Statement of Services/Notice ofPrivacyPractices
 
Informed Consentprovidescounselingservices that includeassessment, evaluation, diagnosis, and direct psychotherapytreatment in accordancewithprofessional standards of practice. These standards of practice include providingeachclient with information concerningseveral aspects of thecounseling process and the counselingrelationship.
 
The Risks and BenefitsofTherapy
 
Psychotherapyhas beenshown to be effective forthe improvement and resolution of manykinds ofpersonal problems. The process ofpsychotherapy, however, does involve risks on the part of theclient. Change,and the processes involved increatingpositive change,can at times be difficult and unsettling. While every attempt will be madeto prepareeach client for this, eachclient must make the decision to enter into this process with aclear understandingof these risks.
 
Estimated Length ofTherapy
 
The length of the courseof psychotherapytreatment can varydependingupon the severityof theproblems presented,and the abilityof eachclient to utilize therapeuticapproaches.Whenever possible, eachclient will be given an estimation ofhow much time the psychotherapyprocess will take.
 
Length and Cost ofTherapy Sessions
 
Unless otherwise stated,psychotherapysessions will consist of 45-50 minutes of direct treatment,with 10-15 minutes allotted after thedirect treatment for the clinician to complete treatment notes and review the content of the psychotherapysession. Unless otherwise agreed to, each psychotherapysession will be charged at the rate of $__________. Clients who have mental health benefits through their insurance will be billed at the ratecovered bytheir insurance, under thearrangementnoted in a section below.
 
Insurance Policy
 
Wherea professional relationship exists betweenthe provider and theclient’s insurancecarrier, theclient will be expected to paythe co-insuranceamount designated under the policies of the insurancecarrier. Claims will be filed bythe providerof services. Wherea professionalrelationship does not exist with a client’s insurancepolicy,the client will be expected to paythe full amountfor each psychotherapysession and to file his/her own claims.In such cases, where necessary, insuranceforms and receipts will be filled out bythe provider so as to allow the filingof claims bytheclient.
 
Cost for Secondary Services
 
Time spent performingservices that support thecounseling, suchas writingreports, contact with outside parties byphone or letter, and supportive phonecontact tothe client outside of regular sessions, will be billed at the rate of $___________,prorated for the amountof time spent engaged inthe service. Time spent in phone contact to set or re-arrangeappointment times, or brief phonecontact togive or receiverelevant treatment information will not be billed. These services aregenerallynot covered byinsurance mental healthbenefits and will be billed directlyto the client.
 
PaymentPolicy
 
Unless otherwise agreedto, payment will beexpected at the end of each psychotherapysession.
 
Cancellation Policy
 
Clientsareexpected to provide 24 hours noticeofcancellation of anyscheduled psychotherapysession. For anyunkept session not cancelled prior to 24 hours,the clientwill be billed the full amount of the cost of the session, unless agreed tootherwise priorto the unkept session. This cost is not covered byinsurance, and the full amount will be billed to the client.
 
Client Rights
 
Each client has the right to expect competent psychotherapytreatment in accordance with accepted professional standards. Each client has theright to request information about anyaspect of treatment, includingbut not limited to assessment results, treatment techniques utilized, courseand direction of treatment. Eachclient has the right to providefeedback to the provider aboutwheretreatment is being successful and unsuccessful, and to terminate treatment at anytime.
 
Client Responsibilities
 
Each client is held to be responsible for engagingin the therapeutic processin ways that further treatment progress, makingavailable to the providersuch information as is needed to provide effective treatment, and participatingin directing the courseand directionof treatment.
 
Confidentiality
 
The confidentialityof allrecords is coveredbystateand federal law. Federal standardsformaintenance of yourrecords have been defined bythe HealthInsurance Portabilityand AccountabilityAct of 1996 (HIPAA). The records ofclients with alcohol anddrug abuse problems mayalso subject to further restrictions as outlined in FederalLaw 42 CFR Part 2. Theseguidelines mean that all client information, includingrecords of treatment, maynot bereleased except under the followingconditions:
1) When the client signs a valid release ofinformation;
2) When a disclosure ismadetomedical personnel in a medical emergency;
3) When a client expresses suicidal orhomicidal intent with imminent risk;
4) Whenthere is suspectedchildor elder abuse or neglect;
5) When disclosure is required by a validcourt order. Your Rights
Under HIPAA,you havethe followingrights:
1) The right to inspect orcopyyour own healthinformation, exceptto the extent thatthe information contains psychotherapy notes or information compiledfor use in a civil,criminal, or administrative proceeding.
2) The right to requestrestrictions on certain usesand disclosures ofyour treatment information.
3) The right to amend health care information maintained in your client record.
4) The right to requestandreceive an accounting of disclosures ofyour health relatedinformation made during a period up to six years prior to your request.
 
Clinician Duties
 
Clinical Informationis required bylaw to maintain the privacyofyour health information and to provideyou with noticeof its legal duties and privacypracticesconcerningyour health information.In addition to fulfillingthis obligation through the provision of this Statementof Services/Noticeof Privacy Practice, theclinician is responsible for providing anyadditional information that mayberequired tomake you fullyaware ofyour privacyand treatment rights.
 
 
 
Statement of Validation.
 
I have read this Statement of Services, it has been adequately explained to me, and I understand its contents.