Welcome to The Relationship Suite.
This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment and health care operation. HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which you are given with this agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that we obtain your signature acknowledging that we have provided you with this information. Please read this document carefully, taking notes of any questions you may have. We can discuss these questions during session. When you sign this agreement, it constitutes as a binding agreement between us. If at any time, you feel your needs are not being met, I invite you to express these concerns so they can be worked through. You may revoke this Agreement in writing at any time.
The therapy experience varies depending on the personalities of both the therapist and client and the particular problems which the client bring in to treatment. There are a number of different theoretical approaches that can be utilized in the field of psychotherapy. All of these approaches are designed to address the problems that you are coming to therapy to work on.
Therapy requires active effort on your part. It is seen as beneficial if you understand exactly what is involved in your treatment, and the theory behind why certain treatment protocols are chosen. Therefore, treatment is almost always discussed in therapy, and you should feel free and indeed encouraged, to ask questions about what is being offered and done during the course of treatment. In order to be most successful, you will have to work both during our sessions and at home. You should expect to come away from the therapy experience having learned many specific things that you can do to address the issues that are currently troubling you and that have troubled you in the past. You should expect, as does your therapist, great improvement in your condition, but there are no guarantees about what you will be able to accomplish, even with great effort on both our parts.
Therapy, like everything in life, has both benefits and risks. Sometimes psychotherapy involves recalling and talking about unpleasant events in your life. Because of this, at times, therapy may bring up feelings of discomfort, such as experiencing uncomfortable levels of feelings, like sadness, guilt, anxiety, anger, frustration, disappointment, loneliness and helplessness. Therapy can also result in humor and fun, relief, new insights and behavior change. The greater the investment you make in therapy by expressing your feelings and opinions about the process, the more successful this endeavor will be for you. Therapy also has been shown to have benefits for people who undertake it, often leading to a significant reduction of feelings of distress, better relationships, and/or the resolution of specific problems.
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 initial impressions of what our work will include, if you decide to continue. You should evaluate this information along with your own sense about 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 secure an appropriate referral to another mental health professional.
Sessions, Fees, Insurance, and Cancellation policies
After a period of evaluation that will last from 1 to 4 sessions, we will begin sessions that will meet your treatment objectives. Sessions are typically conducted one-time per week for 50-55 minutes at a mutually agreed upon time. Therapy is a time sensitive activity and your appointment is reserved specifically for you. More or less frequent sessions are sometimes scheduled, depending on the needs of the client. Once the appointment hour is scheduled, you will be expected to pay for the full session fee unless you provide XX hours advanced notice of cancellation (see cancellation policy below).
Fees are due at the time of session. Signing the Signature Page of this document indicates that you have been informed and are in agreement with my fees. The fees that you are quoted at the start of your therapy may be increased after the end of the calendar year in which you start treatment. You will be notified at least one month in advance of an increase in fees. The Relationship Suite accepts the following payment methods: cash, checks, credit card payments, Chase Zella pay and Venmo. Checks should be made out to The Relationship Suite PLLC. To pay by Venmo, please searchThe Relationship Suite. As for credit card payments, we take Visa, Mastercard, Discover and American Express. Please be aware that there will be a 3.5% additional charge for all credit card transactions.
At this time, The Relationship Suite does not participate in any health insurance of managed care company plans. If you have “out of panel” or “out of network” insurance benefits, you will still be required to pay the full fee at the time that services are provided. Your therapist can then provide you with a receipt, which has all the information that your insurance company typically requires. You could ten submit the receipt to your insurance company for whatever reimbursement they allow. I cannot guarantee that your insurance company will reimburse you for services.
Please note, if you do not show up for a scheduled appointment, or if you cancel less than 72 hours before the appointment time, you should expect to be billed for the entire amount of the session cost. I understand that you are busy and sometimes, things out of our control come up. Please keep in mind that all cancellations fees are subject to therapist discretion.
Please note: If your account is more than 60 days overdue and suitable arrangements for payment have not been agreed to, your therapist will have the option of using legal means to secure payment, including the use of collections agencies or small claims court. If such legal action is necessary, the costs of bringing that proceeding will be included in the claim. In most cases, the only information that would be released about a client’s treatment would be the client’s name, the nature of the services provided, and the amount due.
A certain amount of “out of session” work time on the part of the therapist is built into the charges for your session time, but under certain circumstances additional time spent on a case can become significant, and will therefore be charged. This might occur, for instance, in the preparation of a report or letter to a school or place of work, or when there is a need to make numerous phone calls, or calls that last more than just a few minutes. Additionally, although we do not accept insurance payments directly and function only on an out-of-network basis, there are times that you might request that your therapist contact your insurance company or managed care organization and negotiate for a higher level of care or for additional sessions. These phone calls can sometimes be quite time consuming, and often involve several stages, such as first speaking with a Customer Service Representative, then a Customer Care Manager, and then a Physician Review. In all these cases and more, you may be charged a prorated fee for the time spent involved in these activities. You will be informed of this arrangement, however, before any of the work is done, so that you have the opportunity to accept or decline these services.
Length and Termination of Therapy Sessions
My goal is never to keep anyone in therapy longer than necessary. The purpose of therapy should be for you to resolve your current problems and take the experience of therapy with you after you leave. The number of therapy sessions may vary depending on the type and severity of problems. Your therapist will take into account individual factors and discuss a time frame that meets your needs. Because of the importance of the therapeutic relationship between client and therapist, we encourage you to talk to your therapist if you are considering leaving therapy. The therapy process involves a growth experience. Therefore, terminating the relationship is part of that growth experience. We can determine a “planned ending”, in which we meet for a specified number of weeks in order to process feelings about the termination of services, reflect on growth and progress and have the opportunity to say goodbye. You may choose to re-engage in the therapy process at any time but must contact the therapist to re-establish treatment services.
