your session with your therapist, and they will be available to provide further information and address your concerns.

PROFESSIONAL FEES:

Below are Wavelength Psychotherapy's professional rates for service(s).

PLEASE NOTE: Fees are subject to quarterly review. 

PAYMENT:

Wavelength policy requires that all anticipated payment responsiblities and visit fees be collected at the time of service. All fees for services rendered must be paid at the time of service, unless alternative arrangements have been pre-approved by Wavelength's billing department (hello@wavelengthpsychotherapy.com).

For both insurance and self-pay clients, credit card information is required to be kept on file to facilitate the payment of professional service fees. This includes, but is not limited to, charges for copayments, coinsurance, late cancellations, missed appointments, and overdue balances.

Payment methods accepted include: Most Credit Cards and Cash (for in-person clients only).

HEALTH INSURANCE AND BILLING:

Your health insurance is a contractual agreement between you and your insurance company, intended to assist in covering medical care costs. If you opt to use your health insurance for your care expenses, our billing department will promptly submit claims directly to your insurance provider after each service. We submit claims on a biweekly basis. 

Once we have submitted your claim to your health plan, it generally takes 45-90 days for the plan to review the details of the claim and determine the final cost for the session. Health plans can also reprocess claims weeks or months after the initial processing if they identify an error in their internal processes after the fact.

It is important to note that insurance companies do not guarantee payment for services, and you, the client, assume ultimate responsibility for any expenses incurred if your insurance coverage falls short of expectations. You are responsible for payments of services not covered by your insurance carrier and must negotiate with your insurance company directly for any unpaid services. Unpaid services may encompass, but are not limited to:

•  If your insurance carrier denies or rejects payment(s) for any rendered services, resulting in non-coverage, you will receive an invoice and be charged the full session rate. 
• In the event of a lapse in your insurance policy, and we are not notified before your next appointment, you will be invoiced and charged the full session rate.
• Your health plan determines that the services received are not medically necessary and/or covered by the insurance plan, you will be invoiced and charged the full session rate.

We strongly advise you to familiarize yourself with your outpatient mental health benefits before your first appointment. 

*A NOTE ON SECONDARY INSURANCE: Please be advised that insurance companies do not coordinate benefits with secondary insurance. We do not submit secondary claims; however, if you wish to forward your claims to your secondary insurance for reimbursement, we will provide you with an invoice for each session, which you can forward to your secondary insurance and/or supplemental insurance.

*A NOTE ON MEDICAID, MEDICARE and/or COMMUNITY-BASED INSURANCE PLANS: We do not accept Medicaid, Medicare, or any Community-Based insurance plans. It is the client’s responsibility to review their individual insurance card for this information prior to proceeding with this packet. If you have any questions about your insurance coverage, we recommend contacting your insurance provider directly to confirm your plan details.

BALANCES:

Wavelength Psychotherapy, LLC does not permit clients to carry a balance.

Any outstanding balances not settled within 30 days of services rendered will be automatically charged to the card on file. This includes all fees and charges associated with the provided services.

If you are unable to pay, we will discuss whether it makes sense to pause your care or develop another payment strategy so that you can avoid incurring further charges. Should the need arise, our therapists will make every effort to help you find the care you need with a different service provider.

If no attempt to pay within 90 days for outstanding fees is made legal recourse may occur.

SELF PAY 

If you are paying out-of-pocket, all fees are charged directly to you at the time of service using the payment method on file, not through your insurance company. You are responsible for payment.

At the end of each month, a superbill detailing the services provided will be issued through our Electronic Health Record system. You may use this document to submit directly to your insurance carrier for reimbursement. Please note, we are not responsible for assisting with the reimbursement process beyond providing the superbill.

OUT OF NETWORK:

If you are eligible for out-of-network services, it means that Wavelength Psychotherapy is not affiliated or credentialed with your insurance company. However, if your plan includes out-of-network benefits, your insurance company will typically reimburse you directly once you've met your deductible. 

