INFORMED CONSENT & OFFICE POLICIES
(Please Read Carefully)
Appointments are generally made on a regular, weekly basis, with on-going appointments on the same day and time of the week, if and when possible.
Appointment reminder text/email are a courtesy and generated through Therapy Notes. Text reminders come from (215) 543-7686. Please add email@example.com to your address book.
To make, cancel or reschedule appointments, please call or text Dr. Grant to his HIPAA compliant office number at 317.572.7847.
For proper preparation, should you want to bring a spouse/partner etc., to a session, this should be discussed in a session prior to the visit with your guest.
If after 60 days since your last visit, your file becomes inactive (i.e. you are no longer considered an active patient of Dr. Grant’s). Should you return after 60 days since your last visit, you will need to complete a new Demographic Form and Informed Consent.
You might wonder what psychotherapy is.
Psychotherapy is a process in which the patient explores his or her internal processes (e.g., thoughts and feelings) and behaviors (i.e. overt and covert) with the guidance of the psychotherapist. Psychotherapy can be an enjoyable, rewarding, but difficult process as the person in the process changes and learns things about him or herself. Dr. Grant's philosophy is that you get out of psychotherapy what effort and time you are willing to put into it; commitment and dedication is important in the psychotherapeutic process. Metaphorically as your compass, Dr. Grant assists his patients in finding their own answers to their questions/problems. Dr. Grant firmly believes in the saying that "Life is a journey and only you hold the map."
It's important to manage your expectations
. The process of psychotherapy and knowing onself better can be a slow process. Be patient. Be intentional. Be kind and compassionate to yourself. Change doesn't happen overnight.
Sometimes patients might may feel worse before they feel better; this is normal but most patients find the process a relief.
Please place your cell phone on silence while in session.
Payment for the session will be due at the end of the session unless prior arrangements have been made.
You may pay in cash, check, HSA, or credit card.
There will be a $30.00 charge for all checks that are returned.
When paying by credit card, Therapy Notes (i.e. electronic medical records platform) OR the Pocket Suite platform is utilized to collect for services rendered. When paying by credit card, your credit card will be stored in the Therapy Notes or Pocket Suite platforms to make payment and checkout nice and easy. These avenues offer PCI Compliant Credit Card Storage that is safe and secure. There's also the option of paying for the cost of your session via an invoice that is sent via text to your cell phone. Please note that message and data rates may apply.
Credit cards on file are never charged without your permission.
If applicable, your co-pay/co-insurance/deductible will be due at the end of each session; using your health insurance is not a guarantee of payment for services rendered.
Fees below could be different based on Dr. Grant's contracted rates with your insurance carrier, your co-pay, your co-insurance and/or deductibles. Inquire within.
Diagnostic Interview (i.e. first session up to 60 minutes) $175.00
Individual Psychotherapy (i.e. follow-up) $125.00 for 20 to 37 minutes
Individual Psychotherapy (i.e. follow-up) $150.00 for 38 to 52 minutes
Individual Psychotherapy (i.e. follow-up) $175.00 for 53+ minutes
Couples Psychotherapy $200.00 an hour (i.e. 55 to 60 minutes)
Group Psychotherapy: Men's Group $40.00 (i.e. ~ 1.5 hours); Wellness Group $20, ~1 hour, lead by doctoral student
Dr. Grant does not bill insurance for group therapy.
If you're paying out of pocket for services, please ask about the 20% discount
Please arrive, if possible, 5 minutes prior to your scheduled appointment.
When late, please note: if you have a 45 minute appointment starting at 9:00am and you show up at 9:20am, you have 25 minutes left in your session.
Failing to cancel your scheduled appointment without a 24 hour notice:
If you miss an appointment or cancel less than 24 hours prior to your appointment,
you will be charged $50
; this fee is waived if you’re able to be seen the same week. Appointments that are not kept due to inclement weather are waived.
You cannot use HSA funds to pay a late cancellation/no show fee; you will need to use your personal banking/checking or credit card.
This policy exists because we cannot double book appointments. When your appointment is secured, your spot cannot be filled without a 24 hour notice. This policy also pays respect to the therapist who showed up for you. We also honor our cancellations on our patients. If we cancel without a 24 hour notice, you'll receive a $50 credit in your account.
Dr. Grant is unable to bill your health insurance for missed sessions or sessions less than 20 minutes.
If you have not shown for your appointment, been late, or cancelled 2 or more times consecutively, Dr. Grant may decline to schedule future appointments. In this case, appropriate referrals will be made, if requested.
If you're participating in couples therapy, session begins when both couples have arrived.
Please do not bring weapons to the session (i.e. guns, knives etc).
Please do not arrive intoxicated and/or high.
Arriving in this condition does not provide an environment to actively participate in the therapeutic process. If warranted, Dr. Grant will call your emergency contact and have you picked-up.
