PSYCHOTHERAPIST/CLIENT
SERVICES AGREEMENT
CONFIDENTIALITY AND
PRIVACY
Welcome to Hoffman
Psychological Associates (HPA).
This agreement contains important information about our professional
services and business policies. It
also contains summary information about the Health Insurance Portability and
Accountability Act (HIPAA), a new federal law that provides you privacy
protections and patient rights with regard to the use and disclosure of your
Protected Health Information (PHI) used for the purpose of treatment, payment,
and health care operations.
We are required by law to
safeguard the information we learn about you through the course of
treatment. Relevant treatment
information may be discussed between the professional staff involved in your
care to insure the best care, including supervision, consultation, and referrals
between HPA therapists for your therapy.
HIPAA requires that we
provide you with an Explanation of Privacy Practices (Privacy Notice). If you choose to use your health care
insurance to pay for psychotherapy services, you are giving your consent for us
to disclose the minimum necessary PHI to your health insurer to determine your
benefits and obtain reimbursement (payment).
Psychotherapy is not easily
described in general statements. It
varies depending on the personalities of the psychotherapist and patient, and
the particular problems you are experiencing. There are many different methods we may
use to deal with the problems that you hope to address. Psychotherapy is not like a medical
doctor visit. Instead, it calls for
a very active effort on your part.
In order for the therapy to be most successful, you will have to work on
things we talk about both during our sessions and at home.
Psychotherapy can have
benefits and risks. Since therapy
often involves discussing unpleasant aspects of your life, you may experience
uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and
helplessness. On the other hand,
psychotherapy has also been shown to have many benefits. Therapy often leads to better
relationships, solutions to specific problems and significant reductions in
feelings of distress. But there are
no guarantees of what you will experience.
Our first few sessions will
involve an evaluation of your needs.
By the end of the evaluation, we will be able to offer you some first
impressions of what our work will include and a treatment plan to follow, if you
decide to continue with therapy.
You should evaluate this information along with your own opinions of
whether you feel comfortable working with us. Therapy involves a large commitment of
time, money, and energy, so you should be very careful about the therapist you
select. If you have questions about
procedures, we should discuss them whenever they arise. If your doubts persist, we will be happy
to help you set up a meeting with another mental health professional for a
second opinion.
We normally conduct an
evaluation that will last from 2 to 4 sessions. If psychotherapy is begun, we will
usually schedule one 50-minute session (one appointment hour of 50 minutes
duration) per week at a time we agree on, although some sessions may be longer
or more frequent. Once an
appointment hour is scheduled, you will be expected to pay for it unless you
provide 24 hours advance notice of cancellation [unless we both agree
that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance
companies do not provide reimbursement for cancelled sessions. Office hours are Monday and Tuesday
from 9:00 a.m. – 6:00 p.m. and Wednesday and Thursday from 9:00 a.m. – 8:00
p.m.
In the event of an emergency
you may reach us through our office phone number: 717-232-6011. If the office is not open, we have an
answering service, which will contact us.
Patients under 18 years of
age who are not emancipated and their parents should be aware that the law may
allow parents to examine their child’s treatment records. Because privacy in psychotherapy is
often crucial to successful progress, particularly with teenagers, it is
sometimes our policy to request an agreement from parents that they consent to
give up their access to their child’s records. If they agree during treatment, we will
provide them only with general information about the progress of the child’s
treatment, and his/her attendance at scheduled sessions. We will also provide parents with a
summary of their child’s treatment when it is complete. Any other communication will require the
child’s authorization, unless we feel that the child is in danger or is a danger
to someone else, in which case, we will notify the parents of our concern. Before giving parents any information,
we will discuss the matter with the child, if possible, and do our best to
handle any objections he/she may have.
The fees for psychotherapy
in this office are $100 per session (50 minutes), and $60 per half session (25
minutes). The fee for initial
evaluation (usually 50 minutes) is $120.
Because statement and billing costs ultimately increase the cost of
services for you, we request payment for visits at the time services are
rendered. In certain instances,
consultation with other agencies or professionals may be a necessary part of
your treatment. To keep costs of
these services down, an attempt will be made to do as much of this as possible
in a brief time frame by telephone.
However, if consultations go beyond 15 minutes, you will be charged $25
per quarter hour for these services.
Please note that your insurance company may not pay for these
consultations. Also note that
psychotherapy is not done over the telephone and telephone consultations are not
substitutes for psychotherapy. In
the event that you are unable to pay at the time of service, it is important
that you make arrangements with the office for a payment plan. We accept VISA and MasterCard. It is the policy of the office to bill
the client on a monthly basis for any outstanding balance. An invoice is considered overdue if
we have received no payment within a 30-day period and will be assessed at 1 ½%
finance charge. Accounts, which are
60 days overdue, may be turned over to a collection agency.
Your signature below
acknowledges agreement to the following:
If you have any concerns,
questions or objections to the above, please discuss them with your
therapist.
I have read the
Psychotherapist-Client Services Agreement and consent to receive psychotherapy
services under the terms outlined.
_________________________________________
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