Suffolk Cognitive-Behavioral, PLLC

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A #e$arate %&"PPA #ignature for'( i# atta)he*+
,Thi# *o)u'ent i# availa-le on our .e-#ite an*/or -0 re1ue#t2+
PSYC&OT&ERAP"ST-PAT"ENT SER"CES A3REEMENT
Welcome to the Suffolk Cognitive-Behavioral. This document (the Agreement) contains important
information about our professional services and business policies. t also contains summar! information
about the &ealth "n#uran)e Porta-ilit0 an* A))ounta-ilit0 A)t ,&"PAA2+ When !ou sign this document"
it #ill also represent an agreement bet#een us. $ou ma! revoke this Agreement in #riting at an! time. That
revocation #ill be binding on me unless have taken action in reliance on it% if there are obligations
imposed on me b! !our health insurer in order to process or substantiate claims made under !our polic!% or
if !ou have not satisfied an! financial obligations !ou have incurred.
INFORMED CONSENT TO TREATMENT
&s!chotherap! can have benefits and risks. Since therap! often involves discussing unpleasant aspects of
!our life" !ou ma! e'perience uncomfortable feelings like sadness" anger" etc. (n the other hand"
ps!chotherap! has also been sho#n to have man! benefits.. (f course" there are no guarantees of #hat !ou
#ill e'perience. (ur first session #ill involve an evaluation of !our needs. B! the end of the evaluation"
#ill be able to offer !ou some first impressions of #hat our #ork #ill include and a treatment plan to
follo#. $ou should participate in this formulation and evaluate this information along #ith me. As in all
health care settings" !ou have a right to a second opinion and should seek one if !ou so desire. &arental or
guardian consent for treatment of a minor is generall! re)uired e'cept under certain conditions. Though"
*e# $ork la# gives children of an! age the right to independentl! consent to and receive mental health
treatment #ithout parental consent if the! re)uest it" and if determine that such services are necessar! and
if the parent is not reasonabl! available or re)uiring parental consent #ould have a detrimental effect.
CONSENT TO TREATMENT
" #ith m! signature at the close of this document" hereb! authori+e that me or the patient for #hich am a
guardian" receive evaluative and,or therapeutic services at the Suffolk Cognitive-Behavioral &s!cholog!"
&--C.
BUSINESS PRACTICES
!EES AND PAYMENT
.egular sessions are fort!-five minutes in length. /ees are determined based on this time unit. &a!ment is
due each session for services rendered. /ailure to pa! for more than t#o sessions can result in suspension
of therap! until pa!ment is made. n addition to #eekl! appointments" #e charge this amount for other
professional services !ou ma! need" in a pro-rated basis as needed. (ther services include report #riting"
telephone conversations lasting longer than 0 minutes" consulting #ith other professionals #ith !our
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permission" preparation of records or treatment summaries" and the time spent performing an! other service
!ou ma! re)uest of me. f !ou become involved in legal proceedings that re)uire m! participation" !ou #ill
be e'pected to pa! for all of m! professional time" even if am called to testif! b! another part!.
CANCELLAT"ONS
(nce treatment has begun" !our therapist reserves specific time(s) for !ou. A 45-hour noti)e is re)uired
for all cancellations. /ull fee #ill be charged if less time is allo#ed. f the session can be rescheduled"
there #ill be no charge. .escheduling is" ho#ever not al#a!s possible.
2'traordinar! circumstances are to be discussed #ith !our therapist. &hone sessions ma! also be
scheduled or used to reschedule a missed appointment. &hone sessions are billed on a pro-rated
basis according to the established full session rate. &atients incur all telephone charges.
CONTACT"N3 6S
We are often not immediatel! available b! telephone. When #e are unavailable" m! telephone our ans#ered
b! voice mail or b! m! secretar!. #ill make ever! effort to return !our call on the same da! !ou make it"
#ith the e'ception of #eekends and holida!s. .egarding 3emergenc!4 contact% f there is ever a
circumstance in #hich there is an immanent and immediate danger to !our life or the life of another" !ou
agree to contact 511 or go immediatel! to !our emergenc! room.
RELEASE O! "N!ORMAT"ON
The la# protects the privac! of all communications bet#een a patient and a ps!chologist. n most
situations" can onl! release information about !our treatment to others if !ou sign a #ritten 3authori+ation
form4. There are ho#ever" other situations that re)uire onl! that !ou provide #ritten" advance consent.
$our signature on this Agreement provides consent for those activities" as follo#s6
ma! occasionall! find it helpful to consult other health and mental health professionals about a
case. 7uring a consultation" make ever! effort to avoid revealing the identit! of m! patient.
practice #ith other mental health professionals and that emplo! administrative staff. n most
cases" need to share protected information #ith these individuals for both clinical and
administrative purposes. f !ou are involved in a court proceeding and a re)uest is made for
information concerning the professional services that provided !ou" such information is protected
b! the ps!chologist-patient privilege la#. cannot provide an! information #ithout !our #ritten
authori+ation" unless a court orders it b! subpoena. f !ou are involved in or contemplating
litigation" !ou should consult #ith !our attorne! to determine #hether a court #ould be likel! to
order me to disclose information.
f a government agenc! is re)uesting the information for health oversight activities" ma! be
re)uired to provide it for them.
f a patient files a complaint or la#suit against me" ma! disclose relevant information regarding
that patient in order to defend m!self.