*Clients receiving out-of-network care at Wavelength are required to pay the entire cost of services upfront. 

Once you confirm your plan provides out-of-network coverage our team, we will send a superbill each month for you to submit directly to your insurance carrier for reimbursement. The insurance company will assess the superbill, determine the eligible amount based on their out-of-network coverage policy, and then issue reimbursement directly to you (the client). 

Remember to confirm the estimated reimbursement amount with your insurance company as they have the most up-to-date information about your benefits. Additionally, if you are going to have telehealth sessions, it is important to confirm you are eligible for telehealth services.

Questions to ask your insurance representative:

• “Does my plan include out-of-network benefits for mental health care? Specifically, for outpatient psychotherapy?” “And, telehealth visits?”
• “Do I have a deductible for out-of-network mental health services? If yes, what is the remaining amount I will have to pay before my health plan starts to reimburse me for fees that I pay out-of-pocket?”
• “What is the maximum amount my plan will reimburse for mental health service code 90837 with a Psychotherapist?” If the rep does not provide a clear answer, ask: “What is the maximum allowed amount for mental health service code 90837 with a psychotherapist, and what percentage of the maximum allowed amount will my plan pay?” (This percentage of the maximum allowed amount is the amount you would receive as reimbursement.)

LATENESS, MISSED APPOINTMENTS & CANCELLATION POLICY:

As therapists, we work as service providers. Therefore, our only commodity is our time and expertise. We hold your scheduled appointment time(s) specifically for you and you alone.

LATENESS:

If you are running late for your session, please let us know in advance. If you arrive late for your session, we will still end at our regularly scheduled time and you will be billed for the full the professional rate.

If we do not hear from you within 10 minutes into your session, we will text and/or e-mail to check on you. If we do not hear from you within the first 20 minutes of your session you will be deemed a 'no-show,' and your session(s) will be forfeited. You will be charged for the full professional rate to the credit card on file.

MISSED APPOINTMENTS & CANCELLATIONS:

The full professional fee is applied and charged to the card on file for all appointments cancelled with less than a complete 24-hour notice, unless the appointment is rescheduled within the same week as the initially scheduled session. (Please note: that this is contingent upon the availability of your therapist).

This means that if an appointment is scheduled for 3:00 pm on a Tuesday, notice must be given by 3:00 pm on Monday at the absolute latest. If your appointment is on a Monday, the cancellation needs to be provided no later than the prior Friday, by your appointment time, to be considered proper 24-hour notice. You can cancel your appointment by calling your provider and/or emailing.

Again, for all missed (no-show) appointments and late cancellations your credit card on file will be charged directly. We do not bill insurance for your cancellations and/or no-show appointments.

FREQUENT CANCELLATIONS OR MISSED APPOINTMENTS: 

Frequent cancellations (3 or more in 6 months or 3 consecutive) and/or missed appointments (no show) will result in the termination of treatment. If you have arranged with your therapist to have recurring appointments, the next recurring appointment will stay in the calendar. 

Although Wavelength Psychotherapy may send you text or email reminders about upcoming appointments, this is done as a courtesy and only if you consent to receive such communications by providing us with your email address and cell number. It remains your sole responsibility to keep track of and timely attend all scheduled therapy appointments, whether or not you receive the text or email reminder.

It is your responsibility to inform the administrative assistant and/or your therapist (hello@wavelengthpsychotherapy.com) if your phone number or email has changed. 

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Wavelength Psychotherapy, LLC reserves the right to amend the above Financial Policies at any time, and these modifications will apply to all our clients. In the event of any changes to this policy, Wavelength will provide you with a revised policy for your review and signature.

I {namefirstlast} hereby acknowledge that I have read, understand, and agree to all financial policies outlined above and/or pertaining to the use of health insurance, billing, professional rates, payments, balances, lateness, missed appointments and cancellations. By signing this agreement, I legally commit to complying with these policies.