Please do not bring children under the age of 13 years-old.
Unfortunately, children under this age should not be unsupervised at Dr. Grant’s office.
Also, please do not bring children to your appointment who are not active participants in the therapy process. If this happens, Dr. Grant will cancel/reschedule your appointment.
Because Dr. Grant is unable to provide emergency services, should you have a psychiatric emergency (i.e. you have a plan or method of how you might hurt/kill yourself or someone else), please dial 911 or go to your nearest emergency room.
Should you go to the emergency room or to an inpatient psychiatric facility, to ensure confidentiality, Dr. Grant does not make hospital visits and he does not have hospital privileges.
Have the facility fax your discharge paperwork to Dr. Grant so that Dr. Grant will have this information about your inpatient visit.
If you are NOT at imminent risk of hurting yourself or someone else (i.e. you have an urgent need), and you desire to speak with someone and you're unable to get in contact with Dr. Grant within 30 MIN of leaving a message and/or it's after Dr. Grant's office hours, please call one of the Hotline numbers below:
• The National Suicide Prevention Lifeline, please call
• The local Suicide & Crisis Intervention, Indianapolis, please call
*If you're in imminent danger of hurting yourself or someone else, call 911 or go to the nearest ER
When contacting Dr. Grant by phone, email or text, please limit your conversation needs to appointment scheduling and emergencies.
Dr. Grant is unable to accept requests to connect via his personal Facebook and LinkedIn pages. Should you leave comments on Dr. Grant's blog, your comments will be de-identified. To maintain your confidentiality, Dr. Grant can't follow any of your social media pages.
Dr. Grant attempts to return all voicemails/texts/emails within a 24-48 hour period. Dr. Grant is out of the office Friday through Sunday. If you call/text/email during these times, you can expect Dr. Grant to reach out the following Monday.
There is legal privilege in Indiana protecting the confidentiality of the information you share with me. However, there are legal exceptions to confidentiality. As a professional, Dr. Grant can assure you that he strives to maintain the strictest standards of confidentiality.
You provide written permission to share confidential information.
In couples therapy, both couples have to provide written permission for any information to be released regardless of whether or not you're the identified patient.
When Dr. Grant suspects child/elderly adult abuse or neglect.
Dr. Grant believes that you are at imminent risk of hurting yourself or someone else.
• Here, law enforcement and potential victim is contacted.
You file a complaint against Dr. Grant.
In response to a subpoena. (Regarding subpoena's for couples therapy: The purpose of couples therapy is to decrease stress and improve the relationship. Therefore, if you request Dr. Grant's services as your couple's therapist, you are not to use information given to him against the other party in a judicial setting of any kind. Likewise, neither party shall for any reason attempt to subpoena his testimony or his records to be presented in a deposition or court hearing of any kind for any reason, such as a divorce case).
You’re under the age of 18 years-old and dependent on an adult.
No secrets policy-couples therapy
When entering couples therapy, the understanding is that Dr. Grant is treating the couple (i.e. the unit), and not the individual person. There may be a time that Dr. Grant meets individually with each party; however, whatever is shared individually can be shared in couple's therapy. This creates a safe space for everyone. This also means that Dr. Grant adheres to a strict "No Secrets" policy. He will not hold or contain secretes for either partner. If somehow a secret gets revealed, Dr. Grant will offer opportunities to disclose the pertinent information and will provide guidance in this process, if needed. If the individual refuses to share, Dr. Grant reserves the right to discontinue the therapy relationship with the couple and an appropriate referral can be made, if requested.
To participate in couples therapy, you're required to participate in individual therapy.
Why is this you might ask? Dr. Grant believes that what is discussed and explored in couples therapy can be further evolved and developed in individual therapy and vice versa. This is the surest way, that whatever you may bring to the relationship, can be further understood from an I, me, self perspective. For example, what it is about me, that shapes or impacts this relationship? This also provides the opportunity to talk about issues that have nothing to do with your relationship.
Dr. Grant regularly consults with other professionals to gain other perspectives and ideas as to how to best help you reach your goals.
These consultations are obtained in such a way that confidentiality is maintained. In addition, Dr. Grant may use your clinical material for educational purposes for the students he teaches; your information would be de-identified and confidentiality would be maintained. Dr. Grant's supervisees regularly shadow him and his work with patients. There may be a time Dr. Grant asks your permission that a student in training observe/participate in a session with you. If this is not something you're comfortable with, you're more than welcome to decline the offer. There are no penalties in doing so.
Please feel free to bring a beverage to session with a lid, but unfortunately food is not permitted.
There may be times when you need Dr. Grant to fill out paperwork (e.g., for disability).
Please note that disability paperwork is completed during your session. To obtain an accurate picture of who you are, Dr. Grant does not complete disability paperwork unless he has met with you for a minimum of 6 sessions.