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f am providing treatment for conditions directl! related to #orker9s compensation claim" ma!
have to submit such records" upon appropriate re)uest" to Chairman of the Worker9s Compensation
Board on such forms and at such times as the chairman ma! re)uire.
There are some situations in #hich am legall! obligated to take actions" #hich believe are necessar! to
attempt to protect others from harm and ma! have to reveal some information about a patient9s treatment.
These situations are unusual in m! practice.
f receive information in m! professional capacit! from a child or the parents or guardian or other
custodian of a child that that gives me reasonable cause to suspect that a child is an abused or
neglected child" the la# re)uires that report to the appropriate governmental agenc!" such as the
local child protective services office. (nce such a report is filed" ma! be re)uired to provide
additional information.
f a patient communicates an immediate threat of serious ph!sical harm to self or to an identifiable
victim" ma! be re)uired to take protective actions. These actions ma! include notif!ing famil!" the
potential victim" contacting the police" or seeking hospitali+ation for the patient.
PRO!ESS"ONAL RECORDS
The la#s and standards of m! profession re)uire that keep session ps!chotherap! notes in !our &atient
.ecord. 2'cept in unusual circumstances that involve danger to !ourself and,or others or #here
information has been supplied to me confidentiall! b! others" !ou ma! e'amine and,or receive a cop! of
!our &atient .ecord" if !ou re)uest it in #riting. Because these are professional records" the! can be
misinterpreted and,or undul! disturbing to untrained readers. /or this reason" recommend that !ou
initiall! revie# them in m! presence. am allo#ed to charge a cop!ing fee of :0 cents per page (and for
certain other e'penses). f refuse !our re)uest for access to !our records" !ou have a right to of revie#"
#hich #ill discuss #ith !ou upon re)uest.
ADD"T"ONAL RECORD 7 C&ART R"3&TS
;&AA provides !ou #ith several ne# or e'panded rights #ith regard to !our &atient .ecord and
disclosures of protected health information. These rights include re)uesting that amend !our record%
re)uesting restrictions on #hat information from !our &atient .ecord is disclosed to others% re)uesting an
accounting of most disclosures of protected health information that !ou have neither consented to nor
authori+ed% determining the location to #hich protected information disclosures are sent% having an!
complaints !ou make about m! policies and procedures recorded in !our records% and the right to a paper
cop! of this Agreement" the attached *otice form" and m! privac! policies and procedures.
M"NORS 7 PARENTS
n the situations noted previousl! #here parental consent is not re)uired for treatment of a minor"
information about that treatment cannot be disclosed to an!one #ithout the child9s agreement. 2ven #here
parental consent is given" children over age 18 have the right to re)uest restrictions of access to their
treatment records. While privac! in ps!chotherap! is ver! important" particularl! #ith teenagers" parental
involvement is also essential to successful treatment" particularl! #ith !ounger children. Therefore" it is m!
polic! not to provide treatment to a child under age 18 unless he,she agrees that can share #hatever
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information consider necessar! #ith his,her parents. /or children age 18 and over" re)uest an agreement
bet#een m! patient and his,her parents allo#ing me to share general information about the progress of the
child9s treatment and his,her attendance at scheduled sessions. An! other communication #ill involve the
child9s Authori+ation" unless determine that the child is in danger or is a danger to someone else" in #hich
case" #ill notif! the parents of m! concern. Before giving parents an! information" #ill discuss the
matter #ith the child" if possible" and do m! best to handle an! ob=ections he,she ma! have.
B"LL"N3
$ou #ill be e'pected to pa! for each session at the time it is held" unless #e agree other#ise or unless !ou
have insurance coverage that re)uires another arrangement.
f !our account has not been paid for more than >? da!s and arrangements for pa!ment have not been
agreed upon" have the option of using legal means to secure the pa!ment. This ma! involve hiring a
collection agenc! or going through small claims court #hich #ill re)uire me to disclose other#ise
confidential information. n most collection situations" the onl! information release regarding a patient9s
treatment is his,her name" the nature of services provided" and the amount due.
"NS6RANCE RE"MB6RSEMENT
f !ou have a health insurance polic!" it ma! provide some coverage for mental health treatment. ;o#ever
if !our insurance compan! does not pa!" !ou (not !our insurance compan!) are responsible for full
pa!ment of m! fees. t is also !our responsibilit! to find out e'actl! #hat insurance mental health
insurance polic! covers and doesn9t.
$ou should also be a#are that !our contract #ith !our health insurance compan! re)uires that provide it
#ith information relevant to the services that provide to !ou. am re)uired to provide a clinical diagnosis
and sometimes am re)uired to provide additional clinical information such as treatment plans or
summaries. n such situations" #ill make ever! effort to release onl! the minimum information about !ou
that is necessar! for the purpose re)uested. B! signing this Agreement" !ou agree that can provide
re)uested information to !our carrier.
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