Contacting the Therapist
You will be provided with my contact information prior to therapy or at the time of our initial session. Due to my work schedule, I am often not immediately available by phone or email. I will not answer my phone when I am with a client. When I am unavailable, my telephone is answered by my voicemail that I monitor frequently and I check my email regularly. If I am out of the office for an extended period of time, you will be made aware of this with advance notice. As well, this will be indicated in my outgoing voice message and by my email. I will make every effort to return your call or email within 24 hours, except on weekends and holidays. If you are difficult to reach, please leave some times when you are available and a good number to call you back on. Please indicate if I am able to leave a message on your voice mail or if it is a shared phone.
If I will be unavailable for an extended period of time, I will provide you with the name of a colleague to contact, in the event of an emergency or should you need immediate assistance. When this is the case, my telephone greeting and email will refer you to the covering clinician.
Phone. Telephone is generally the best way to reach me for non-emergency message. As mentioned, I do not answer my cell phone while I am with clients but I will make every effort to return your phone call within 24 hours, excluding holidays and weekends. If phone consultation sessions are incorporated in your treatment, then I will make every effort to call you back by the end of that evening or first thing in the morning. In the event of an emergency, please call 911 or go to your nearest emergency room.
Email. My email address is Rachel@therelationshipsuite.com. I check my email regularly. Please be aware that certain communications, such as trying to arrange or change an appointment time, or letting your therapist know that something you had contracted to try to work on, are perfectly acceptable uses of email. However, I typically do not conduct therapy of any kind across email or the Internet. If you have a strong need to discuss something of a clinical nature, it is suggested that you leave a voicemail message requesting to talk to me or set up an appointment to meet face-to-face.
Should you decide to contact me via email please note that this is not a secure means of communication and you are accepting the risk associated with transmitting personal information over the internet. I will make every reasonable effort to maintain email/electronic security.
The law protects the confidentiality of all communications between a client and a therapist, and information can only be released to others outside of the practice with your written permission. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows:
- If you are seeing a psychiatrist, or have recently been treated by another mental health provider, you may be asked to sign a form giving permission to make contact and discuss your case.
- I may occasionally find it helpful to consult with other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together.
- To ensure that I provide you with the best treatment, you should be aware that I receive supervision with another mental health professional. All mental health professionals are bound by the same rules of confidentiality. If I discuss your case, I will use your first name only and there will be no other identifying information. Again, if you do not object, I will not tell you about the supervision meetings in which I may discuss your case.
- Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.
- While I am not part of a group, there are other health professionals in my office and we share a waiting room as well as group room (if applicable). Everyone is bound by the same confidentiality rules as you are.
- Confidentiality regarding sharing information outside of the practice is maintained under all circumstances, except when it is believed that you or someone else may be put at risk if confidentiality is not broken. If it is believed that there is a possibility that you or someone else may be in danger, such as when there exists the potential for suicidal or homicidal behavior, or a minor or elderly person is at risk for abuse, then your therapist may contact whomsoever it is felt is appropriate to protect those that require protection, and share specific information about you and/or our treatment.
There are some situations where I am permitted to disclose information without either you consent or Authorization:
- If you are involved in a court proceeding and a request is made for information concerning the professional services that I provided for you, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your written authorization or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court order would be likely to order me to disclose information.
- If a government agency is requesting the information for health oversight activities, I may be required to provide it for them.
- If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself.
- If a client files a worker’s compensation claim, and my services are being compensated through worker’s compensation benefits, I must, upon appropriate request, provide a copy of the client’s record to the client’s employer.
There are some situations in which I am legally required to take action to protect others from harm, even if that requires revealing confidential information about a client’s treatment.
- If I believe that a child, an elderly person, or a disabled person is being abused, I am a mandated reporter, which means I am required by the law to report the suspected abuse to the Department of Children and Family Services.
- If I believe a client presents an imminent danger to the health and safety of another, I may be required to disclose information in order to take protective actions, including initiating hospitalization, warning the potential victim, if identifiable, and/or calling the police.
Both law and the standards of professional practice require that I keep appropriate treatment records. You are entitled to receive a copy of the records, unless it is believed that seeing them would be emotionally damaging, in which case, the therapist will be happy to provide them to an appropriate mental health professional of your choice. Because these are professional records, they can be misinterpreted and/or can be upsetting, so it is recommended that you and your therapist review them together so that the two of you can discuss what they contain. Clients will be charged an appropriate fee for any preparation time, which is required to comply with an information request.
HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to no authorized; determining the location to which location protected information disclosures are sent; having nay complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of the Agreement. I am happy to discuss these rights with you.
Your signature on the Signature Page indicates that you have read the information in this document and agree to abide by its terms. It is hoped this has served to clarify expectations and that it has answered many questions that you might have had about therapy and my practice. I have tried to balance the need for dealing with the business end of providing services to you while maintaining my integrity as a supportive and caring professional who is committed to helping you be successful in reaching your goals in therapy
If you have any questions about this agreement, please ask your therapist. Your signature below indicates that you have read this agreement and agree to its terms and also serves as an acknowledgement that you have received the HIPAA notice form described above.
I have read the preceding information and understand my rights as a client. By signing below I acknowledge my understanding and agree to all the terms discussed in this disclosure statement. By signing this disclosure statement, I also agree to permit consultation and I provide release for my psychotherapist(s) to seek consultation with an outsider supervisor and/or other psychotherapists or professionals as the need arises. I have been provided the option to receive a copy of this Agreement for my personal records.
Signature of Client Date
Please sign below to give permission for me to contact your referring physician or health care professional to send him/her a letter of appreciation.
Signature of Client Date