Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $155 per 55-minute session. This fee is increased by $5 on the first of each year. At times, Therapist may suggest sessions of other lengths, and if accepted by Patient, these are billed at $215 for 85 minutes or $275 for 115 minutes. Special extended sessions beyond two hours are billed at the hourly session fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. If Patient wishes to use insurance benefits, a separate insurance fee consent will outline the fees specific to the individual’s plan. If Patient does not wish to use insurance benefits, Patient may choose to begin using benefits, if available, at any time in the future. Benefits utilization will begin at the time Therapist is provided policy information; no back-billing will be done. Therapist will xxxx primary insurance when the therapist is contracted with the insurance panel. For out of network and secondary insurance benefits, Therapist will provide a superbill that Patient can use for reimbursement. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in te...
Patient Privilege. The information disclosed by Client, as well as any records created, is subject to the psychotherapist- client privilege. The psychotherapist-client privilege results from the special relationship between Therapist and Client in the eyes of the law. It is akin to the attorney-client privilege or the doctor-client privilege. Typically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Client’s behalf until instructed, in writing, to do otherwise by Client or Client’s representative. Client should be aware that he/she might be waiving the psychotherapist-client privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Client should address any concerns he/she might have regarding the psychotherapist-client privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $160 per 50-minute session. Sessions longer than 50-minutes are charged for the additional time pro rata. Therapist reserves the right to periodically adjust this fee. Client will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. The agreed upon fee between Therapist and Client is $160/hr. Therapist reserves the right to periodically adjust fee. Client will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Client for purposes other than scheduling sessions. Client is responsible for payment for any telephone calls at the same rate as a regular therapy session. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Client’s request and with Client’s advance written authorization. Client is responsible for payment for any telephone calls. Therapist may also engage in correspondence with third parties in the form of letters, emails, text messages, and voicemails. Client is also responsible for the therapist time spent on such communication on the same rate charged for therapy sessions. Clients are expected to pay for services at the time services are rendered. Therapist accepts cash and checks.
Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. Typically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $165 per 55-minute session. This fee is increased by $5 on the first of each year. At times, Therapist may suggest sessions of other lengths, and if accepted by Patient, these are billed at $225 for 85 minutes or $285 for 115 minutes. Special extended sessions beyond two hours are billed at the hourly session fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. If Patient wishes to use insurance benefits, a separate insurance fee consent will outline the fees specific to the individual’s plan. If Patient does not wish to use insurance benefits, Patient may choose to begin using benefits, if available, at any time in the future. Benefits utilization will begin at the time Therapist is provided policy information; no back-billing will be done. Therapist will xxxx primary insurance when the therapist is contracted with the insurance panel. For out of network and secondary insurance benefits, Therapist will provide a superbill that Patient can use for reimbursement. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient’s request and with Patient’s ad...
Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $140 per 50-minute session. At times, Therapist may suggest sessions of other lengths, and if accepted by Patient, these are billed at $200 for 80 minutes or $250 for 110 minutes. Therapist reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, checks, and major credit cards (Visa and MasterCard).
Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Informed Consent By signing below, each Patient acknowledges that he/she has reviewed and fully understands the terms and conditions of this Agreement. Patient has discussed such terms and conditions with Therapist, and has had any questions with regard to its terms and conditions answered to Patient’s satisfaction. Patient agrees to abide by the terms and conditions of this Agreement and consents to participate in psychotherapy with Therapist. Moreover, Patient agrees to hold Therapist free and harmless from any claims, demands, or suits for damages from any injury or complications whatsoever, save negligence, that may result from such treatment. Authorization to Treat Minor The below signed caregiver(s) authorize Therapist to treat their child(ren): Participating Family Members:
Patient Privilege. The information you disclose, as well as any records created, is subject to the psychotherapist- patient privilege. The psychotherapist-patient privilege results from the special relationship between therapist and patient in the eyes of the law. Typically, you are the holder of the psychotherapist-patient privilege. If I receive a subpoena for records, deposition testimony, or testimony in a court of law, I will assert the psychotherapist-patient privilege on your behalf until instructed, in writing, to do otherwise by you or your representative. You should be aware that you may be waiving the psychotherapist-patient privilege if you make your mental or emotional state an issue in a legal proceeding. You should address any concerns you might have regarding the psychotherapist-patient privilege with your attorney. Professional Consultation I consult regularly with other professionals regarding my clients in order to provide you with the best possible service. Names or other identifying information are never used; client identity remains completely anonymous and your confidentiality will be fully maintained. If, for some reason, I believe it is important to consult with another professional in-depth, and I believe identifying information about you may be shared, I will have you sign a release of information allowing me to share this information. Without such a release, I will not consult with another professional providing information that might lead another person to be able to identify you. Social Media I do not accept contact requests from current or former clients on any social networking site. I believe that adding clients as contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. I will not prevent you from nor will I solicit Instagram or Facebook "likes" on my business page, "follows" on Twitter, reviews on Yelp, or anything other type of social media interaction. Please note that in doing so you may lose some of your confidentiality as my client. Payment and Financial Arrangements My standard fee is $210 for a 50-minute session. Prorated fees are offered for extended sessions at the same rate (e.g. $315 for 75 minute session). The fee is to be paid at the start of each session and I accept cash, checks, and credit cards. Full payment is expected at the time of service. If you are late, we will end on time and not run over into the next person’s session. F...
