EMERGENCY PROCEDURES
During regular office hours, Monday – Friday 9:00 a.m. – 5:00 p.m. you may contact our office. However, if you have a life threatening emergency, call 911 and/or seek assistance at the closest emergency medical facility. For non-emergency (non-life threatening) telephone calls will be billed to the client at a rate of $50.00 per fifteen-minute time interval or $150.00 per hour. Each fifteen-minute interval begins at the first minute of the call or at the first minute following the last interval.
DIAGNOSTIC, EDUCATIONAL, AND CAREER ASSESSMENTS
During treatment, we may decide that you need a diagnostic evaluation or other assessments to help determine various aspects of your presenting problems, treatment needs or after care. I will discuss the purpose of the evaluations and/or assessments, the general procedures and the estimated cost. In most circumstances testing is not a covered benefit of your health plan. I will discuss the assessment cost with you in order for you to make an informed decision about this course of action.
APPOINTMENTS AND CANCELLATIONS
- Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the entire fee if cancellation is less than 24 hours. Charges will NOT be waived for any circumstance including, but not limited to: sickness, work, or an unforeseen event.
- The standard meeting time for psychotherapy is 53-55 minutes for an hour session. It is up to you, however, to determine the length of time of your sessions.
- If a client is more than 15 minutes late for an appointment, the appointment will be considered a late cancel and subject to a late cancel fee.
- EAP sessions are set for 45 minutes per session.
- Refusal of payment for late cancellations and no show fee can result in discharge from the practice. Please understand how important is it for clients to keep their appointments with their therapist.
- Disputed Charges: Patients who dispute charges related to services rendered, no show / late cancel fee are subject to charges and time required to cover the dispute. Patients are consenting to a Release of Information in order to counter their dispute.
HOW TO RECHEDULE AN APPOINTMENT
- Call our office at 682-703-1311 - please leave a voicemail if we do not answer.
- Send an email to the front desk - [email protected]
- You may send a secure message through Simple Practice Client Portal to the front desk or to your therapist. Thank you.
Treatment: Payment in full is expected at time services are provided unless other arrangements have been made in advance or in writing. The client or guardian's payment information will be kept on file and charged after session, late cancellation, or missed appointment. Self-pay rates are billed at $150 for the initial diagnostic intake session, $140 per one-hour follow up sessions. There is a $35.00 charge for returned checks.
Late Cancellations and No Shows: Patients are expected to contact the office 24 hours prior to their scheduled appointment, including initial intake, if they need to cancel or reschedule. There is a $100.00 fee for all missed appointments with less than 24 hours (standard business hours) notice. Payment must be made before future appointments are made. Client’s credit card information will be kept on file as a courtesy and respect for counselor’s time for missed appointments without 24-hour notification. Client’s credit card will be charged by the end of the day of the missed appointment. After hour appointments will be charged by the end of the following day.
Court Appearances: In the event that I am requested by the client, the client’s parent/legal guardian, or I am subpoenaed or court ordered to appear in court by a source other than the client/parent/legal guardian, the client and/or the client’s parent or legal guardian is expected to pay for the time spent in preparing for the court appearance as well as the time spent for transportation to/from court and appearing in court at the rate of $400.00/hour. The minimum charge is for four hours or $1,600.00 to be paid no later than 48 hours prior to the scheduled court date. This fee is not reimbursable by a Third-Party Payer and is therefore the full responsibility of the client and/or the client’s parent or legal guardian. Payment is due prior to the rendering of these services via cash, Discover, Visa, MasterCard, money order, or a cashier’s check.
Administrative Services: Copies of patient records require a written authorization from the patient. There is a $25.00 charge for medical records for the first twenty pages and $.50 per page for every copy thereafter. Administrative services (i.e. Letters, FMLA Forms, Disability Forms, Diagnostic Evaluations, etc.) will be billed at a rate of $150.00 per hour.
Collection of Outstanding Debt: Patients are expected to be up to date on their account. Our office sends notice of outstanding debt for up to 120 days and then the account is sent to a collection’s agency. Once the debt has been sent to collections the matter is between the collection agency and the patient.
Disputed Charges: Patients who dispute charges related to services rendered, no show / late cancel fee are subject to charges and time required to cover the dispute. Patients are consenting to a Release of Information in order to counter their dispute. Please call our office if you have a concern about a charge on your account.
TELEPHONE ACCESSIBILITY: If you need to contact me between sessions, please leave a message on my voice mail. I am often not immediately available; however, I will attempt to return your call within 24 hours. Please note that Face- to-face sessions are highly preferable to phone sessions. However, in the event that you are out of town, sick or need additional support, phone sessions are available. If a true emergency situation arises, please call 911 or any local emergency room.
SOCIAL MEDIA AND TELECOMMUNICATION Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I 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 questions about this, please bring them up when we meet and we can talk more about it.
ELECTRONIC COMMUNICATION I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.
Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine by the State of California. Under the California Telemedicine Act of 1996, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist chose to use information technology for some or all of your treatment, you need to understand that: (1) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. (2) All existing confidentiality protections are equally applicable. (3) Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee. (4) Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent. (5) There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs. Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally the therapist.
MINORS: If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.
TERMINATION: Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.
Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.
BY SIGNING THIS AGGREEMENT I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