Wavelength Psychotherapy, LLC requires you to provide your credit card information on file. This is so we can automatically charge professional service charges such as, late cancellations, missed appointments, and/or overdue and unpaid balance(s) for all services rendered. It is the client's responsibility to keep credit card information accurate and up to date. 

If a balance acrues and remains unpaid, Wavelength Psychotherapy, LLC reserves the right to suspend services until the balance is paid in part or in full. If no payment is received, Wavelength Psychotherapy, LLC reserves the right to seek payment by any means, including charging the credit card information on file, retaining a collection agency, and taking legal action.

Wavelength Psychotherapy, LLC stores ALL financial information in an encrypted, HIPAA compliant site (SimplePractice, LLC).

I {namefirstlast} understand that I am eligible to receive a range of services from my therapist. The type and extent of services that I receive will be determined following an initial assessment and thorough discussion with me. The goal of the assessment process is to determine the best course of treatment for me. Typically, treatment is provided over the course of several weeks.

I{namefirstlast} understand that I have the right to ask questions throughout the course of treatment and may request an outside consultation. I also understand that my therapist may provide me with additional information about specific treatment issues and treatment methods on an as-needed basis during the course of treatment and that I have the right to consent to or refuse such treatment. 

I {namefirstlast}understand that I can expect regular review of treatment to determine whether treatment goals are being met. I agree to be actively involved in the treatment and in the review process. No promises have been made as to the results of this treatment or of any procedures utilized within it. I further understand that I may stop treatment at any time, but agree to discuss this decision first with my therapist.

By providing my signature below, I {namefirstlast} understand the practice of behavioral health treatment is not an exact science and acknowledge that no one has made guarantees or promises as to the results that I may receive. I voluntarily request and consent to behavioral health assessment, care, treatment, or services and authorize my Wavelength Psychotherapy, LLC therapist to provide such care, treatment or services as are considered necessary and advisable.

By signing this Informed Consent to Treatment Form, I {namefirstlast} acknowledge that I have both read and understood the terms and information contained herein. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.

The law protects the privacy of all communications between a therapist and a client. In most situations, Wavelength Psychotherapy, LLC therapists can only release information about your services to others if you sign a written Authorization Form that meets certain legal requirements imposed by HIPAA. HIPAA stands for theHealth Insurance Portability and Accountability Act.

Your Wavelength Psychotherapy, LLC assigned therapist will take appropriate precautions to keep your health information confidential and to not disclose it without your consent.

It is important that you read the Notice of Privacy Practices which is located on our website www.wavelengthpsychotherapy.com under Forms for more detailed explanations. You may request a paper copy.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that you discuss any questions or concerns that you may have with your therapist.

Exceptions when your information would not be protected:

1) When there is risk of imminent danger to myself or to another person, my therapist is ethically bound to take necessary steps to prevent such danger.

2) When there is suspicion that a child or elder is being sexually or physically abused, or is at risk of such abuse, my therapist is legally required to take steps to protect the child, and to inform the proper authorities.

3) When a valid court order is issued for medical records, my therapist is bound by law to comply with such requests. 

CONSULTATION:

Therapists at the Wavelength Psychotherapy, LLC consult regularly with other professionals regarding their clients; however, each client's identity remains completely anonymous and confidentiality is fully maintained.

AGREEMENT 

I {namefirstlast} am aware that I must authorize my therapist, in writing, to release information about my treatment but that confidentiality can be broken under certain circumstances of danger to myself or others.

I {namefirstlast} understand that once information is released to insurance companies or any other third party, that my therapist cannot guarantee that it will remain confidential. 

This form is to educate you about Telehealth and/or video conferencing psychotherapy sessions. When we cannot meet in person due to health or other concerns, video conferencing is an option available to all of us.

WILL TELEHEALTH AND/OR VIDEO CONFERENCING PSYCHOTHERAPY WORK FOR YOU?

Currently, Wavelength Psychotherapy offices operate under a hybrid model. Meaning we offer both in-person and Telehealth sessions.

Our therapists are familiar with Telehealth and want you to know that it becomes more natural with time. It is very important that your therapy sessions remain helpful and not harmful for you. So, we will check in regularly about how Telehealth is working for you and make adjustments as needed.

TECHNOLOGY FOR VIDEO CONFERENCING SESSIONS:

Video conferencing psychotherapy sessions are provided on a HIPAA compliant Zoom and/or SimplePractice Platform. Both platforms allow for real time video communication. You will need a computer, tablet, iPad or smartphone with a video camera. Twenty-four hours prior to your appointment, you will receive a reminder with your Video/Zoom link. At time of our session, click on the link. You will enter a virtual waiting room and I will admit you to our private 'Zoom/Video-Room.'

LIMITATIONS (including confidentiality) DUE TO USE OF THIS TECHNOLOGY: 

A variety of technological problems can cause delays in starting meetings or can interrupt a meeting. If you lose internet connection, please email your therapist directly. If you cannot successfully reconnect online, you can continue your meeting on the telephone and/or reschedule for another video meeting.

No one can guarantee that a connection via the internet is 100% secure. The following are steps that we can take to increase security and confidentiality:

1. The Zoom video-conferencing platform is HIPAA-compliant. Our meetings are encrypted with AES-256 bit encryption and are dynamic password protected. You can read more about Zoom security here: https://zoom.us/docs/doc/Zoom-hipaa.pdf

2. Both the client and therapist agree not to have any other individuals in the 'meeting room' while we hold your video session. Please find a private space in your home or other location that allows for confidentiality. Your therapist will do this as well.

3. In our experience, despite our best efforts, interruptions at home tend to occur during video conferencing sessions. People may forget we are holding a meeting and walk in, other phone lines and doorbells may ring, pets also have a way of making their presence known, etc. We should anticipate these kinds of interruptions.

RECORDING POLICY: 

Recording of therapy sessions via in-person or Telehealth is strictly prohibited. If requested, recordings of sessions may be approved only if ALL parties involved (including your therapist) sign an agreement for those particular sessions.

AGREEMENT:

I {namefirstlast}have read the above information on video conferencing psychotherapy (Telehealth), the limitations, the confidentiality caveats and the recording policy. With this understanding, I wish to participate in Telehealth and/or video conferencing psychotherapy sessions when health or other concerns prohibit our ability to meet in person.

TERMINATION OF THERAPY: 

You may terminate therapy at any time or at your discretion. Your Wavelength Psychotherapy therapist, also, reserves the right to terminate therapy services at their discretion. Reasons for termination include, but are not limited to, untimely payment of fees, failure to comply with treatment recommendations, conflicts of interest, failure to participate in therapy, client needs are outside of therapist's scope of competence or practice, or client is not making adequate progress in therapy.

Upon either party’s decision to terminate therapy, Wavelength generally recommends that clients participate in at least one, or possibly more, termination sessions.

These sessions are intended to facilitate a positive termination experience and give both parties an opportunity to reflect on the work that has been done. We will also attempt to ensure a smooth transition to another therapist by offering professional referrals, if requested.

BY SIGNING THIS FORM I {namefirstlast} ACKNOWLEDGE THAT:

• I have read in its' entirety Wavelength Psychotherapy's, LLC, Welcome Packet.
• I have been offered a copy of my completed and signed Welcome Packet.
• Understand my rights under HIPAA (Health Insurance Portability and Accountability Act of 1996).
• By signing this agreement, {namefirstlast}, agrees to waive, release and discharge Wavelength Psychotherapy, LLC, and my assigned Wavelength therapist from any and all liability, including, without limitation, any injuries that may occur during the provision of services under this agreement.
• I, {namefirstlast}, have read, understand and agree to the information provided above and to the terms of this entire agreement including but not limited too, costs of services, payment methods, scheduling, and cancellations policies. 

WAVELENGTH PSYCHOTHERAPY, LLC

HELLO@WAVELENGTHPSYCHOTHERAPY.COM

REVISED DECEMBER 2024