Psychotherapy Fee Agreement

FEES The full fee at Alice Berry Counseling for a 45- to 50-minute psychotherapy or counselling session is $180.00. A sliding fee schedule can be used to arrange a discount on these full fees. The sliding scale is usually based on a family`s annual income. Suggested prices for this scale of mobile charges are as follows: CANCEL APPOINTMENTS While it`s usually best to keep regular appointments, there may be times when you can`t make it to the office. You are asked to call my number below at least 24 hours in advance to cancel the appointment. If you do not cancel more than 24 hours in advance, you may be charged the full normal fee for that session, unless we have agreed otherwise in writing. Exceptions to this policy are serious illnesses, accidents you may be in, and weather conditions that cause transportation difficulties. If I have an open position and you can reschedule during this week, you will not be charged any fees. PSYCHOLOGICAL SERVICES: I consider psychotherapy to be a collaborative process between you, me and anyone else you deem appropriate. During your sessions, you can discuss what you want. I assume you know what is best for you and with our cooperation we can clarify the best way to achieve this. I ask you to pay the full fee at the end of each session, unless we have entered into a different written agreement. I do not currently accept insurance payments.

In addition, a fee of $35.00 will be added to your balance, which is due for each cheque returned by the bank due to insufficient funds. If you have a credit balance and have not made an appointment, you will receive a statement for services around the 15th of each month. Unless there are financial difficulties, which we have discussed and developed an alternative regulation, payment will be required upon receipt of the statement. Thank you in advance for your attention. Psychotherapy can have many benefits and some risks. Since therapy often involves unpleasant aspects of your life, you may sometimes experience unpleasant feelings. On the other hand, psychotherapy has also been shown to have many benefits. Obviously, there is no guarantee as to what you will experience. I believe you have the ability within you to maximize your own success. While privacy in psychotherapy is often critical to successful progress, especially among adolescents, parental involvement is also critical to successful treatment. For children 14 years of age and older, it is usually my policy to seek agreement between my client and their parents, which allows me to share general information about the child`s treatment progress and participation in scheduled sessions. Any other communication requires the child`s permission, unless I feel the child is in danger or presents a danger to someone else, in which case I will inform the appropriate people of my concern.

Before giving any information to the parents, I will discuss the matter with the child if possible and do my best to deal with any objections they may have. MINORS AND PARENTS Clients under the age of 14 and their parents should be aware that the law allows parents to review their child`s treatment records unless I decide that such access would harm the child or we agree otherwise. Under Illinois law, clients 14 years of age and older can keep all medical records, including psychotherapeutic records, private, including of their parents. Confidentiality is strictly necessary unless a customer reports child abuse or elder abuse, or when a customer is in imminent danger of injuring themselves or someone else. With the exception of these exceptions, no information about these sessions may be shared with third parties, including parents, without the child`s written consent. This customer service agreement contains important information about my services and business policies. When you sign this form, it constitutes an agreement between us. You may revoke this Agreement at any time in writing. This revocation binds me, unless I have to take measures that are described within the limits of confidentiality, or if you have not fulfilled any financial obligation that you have contracted.

In addition to this customer service agreement, you will receive another form. The Health Insurance Portability and Accountability Act, or HIPAA, is a federal law that provides protection and privacy rights regarding the use and disclosure of your protected health information (PHI). HIPAA requires that I provide you with a Privacy Practices Notice describing and explaining HIPAA and its application to your personal health information. PRIVACY There are laws that clarify the confidentiality of all communications between you and me. In most cases, I can only disclose information about you if you sign a written approval form. There are situations where I am legally obliged to break confidentiality. The law states four of these situations and they are: 1. when you report child abuse. 2.

if you report elder abuse. 3. if you are in imminent danger of harming yourself. 4. if you are in imminent danger of harming someone else. Any other situation requires that you have me sign a prior written consent form before confidential information can be disclosed. Your signature under this Agreement demonstrates your understanding of confidentiality and the legal limits of confidentiality. Written data protection procedures. The rule requires that the companies concerned have in place written data protection procedures, including a description of the personnel who have access to the protected information, how it is used and when it can be disclosed. Affected companies should generally take steps to ensure that all business partners who have access to protected information accept the same restrictions on the use and disclosure of that information. Amount of annual income per hour of psychological services $0 – $12,000 per year $20 My philosophy is to see you as a whole person whose mind, body and social activities are interconnected.

My view is to see emotional, social and physical health challenges as normal human experiences influenced by lifestyle and adaptation. These challenges can be an opportunity to improve your health, as well as an opportunity for growth. In order to meet the individual needs of each client, I integrate current scientific findings into your own intuitive healing process. There are a variety of services and techniques that can be useful to integrate them into your sessions. You may want to know which combination, if any, is best for you. I also respect the fact that the most important thing for you is to feel comfortable with your therapist. If you have any questions or concerns about our cooperation, please do not hesitate to let me know. Sometimes the therapist you start with won`t feel right for you. I encourage you to express it to me, and if you wish, I can help you find the right professional that best suits your needs and style. Restrictions on the use of personal health data. The confidentiality rule sets limits on how health plans and covered providers can use individually identifiable health information. To promote the best quality of care for patients, the rule does not limit the ability of doctors, nurses and other providers to share the information needed to treat their patients.

However, in other situations, personal health information generally cannot be used for non-health care purposes, and affected companies may only use or disclose the minimum amount of protected information necessary for a specific purpose. In addition, patients should sign a specific permit before a covered entity can share their medical information with a life insurer, bank, marketing company, or other external company for purposes unrelated to their healthcare. Your signature below indicates that you have read the information contained in this document and that you agree to its terms, and also serves as confirmation that you have received the HIPAA notification form described above. The amount actually paid by the customer may differ from the list above. The client and I will work together to set a fair fee for the service. Many other factors are taken into account when setting expense fees for a client, including access to additional sources of income, exorbitant medical costs, and other excessive financial expectations. All clients are asked to pay something for the services provided as part of their recognition of the importance of these services. PROTECTING THE CONFIDENTIALITY OF PATIENT HEALTH INFORMATION PHONE OR VIDEO CALLS If you dial the primary number listed above, your call will be answered by me or my voicemail.

If I am not answering your call at this time, please leave a message in my confidential voicemail with the best time to reach you and I will call you back as soon as possible. If you have an emergency situation and need immediate help and I don`t answer your call right away, you should consider going to the nearest emergency room. Public responsibilities. In certain circumstances, the definitive regime allows but does not require subject entities to continue to disclose health information for certain public responsibilities. These permitted disclosures include: emergencies; identification of the body of a deceased person or the cause of death; public health needs; research that includes limited data or that has been independently approved by an institutional review committee or privacy committee; oversight of the health system; judicial and administrative proceedings; limited enforcement; and activities related to national defence and security. .