Health Insurance and Confidentiality of Records: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. If you so instruct, your provider, only the minimum necessary information will be communicated to the carrier. Your provider has no control over, or knowledge of, what insurance companies do with the information submitted or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy, or to further capacity to obtain health or life insurance or even a job. The risk stems from the fact that mental health information is likely to be entered into the insurance company system and is likely to be reported to the National Medical Data Bank. Access to computer systems or to the NMDB database is inherently vulnerable to unauthorized access. Medical data has also been reported to have been legally accessed by law enforcement and other agencies.
Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you nor your attorney(s) nor anyone else acting on your behalf will call on your provider to testify in court or at any other proceeding, nor will disclosure of the psychotherapy records be requested unless otherwise agreed upon.
Supervision/Consultation: Supervision is an important part of maintaining quality therapy. Your provider consults regularly with other professionals regarding clients; however, each client's identity remains anonymous and complete client confidentiality is fully maintained.
Electronic Communication: It is important to remain aware that computers and unencrypted email, texts, and e-faxes can be relatively easily accessed by unauthorized people and can compromise the privacy and confidentiality of such communication. Emails, texts, and e-faxes, in particular, are vulnerable to such unauthorized access due to servers and communication companies may have unlimited and direct access to all emails, texts, and e-faxes mediated by them. While data on your provider's laptop is encrypted, emails and e-fax are not. It is possible that e-faxes, texts, and email can be sent mistakenly to the wrong address/computer. You should not communicate any information with your provider without recognizing the inherent risks of electronic communication. Your provider's laptop is equipped with a firewall, virus protection, and a password. Please notify your provider if you decide to avoid or limit, in any way, the use of e-mail, texts, mobile phones, or other forms of electronic communication.
Payment for Service: Your provider may use any legal or other means (courts, collection agencies, etc.) to obtain payment. you will be responsible for any fees incurred from returned checks. If your account, after insurance reimbursement, is 90 days or more in arrears, a 9% per annum service charge may be added to your bill. If your account is turned over to a licensed collection agency, an additional fee of 40% of the unpaid balance may be added to your unpaid balance. You will be responsible for the unpaid balance as well as any fees associated with the collection process. These fees can include but are not limited to any additional agency fees, attorney fees, and court fees. You agree, in order for us to service our account or collect any amounts you may owe, we may contact you by telephone any telephone number associated with your account, including wireless phone numbers, which could result in charges to you. We may also contact you by sending text messages or e-mails, using any e-mail address you provide to us. Methods of contact may include using prerecorded/artificial voice messages and/or use of an automatic dialing service, as applicable.
Mediation and Arbitration: All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a precondition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by the agreement of the provider and client(s). The cost of such mediation, if any, shall be split equally unless otherwise agreed upon. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Sangamon County, Illinois, in accordance with the rules of the American Arbitration Association which are in effect at the tie the demand of arbitration is filed. Notwithstanding the foregoing in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, your provider can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum as and for attorney feeds. In the case of arbitration, the arbitrator will determine that sum.
The Process of Therapy/Coaching/Evaluation and Scope of Practice: Participation in therapy/coaching/evaluation can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to see therapy,. working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and behavior. Your provider will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with life situations. During evaluation or therapy or coaching, remembering or talking about unpleasant events, thoughts, and feelings can result in you experiencing considerable discomfort or strong feelings, or anxiety, depression, insomnia, etc. Your provider may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situation,s which can cause you to feel very upset, angry, depressed, challenged or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, your provider is likely to draw on various psychological approaches according, in part, to the problem that is being treated and what may be most beneficial to you. These approaches include, but are not limited to, behavioral, cognitive-behavioral, cognitive, psychodynamic, existential, metacognitive, family systems, developmental, humanistic, mindfulness-based, or psychoeducational. Your provider provides neither custody evaluations nor prescription recommendations nor legal advice, as these activities do not fall within the scope of practice.
Treatment Plans: Within a reasonable period of time after the initiation of treatment, your provider will discuss with you their working understanding of the problem presented, treatment plan, therapeutic objectives, and their view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, your provider's expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits.
Termination: As set forth above, after the first couple of meetings, the provider will assess if they can be of benefit to you. Your provider does not work with clients who, in their opinion, cannot be helped with the provider's area of expertise. In such a case, if appropriate, they will refer you to other providers. If at any point during therapy your provider either assesses that they are not effective in helping you reach the therapeutic goals or perceived you as unable to benefit from the therapy and if appropriate and/or necessary, they would provide you with referrals. If requested and authorized in writing, your provider will talk to the new provider to help provide a supportive transition. You have the right to terminate therapy and communication at any time. If you choose to do so, and upon your request and if appropriate and possible, your provider will provide you with referrals to qualified professionals whose services you might prefer.
Dual Relationships: Despite a popular misperception, not all dual or multiple relationships are unethical or avoidable. Therapy never involves sexual or any other dual relationship that impairs your provider's objectivity, clinical judgment, or can be exploitative in nature. Your provider will assess carefully before entering into non-sexual and non-exploitative dual relationships with clients. Your provider will never acknowledge working with you without your written consent. Your provider will discuss with you the potential benefits and complexities that may exist within a dual relationship. Dual relationships can enhance trust and therapeutic effectiveness but can also detract from it and often it is impossible to know which ahead of time. It is your responsibility to advise your provider if the dual relationship becomes uncomfortable for you in any way. Your provider will always listen carefully and respond to your feedback and will discontinue the dual relationship if they find it interfering with the effectiveness of the therapy or your welfare and, of course, you can do the same at any time.
Social Networking and Internet Searches: Your provider will not accept friend requests from current or former clients on any social networking site. Connecting with clients via social networking platforms is likely to compromise privacy and confidentiality. For these same reasons, your provider requests that clients not communicate with them via any interactive or social networking platforms/websites.
Cancellation - Scheduling an appointment involves the reservation of time specifically for you; therefore, a minimum of 24 hours (1 day) notice is required for re-scheduling or canceling an appointment. Unless a different agreement is reached with your provider, the full fee will be charged for sessions missed without such notice. Insurance companies do not reimburse for missed sessions.
It is important that you are aware that computer e-mail, texts, and e-fax communication may be accessed by unauthorized people and can compromise the privacy and confidentiality of such communication. E-mails, texts, and e-faxes are vulnerable to such unauthorized access due to servers or communication companies having unlimited or direct access to all e-mails, texts, and e-faxes that are passed through their services. While the data on your provider's laptop is encrypted, e-mails, texts, and e-faxes are not. It is always a possibility that these communications can be sent mistakenly and unintentionally to a wrong address/computer. Your provider's laptop is equipped with a firewall, a virus protection, and a password. Please note that some communications, depending on its relevance to treatment may be placed in your clinical record.
Please notify your provider if you divide to avoid or limit, in any way, the use of e-mail, texts, mobile phone calls, phone messages, or e-faxes. If you communicate confidential or private information via unencrypted e-mail, texts, or e-fax or via phone messages, it will be assumed that you have evaluated the risks and made an informed decision, your provider will view it as your agreement to take the risk that such communication may be intercepted, and your desire to communicate on such matters will be honored. Please do not use texts, e-mail, voicemail, or faxes for emergencies. In case of emergency, call 911 or go the nearest Emergency Department.
Your signature indicates your understanding and agreement with the above. Your signature also indicates permission for your provider to communicate with you via unencrypted e-mail, texts, cell phones, and e-faxes.
If you would like to get an idea of my approach with counseling and coaching, please take a look at some of the articles I've written and posted on my website:
I'll look forward to seeing you soon.
All the Best,