Patient Privilege. The information disclosed by patients, as well as any records created, is subject to the psychotherapist – patient privilege. The psychotherapist– patient privilege results from the special relationship between therapist and patient in the eyes of the law. It is akin to the attorney– patient privilege or the doctor– patient privilege. Typically, the patient is the holder of the psychotherapist – patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist – patient privilege on Patient’s behalf until instructed, to do otherwise by Patient or Patient’s representative. Patient should be aware that she/he might be waving the psychotherapist– Patient privilege if she/he makes mental or emotional state an issue in a legal proceeding. Patient should address any concerns she/he might have regarding the psychotherapist – patient privilege with his/her attorney. There are however exceptions to privilege, which includes, but is not limited to: 1) a patient is a danger to self or others, 2) a judge issues a court order, 3) a patient introduces his/her mental condition into testimony, 4) someone is under 16 and victim of a crime, 5) the court is using therapy to establish sanity or competence to stand trial, 6) a patient has treated information as though it is not confidential, 7) information pertaining to the Patriot Act, 8) information listed on the health insurance claim form or child abuse report, 9) a patient complaint or lawsuit against me.
Patient Privilege. All Patients over the age of 13, unless otherwise designated by law, hold their own privilege, or the right to choose whether or not to release confidential information about their treatment. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient‟s behalf until instructed, in writing, to do otherwise by Patient or Patient‟s representative. Patient should be aware that he/she might be waiving the psychotherapist- patient privilege with his/her attorney. Patient should also be aware that a court judge may also waive this privilege in certain cases. Fee and Fee Arrangements The usual and customary fee for service is $110.00 per 45 minute session. Sessions longer than 45 minutes are charged for the additional time pro rata. Therapist reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment at least 30 days in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is _. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than fifteen minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient‟s request and with Patient‟s advance written authorization. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than fifteen minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash and checks.
Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist- patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. If Therapist receives a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by a person with the authority to waive the privilege on Patient’s behalf. When a patient is a minor child, the holder of the psychotherapist-patient privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-patient privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-patient privilege with his/her attorney. Patient, or Representative, should be aware that he/she might be waiving the psychotherapist- patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Professional Consultation Professional consultation is an important component of a healthy psychotherapy practice. Therapist regularly participates in clinical, ethical, and legal consultation with appropriate professionals. Therapist will not reveal any identifying information regarding Patient or Patient’s family members or caregivers.
Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $145 per 55-minute session. This fee is increased by $5 on the first of each year. At times, Therapist may suggest sessions of other lengths, and if accepted by Patient, these are billed at $205 for 85 minutes or $255 for 115 minutes. Special extended sessions beyond two hours are billed at the hourly session fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. If Patient wishes to use insurance benefits, a separate insurance fee consent will outline the fees specific to the individual’s plan. If Patient does not wish to use insurance benefits, Patient may choose to begin using benefits, if available, at any time in the future. Benefits utilization will begin at the time Therapist is provided policy information. Therapist will xxxx primary insurance when the therapist is contracted with the insurance panel. For out of network and secondary insurance benefits, Therapist will provide a superbill that Patient can use for reimbursement. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third par...
