Welcome to My Practice

GENERAL INFORMATION AND POLICIES

This information sheet covers a number of important issues related to your therapy, which I will be glad to discuss further with you if you have questions.

Confidentiality – All information discussed in psychotherapy is confidential, and I am obligated by law and the psychiatry code of ethics to protect your right to confidentiality. This means I must have your permission before revealing any information about you to anyone, with the following exceptions:

Legal limitations – I am obligated by law to disclose information you tell me in psychotherapy under certain legally-defined situations. These situations include: (1) if you are a danger to yourself or others; (2) if you tell me about an incident of child abuse by you or someone else; (3) if you tell me about an incident of abuse of someone over age 65 or of a disabled adult. There are other specific legal limitations which rarely occur. We can discuss these situations if you have questions or if the specific conditions arise.

Insurance information – If you submit my monthly statement to your insurance company, be aware that the company may request certain information from me as a requirement of your reimbursement. This information could include date of appointments, diagnoses, medications prescribed, and treatment summary (the minimum necessary). It is my policy not to release copies of my psychotherapy notes to an insurance carrier.¹

Communications with other professionals – It is possible that I will need to communicate with other health care professionals working with you, which is permissible by law, if necessary, under certain circumstances. I will discuss these communications with you and obtain your written consent before they take place. 

Scheduling and cancellation – Psychotherapy is most effective when we are able to meet consistently at least once a week. When I agree to work with you, I make a commitment to set aside time in my schedule for that purpose. Therefore I ask for payment for our scheduled appointment times once we have established a regular time and frequency for your sessions. My usual policy for different types of cancellations is outlined below. We can discuss any questions or unusual circumstances as they arise.

Holidays or my vacation – There is no charge for regularly scheduled appointments that occur on a holiday or during my vacation. I usually recommend that we schedule an alternate time for an appointment missed because of a holiday in order to maintain the consistency for our sessions. However, you are under no obligation to do so. The holidays I usually take are President’s Day, Memorial Day, July 4th, Labor Day, Thanksgiving (Thursday and Friday), Christmas Day, and New Year’s Day. I generally take four weeks of vacation during the year and will give you ample notice of those dates.

Vacation or other planned absences – I generally charge for missed appointments if you give me less than two weeks notice, with the option of rescheduling the appointment to an alternate time. With two weeks notice or more, I generally do not charge for the missed appointment. I prefer to discuss individual circumstances as they arise.

Fees and payment – My fee is ______ per session. Reduced fees may be negotiated based on financial circumstances and will be adjusted as those circumstances change. Fees will be increased approximately ____ % each year, and I will give you approximately one month’s notice before a fee increase goes into effect.

Sessions are 50 minutes in length. I schedule appointments to begin and end on time, which means that your session time is reduced if you are late in arriving. If you need to talk with me between scheduled sessions, you may leave a message on my answering machine at any time (510/555/0000). I will usually call you back within _______ hours.

I do not charge for telephone calls of less than 10 minutes. My charge for telephone calls of 10 minutes or more is prorated based on the fee for a 50-minute session. (For example, the charge for a 10-minute telephone call would be one-fifth of your session fee.)

Payment for each session is due at the time of the session. Payment for telephone calls is due at a next scheduled session. If you have insurance coverage for psychotherapy, I will give you a statement at the end of each month to send to your insurance company for reimbursement.

Emergencies – We can discuss what constitutes a psychiatric emergency vs. an urgent psychiatric matter, if you wish. However, if you experience what you believe is a psychiatric emergency, please call or go to your nearest emergency department.

And finally – If you have questions, please ask me and I will do my best to answer them. I look forward to working with you.

Effective date: ______________

^[1]Physicians who contract with 3^rd -party payers, or submit statements directly to 3^rd-party payers, should revise this paragraph to reflect the information requirements of those carriers.

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