Patient Services Agreement

Welcome to my practice. This document (the Agreement) contains important information about my professional services and business policies. When you sign the Agreement, it will represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have taken action in reliance on it; or if you have not satisfied any financial obligations you have incurred. The Health Insurance Portability and Accountability Act (HIPAA) requires that I offer you my Notice of Privacy Practices (NPP). The NPP explains HIPAA and its application to your personal health information in greater detail.

When you sign the Agreement, it is verification that you have been offered our NPP. The NPP is available in-office and by clicking on this link. We can discuss any questions that you have about our privacy practices during any of our sessions. Hope Counseling provides individual psychotherapy in person and via telehealth. Patients are required to pay for services at the time of service.

PSYCHOLOGICAL SERVICES Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychotherapist and patient, and the particular problems you are experiencing. There are many different methods I may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. There are no guarantees of what you will experience. Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion.

MEETINGS I normally conduct an evaluation that may last from 2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. I will usually schedule one 45 to 50 minute session per week at a time we agree on, although some sessions may be longer or may be more or less frequent. Please be aware that you are responsible for remembering the date and time of your appointment. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 48 hours advance notice of cancellation (unless I feel that you were unable to attend due to circumstances beyond your control).

PROFESSIONAL FEES I offer a sliding scale fee schedule ranging from $100-$150 depending on income. Your specific rate will be discussed with you at your initial session. In addition to weekly appointments, I charge for other professional services you may need, such as report writing, telephone conversations lasting longer than 5 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $100 per 15 minutes for preparation, transportation, and attendance at any legal proceeding. Please note that it is my policy to avoid being a party to litigation under most circumstances.

CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. My hours vary from day-to-day. When I am unavailable, my telephone is answered by voicemail that I monitor frequently. I will make every effort to return your call on the same day you make it, with the exception of holidays, vacation days, and other days off. If you are difficult to reach, please inform me of some times when you will be available. In case of emergency, please contact 911 or your local crisis line.

LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a patient and a psychotherapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA and/or Minnesota law. In some situations, no authorization is required. At Hope Counseling, I will follow both HIPAA and Minnesota law with regard to protecting and releasing information. If you have questions about a specific confidentiality issue, please feel free to ask. There are some situations in which I am legally obligated to take actions which I believe are necessary to attempt to protect you or others from harm, and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice. • If I have reasonable cause to believe that a child under 18 known to me in my professional capacity may be an abused or neglected child, the law requires that I file a report with the local office of the Department of Children and Family Services. If I have reason to believe that an adult over the age of 60 living in a domestic situation has been abused or neglected in the preceding 12 months, the law requires that I file a report with the agency designated to receive such reports by the Department of Aging. • If you have made a specific threat of violence against another or if I believe that you present a clear, imminent risk of serious physical harm to another, I may be required to disclose information in order to take protective actions. These actions may include notifying the potential victim, contacting the police or seeking hospitalization. • If I believe that you present a clear, imminent risk of serious physical or mental injury or death to yourself, I may be required to disclose information in order to take protective actions. These actions may include seeking your hospitalization or contacting family members or others who can assist in protecting you. If such a situation arises, I will make every effort to discuss it with you before taking any action, as appropriate, and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential actions, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed.

PROFESSIONAL RECORDS The laws and standards of my profession require that I keep Protected Healthcare Information (PHI) about you in your Clinical Record. Professional records can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that if you need your records, that you review them in the presence of another health professional or preferably have them forwarded directly to another health professional. Please note that Psychotherapy Notes may not be released without an appropriately completed Authorization.

MINORS AND PARENTS Parents of children between 12 and 18 are discouraged from examining their child’s records unless the child consents and unless I find that there are compelling reasons for allowing the access. Parents are entitled to information concerning their child’s current physical and mental condition, diagnosis, treatment needs, services provided, and services needed. Since parental involvement is often crucial to successful treatment, in most cases, I require that patient between 12 and 18 years of age and their parents enter into an agreement that allows parents access to certain treatment information. If everyone agrees, during treatment, I will provide parents with general information about the progress of their child’s treatment, and his/her attendance at scheduled sessions. I may also provide parents with a summary of treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.

BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise Fees for professional services are as follows: $100-$150 per 45 to 50 minute session. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, Hope Counseling has the option of using legal means to secure the payment. This may involve using my collection agency which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, address, employment information, and telephone numbers, the nature of services provided and the amount due. If such legal action is necessary, its costs will be included in the claim.

AGREEMENT Your signature at first appointment indicates you are in agreement with and will comply with the guidelines in this document. Hope Counseling reserves the right to modify the PPSA at anytime and will notify clients of changes as they arise. At that time, patients will be required to sign the revised PPSA.