As a courtesy to you, Dr. Grant will check your mental health insurance benefits; however, it is your responsibility to know and understand the limits of your coverage. You agree to be responsible for all charges, even those denied for coverage by your insurance company.
Please call 317.572.7847 should you have questions concerning your insurance benefits or account balance.
If there have been multiple attempts to collect your unpaid balance, and a prior arrangement/agreement has not been made to collect your unpaid balance, Dr. Grant will be unable to see you until your account has been brought current or a payment agreement has been made. This doesn’t apply in emergency cases.
If 90 days have passed since your last visit or last payment without making any arrangement/agreement to pay your balance, Dr. Grant will turn your account over to a collection agency to collect your unpaid balance on behalf of Dr. Grant. Should this happen, please know that your credit score could be impacted.
Should you want to use your Employee Assistance Plan (EAP) benefits, Dr. Grant only permits one series of sessions per year from the start date of your first appointment. That is, unless a new problem presents itself while in treatment and is unrelated to the reason(s) you reached out for treatment initially. For example, you initially reached out for treatment for relationship problems, but your pet died while in treatment.
Please make a note of the following professional services that cannot be billed to your insurance company and for which you are responsible:
Phone consultations to an attorney, a physician, or any other provider with whom you receive services from.
Providing your physician or psychiatrist a brief note of your progress is and can be expected; however, please make sure to complete the Release of Information Form. However, you will retain the costs for letters that you have authorized to provide to courts, attorneys, employers, schools, professional licensing agencies, and letters to doctors regarding gender confirmation surgery, etc.
Time spent conducting psychological testing, report writing, reviewing records, and record copying. Please inquire about the cost of these services.
Costs of the above services (i.e. a, b) are based on Dr. Grant's standard session fee. For instance, if Dr. Grant charges $100.00 per 45 minute session, and you need him to write a letter that takes him 20 minutes to write, your charge would be $ 44.44. **Note** Letters or the like will not be mailed, emailed, or faxed until payment has been received.
Court attendance. Should Dr. Grant appear on your behalf in court, the cost out-of-pocket per hour (i.e. 60 minutes) is $200.00. You’re also required to pay for costs of travel to and from court at $.60 per mile. **Note** That 3 hours will be collected up front prior to Dr. Grant's arrival to court. Whatever time is unused, Dr. Grant will provide a reimbursement 30 days after the court date.
If you see one of Dr. Grant's doctoral practicum students, sessions are $50.00, that is, unless you have a copay that is less than $50. Dr. Grant does not charge more than your copay to see his doctoral students; however, insurance claims cannot be submitted on your behalf since the student is considered 'in training.' If you're unabel to afford the $50 session fee, please have a discussion with your therapist or Dr. Grant on what is reasonable for you based on your financial situation. We do try to meet the financial needs of all our patients.
If you cancel your appointment without a 24 hour notice OR no show for your scheduled appointment with the student, you will still be charged $50.00.
This policy is waived if you can be seen the same week you were scheduled. Although not an exhaustive list, here are some examples of how the cancellation policy is applied: If you cancel your appointment because you're sick, you'll still be charged $50.00. If you're stuck in a meeting, you'll still be charged $50. If you're stuck in traffic, you'll still be charged $50.
Teletherapy. Dr. Grant uses the HIPAA compliant, doxy.me online platform for online therapy. Cost per hour: 60 minutes is $175; 30 minutes is $87.5.
Contact information is updated annually at the beginning of each year. Thus, should you have any changes to your address, phone number, etc., it is your responsibility to make Dr. Grant aware of these changes
Consent for treatment:
PLEASE CHECK THE BOX! I HAVE READ AND AGREE WITH THE ABOVE OFFICE POLICIES. I FURTHER CONSENT VOLUNTARILY TO RECEIVE TREATMENT AND SERVICES FROM MATTHEW GRANT, PSY.D. HSPP. BY SIGNING BELOW, I ACKNOWLEDGE THAT TREATMENT AND SERVICES, GIVEN OR PERFORMED BY MATTHEW GRANT, PSY.D., HSPP CANNOT MAKE OR OFFER A GUARANTEE OR WARRANTY. I UNDERSTAND THAT I AM CONSENTING TO THOSE SERVICES THAT MATTHEW GRANT, PSY.D., HSPP IS QUALIFIED TO PROVIDE WITHIN THE SCOPE OF HIS LICENSE AND TRAINING. YOU HAVE THE RIGHT TO WITHDRAW YOUR CONSENT FOR TREATMENT AT ANY TIME AND FOR ANY REASON. I'M AWARE THAT DR. GRANT ONLY PROVIDES CLINICAL SERVICES, AND WILL REFER PATIENTS TO OTHER PROVIDERS FOR FORENSIC SERVICES.
Should be Empty: