CLIENT-PSYCHOTHERAPIST CONTRACT AND BUSINESS POLICIES
Commitment to Weekly Attendance. Clients are expected to attend therapy every week, and to make every reasonable effort to avoid absences, including rescheduling within the week when there is an unavoidable conflict with the regular session time. However, rescheduling is often difficult given the limited time slots available. This is especially true for teletherapy clients, because I am limited to seeing teletherapy clients during those times when I am in a location with strong internet connectivity. So the more advanced notice you can provide, the better.
Cancellation Policy. I require a minimum of 48 hours notice (2 business days) for cancellations and reschedules. Do not assume I received your message until you hear back from me. Clients who do not provide 48 hours notice are responsible for full payment for the session, which I will charge to your credit card on file. Please note: insurance will not pay for missed sessions, so you will be responsible to pay my full contracted rate (your copayment + the amount your insurance would normally pay me).
Contacting Me. You can reach me at (415) 295-2150. If it is something that can wait until our next session, it’s best if we discuss it in person. I reply to calls during business hours (8a-6p), except in the case of a crisis, in which case I’ll call you back as soon as I can.
*Please note: I do not communicate with clients by text message. Email exchanges are reserved only for scheduling concerns, and for me to send you handouts or referral information, if desired. These are boundaries I have chosen thoughtfully and which I believe are in the best interest of both myself and my clients.*
Confidentiality. All information disclosed to me by a client is held confidential and will not be disclosed to anyone without your written permission, except where disclosure is required by law; where you have requested the disclosure; or where disclosure is made to another health professional for the purpose of professional consultation and coordination of care.
Conditions for Disclosure of Confidential Information. I am required by law to break confidentiality in the following situations: (a) where the therapist has reasonable suspicion of child, elder or dependent adult abuse, actual or potential (including abuse in the past); (b) where the client has made a serious threat of physical violence against another identifiable person; (c) where the client poses a danger to himself or herself or to the person or property of another; or (d) where a court order has been issued requiring disclosure.
Fees. Payment is due prior to the start of each session by cash, check, or Venmo. I reserve the right to periodically adjust my fee with notice. We will discuss my fee by the end of your first session.
Insurance Plan. You agree to update me immediately upon any changes to your health insurance. It is important for me to track whether or not you have insurance for which I am a contractor provider.
Therapist Availability and Process for Emergencies. In the event that you are feeling unsafe or in immediate crisis, I invite you to call me at (415) 295-2150. I make every effort to return calls on the same day, but as a sole practitioner, I cannot guarantee 24-hour crisis service. If you do not hear back from me or you require immediate assistance, you can call 911 or go to the nearest emergency room. I also have a list of crisis lines and other resources on the homepage of my website at MaysieTiftTherapy.com. If you are having suicidal thoughts or making plans to harm yourself, you can get immediate, free 24-hour support by calling the National Suicide Prevention Lifeline at 1.800.SUICIDE, or by texting 741741. Any time you feel you need an extra session, please let me know. Many insurances allow clients to attend therapy more than once per week.
TELEMEDICINE
Telemedicine/Telehealth. You have elected to engage in telemedicine with Maysie Tift, MFT as part or all of your treatment. You understand that “telemedicine” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, and/or data communications. You understand that telemedicine also involves the communication of your medical/mental information, both orally and visually, to health care practitioners located in California or outside of California. you understand that you have the following rights with respect to telemedicine:
1. You have the right to withhold or withdraw consent at any time without affecting your right to future care or treatment, nor risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
2. The laws that protect the confidentiality of your medical information also apply to telemedicine. Certain mandatory and permissive exceptions to confidentiality, such as those listed above, also apply to telemedicine. You understand that the dissemination of any personally identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your written consent.
3. You understand that there are risks and consequences from telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of your psychotherapist, that: the transmission of your medical information could be disrupted or distorted by technical failures; the transmission of your medical information could be interrupted by unauthorized persons; and/or the electronic storage of your medical information could be accessed by unauthorized persons. In addition, you understand that telemedicine based services and care may not be as complete as face-to-face services. You also understand that if your psychotherapist believes you would be better served by another form of psychotherapeutic services (e.g. face-to-face services) you will be referred to a psychotherapist or mental health agency who can provide such services in your area. Finally, you understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite your efforts and the efforts of your psychotherapist, your condition may not be improve, and in some cases may even get worse.
4. You understand that you may benefit from telemedicine, but results cannot be guaranteed or assured.
5. You understand that payment for telemedicine sessions may be difficult to obtain from insurance companies in some cases. You understand that you are responsible to pay in full for any sessions that your insurance refuses to cover, and your cost will be based on Ms. Tift’s full fee if she is not in network with your insurance company. Please let Ms. Tift know if you’ve been denied reimbursement.
6. You accept that telemedicine does not provide emergency services. Ms. Tift will discuss an emergency response plan with you.
7. You understand that you are responsible for (a) providing the necessary computer, telecommunications equipment and internet access for telemedicine sessions, (b) the information security on your computer and related devices, and (c) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for your telemedicine sessions.
8. You understand that you may use email to communicate with Ms. Tift about scheduling and other logistics, but confidentiality of emails cannot be guaranteed. Ms. Tift discourages clients from disclosing confidential or sensitive information by these methods.
9. You understand that you have a right to access your medical information and copies of medical records in accordance with California law.
Acknowledgement. By signing below, you acknowledge that:
1. You have reviewed and fully understand the terms and conditions of this Agreement, and have been given access to this document to review if you desire. You have discussed such terms and conditions with Maysie Tift, the Therapist, and have had any questions with regard to its terms and conditions answered to your satisfaction. You agree to abide by the terms and conditions of this Agreement, and you consent to participate in psychotherapy with Maysie Tift, MFT. Moreover, you agree to hold Maysie Tift free and harmless from any claims, demands, or suits for damages from any injury or complications whatsoever, save negligence, that may result from such treatment.
2. You have been informed that Ms. Tift's Notice of Privacy Practices is posted for you on her website (“Forms and Handouts for Clients” page)
3. You authorize the release of any medical or other information necessary to process insurance claims.
4. You authorize payment of medical benefits to Maysie Tift, MFT for mental health services.
5. You are financially responsible to Maysie Tift, MFT for all charges, including unpaid charges by your insurance company or any other third-party payor. You authorize Ms. Tift to charge your credit card on file for missed sessions, and for cancellations/ reschedules with less than 48-hours notice.