THERAPY CONSENT, POLICIES, & AGREEMENT
* Signable version will be sent to potential clients through our portal after you make an appointment. *
PART I: THERAPEUTIC PROCESS
BENEFITS/OUTCOMES: The therapeutic process seeks to meet goals established by all persons involved, usually revolving around a specific complaint(s). Participating in therapy may include benefits such as the resolution of presenting problems as well as improved intrapersonal and interpersonal relationships. The therapeutic process may reduce distress, enhance stress management, and increase one’s ability to cope with problems related to work, family, personal, relational, etc. Participating in therapy can lead to greater understanding of personal and relational goals and values. This can increase relational harmony and lead to greater happiness. Progress will be assessed on a regular basis and feedback from clients will be elicited to ensure the most effective therapeutic services are provided. There can be no guarantees made regarding the ultimate outcome of therapy.
EXPECTATIONS: In order for clients to reach their therapeutic goals, it is essential they complete tasks assigned between sessions. Therapy is not a quick fix. It takes time and effort, and therefore, may move slower than your expectations. During the therapy process, we identify goals, review progress, and modify the treatment plan as needed.
RISKS: In working to achieve therapeutic benefits, clients must take action to achieve desired results. Although change is inevitable, it can be uncomfortable at times. Resolving unpleasant events and making changes in relationship patterns may arouse unexpected emotional reactions. Seeking to resolve problems can similarly lead to discomfort as well as relational changes that may not be originally intended. We will work collaboratively toward a desirable outcome; however, it is possible that the goals of therapy may not be reached.
STRUCTURE OF THERAPY:
Intake Phase – During the first session, therapeutic process, structure, policies and procedures will be discussed. We will also explore your experiences surrounding the presenting problem(s).
Assessment Phase – The initial evaluation may last 2-4 sessions. During this assessment phase, I will be getting to know you. I will ask questions to gain an understanding of your worldview, strengths, concerns, needs, relationship dynamics, etc. During this relationship building process, I will be gathering a lot of information to aid in the therapeutic approach best suited for your needs and goals. If it is determined that I am not the best fit for your therapeutic needs, I will provide referrals for more appropriate treatment.
Goal Development/Treatment Planning – After gathering background information, we will collaborate to identify your therapeutic goals. If therapy is court ordered, goals will encompass your goals and court ordered treatment goals, based on documentation from the court (please provide any court documents). Once each goal is reached, we will sign off on each goal and you will receive a copy.
Intervention Phase – This phase occurs anywhere from session two until graduation/discharge/termination. Each client must actively participate in therapy sessions, utilize solutions discussed, and complete assignments between sessions. Progress will be reviewed and goals adjusted as needed.
Graduation/Discharge/Termination – As you progress and get closer to completing goals, we will collaboratively discuss a transition plan for graduation/discharge/termination.
LENGTH OF THERAPY: Therapy sessions are typically weekly or biweekly for minutes depending upon the nature of the presenting challenges and insurance authorizations. It is difficult to initially predict how many sessions will be needed. We will collaboratively discuss from session to session what the next steps are and how often therapy sessions will occur.
APPOINTMENTS AND CANCELLATIONS: You are responsible for attending each appointment and agree to adhere to the following policy: If you cannot keep the scheduled appointment, you MUST notify our office to cancel or reschedule the appointment prior to 24 hours of the scheduled appointment time. If you cancel more than three times, we may re-evaluate your needs, desires, and motivations for treatment at this time. Appointments canceled or rescheduled in under 24 hours or no shows will be charged $150 for individual therapy and $200 for couples counseling.
*** Group therapy appointments are $35 per group whether or not you are able to attend and are not a part of the 24 hours cancellation policy. ***
Psychotherapy is a uniquely personal service; therefore, consultations may be briefly interrupted. I may periodically take time off for vacation, seminars, and/or become ill. Attempts will be made to give adequate notice of these events. If I am unable to contact you directly, a colleague may contact you to cancel or reschedule an appointment.
FEES: The fee for each therapy session is $150 for individual sessions, $200 for couple’s counseling and $35 for group sessions. Payment is due at the time of service. Acceptable forms of payment are: credit/debit card. In the event that a scheduled individual therapy appointment time is missed or canceled less than 24 hours in advanced, please refer to the “Appointments and Cancellations” policy above.
The clinician reserves the right to terminate the counseling relationship if more than 3 sessions are missed without proper notification.
The clinician charges his/her hourly rate in quarter hours for phone calls over 10 minutes in length, email correspondence, reading assessments or evaluations, writing assessments or letters, and collaborating with necessary professionals (with your permission) for continuity of care. All costs for services outside of session will be billed. Price to be charged equals $15 for each quarter hour.
TRIAL, COURT ORDERED APPEARANCES, LITIGATION: Rarely, but on occasion, a court will order a therapist to testify, be deposed, or appear in court for a matter relating to your treatment or case. In order to protect your confidentiality, I strongly suggest not being involved in the court. If I get called into court by you or your attorney, you will be charged a $400 FEE FOR COURT ORDERED APPEARANCE to include travel time, court time, preparing documents, etc.
COPIES OF MEDICAL RECORDS: Should you request a copy of your medical records, the cost is $1.00 per page. Payment for your medical records will be due prior or upon receipt and can be picked up at the office. Please allow at least 2 weeks to prepare medical records.
PHONE CONTACTS AND EMERGENCIES: Office hours are from Monday, Tuesday, Wednesday, Friday 9am - 3pm. If you need to contact the clinician for any reason, please contact your clinician, leave a voicemail, and a return call will be made 24 Hours or as soon as possible. In case of an emergency, you can access emergency assistance by calling the National Mental Health Crisis or Suicide Hotline dial 988. If either you or someone else is in danger of being harmed, dial 911.
PART II: REASONS HOPE IN HEALING THERAPY INC DOES NOT ACCEPT INSURANCE
Reduced Ability to Choose: Most health care plans today (insurance, PPO, HMO, etc.) offer little coverage and/or reimbursement for mental health services. Most HMOs and PPOs require “preauthorization” before you can receive services. This means you must call the company and justify why you are seeking therapeutic services in order for you to receive reimbursement. The insurance representative, who may or may not be a mental health professional, will decide whether services will be allowed. If authorization is given, you are often restricted to seeing the providers on the insurance company’s list. Reimbursement is reduced if you choose someone who is not on the contracted list; consequently, your choice of providers is often significantly restricted.
Pre-Authorization and Reduced Confidentiality: Insurance typically authorizes several therapy sessions at a time. When these sessions are finished, your therapist must justify the need for continued services. Sometimes additional sessions are not authorized, leading to an end of the therapeutic relationship even if therapeutic goals are not completely met. Your insurance company may require additional clinical information that is confidential in order to approve or justify a continuation of services. Confidentiality cannot be assured or guaranteed when an insurance company requires information to approve continued services. Even if the therapist justifies the need for ongoing services, your insurance company may decline services. Your insurance company dictates if treatment will or will not be covered. Note: Personal information might be added to national medical information data banks regarding treatment.
Negative Impacts of a Psychiatric Diagnosis: Insurance companies require clinicians to give a mental health diagnosis (i.e., “major depression” or “obsessive-compulsive disorder”) for reimbursement. Psychiatric diagnoses may negatively impact you in the following ways:
Denial of insurance when applying for disability or life insurance;
Company (mis)control of information when claims are processed;
Loss of confidentiality due to the increased number of persons handling claims;
Loss of employment and/or repercussions of a diagnosis in situations where you may be required to reveal a mental health disorder diagnosis on your record. This includes but is not limited to: applying for a job, financial aid, and/or concealed weapons permits.
A psychiatric diagnosis can be brought into a court case (i.e.: divorce court, family law, criminal, etc.).
It is also important to note that some psychiatric diagnoses are not eligible for reimbursement. This is often true for marriage/couples therapy.
Why Clinicians Do Not Take Insurance: These involve enhanced quality of care and other advantages:
You are in control of your care, including choosing your therapist, length of treatment, etc.
Increased privacy and confidentiality (except for limits of confidentiality).
Not having a mental health disorder diagnosis on your medical record.
Consulting with me on non-psychiatric issues that are important to you that aren’t billable by insurance, such as learning how to cope with life changes, gaining more effective communication techniques for your relationships, increasing personal insight, and developing healthy new skills.
After reading my position on why Hope in Healing Therapy Inc doesn’t accept health insurance. Hope in Healing Therapy Inc will give you the option to use Mentaya to bill your insurances Out of Network Benefits.
If you would still prefer to use your In Network benefits: If you provide me with a list of therapists on your insurance provider list, we will do my best to recommend a therapist for you.
EMERGENCY CONTACT:
It is necessary that your clinician of Hope in Healing Therapy Inc. has someone to contact on your behalf. In case of an emergency who should we contact?
_____________________________________________________________________________________Full Name Relationship Phone Number(s)
Please check here that you agree and sign below. Thank you.
☐ I agree to allow Hope in Healing Therapy Inc. to contact my emergency contact on my behalf in the case of emergency
_____________________________________________________________________________________ Signature Date
PART III: CONSENT
1. I have read and understand the information contained in the Therapy Agreement, Policies and Consent. I have discussed any questions that I have regarding this information with my therapist at Hope in Healing Therapy Inc.. My signature below indicates that I am voluntarily giving my informed consent to receive counseling services and agree to abide by the agreement and policies listed in this consent. I authorize my therapist at Hope in Healing Therapy Inc. to provide counseling services that are considered necessary and advisable.
2. I authorize the release of treatment and diagnosis information (as described in Part III, above) necessary to process bills for services to my insurance company, and request payment of benefits to Hope in Healing Therapy Inc.. I acknowledge that I am financially responsible for payment whether or not covered by insurance. I understand, in the event that fees are not covered by insurance, your therapist, of Hope in Healing Therapy Inc. may utilize payment recovery procedures after reasonable notice to me, including a collection company or collection attorney. Hope in Healing Therapy makes all charges 24 hours before the appointment, should you not be able to pay your appointment will be canceled.
Printed Name: ________________________________
Signature:____________________________________
Date:_________________________________________
Your signature signifies that you have received a copy of the “Therapy Agreement, Policies and Consent” for your records.
Clinician Signature: ______________________________________________ Date: ______________