This is a copy of the form you would sign to begin treatment with me:
CONSENT FOR TREATMENT
Please read this document carefully and ask any questions you have before signing. Once signed, this document constitutes an agreement between us.
I use a type of psychological treatment called Intensive Short-Term Dynamic Psychotherapy (ISTDP) and as the name suggests, it is intensive. Not all people will benefit from this treatment nor is it suitable for everyone. Our first appointment will be a two-hour trial therapy to assess your suitability for this type of treatment, your willingness to engage in the therapeutic process and to make recommendations for you should ISTDP not be the treatment of choice.
If we meet online for psychotherapy, here are a few things to know:
I’ll never disconnect during a session unless there’s been a technical or internet problem. In the event of a disconnection, I’ll make an attempt to re-connect, and if I cannot, I will call you at the number I have on file.
Please make sure your internet connection is reliable enough that it can sustain a video call for an entire session. If you're on WiFi, the closer you are to the router, the better the signal. A direct ethernet connection provides the best quality.
I cannot guarantee or be responsible for the privacy on your end of the session. You agree to make adequate arrangements such as:
having a room to meet in which is both private and inaccessible to employees, co-workers, family, children, distracting pets, etc.
silencing phones, or when using a smartphone, using the do not disturb function
being aware of what I am able to view in the background of your meeting space.
We will use video software that is accessed through my patient portal. You will be invited to create an account so that you can access the secure video.
Please use headphones with a built-in microphone during video calls. This prevents my voice being picked up by your microphone and echoing back to me.
You agree that if online psychotherapy is no longer a recommended treatment based upon my clinical findings, I will help refer you to a therapist within your community or, if you live locally, require that you meet with me in person for continued treatment.
You must be physically located in Vermont or Ohio during your online session (the only two states where I am licensed to practice).
Remember that if you're seeing me online using a shared network, especially with an employer, or using a work computer, your activities on the network and device could compromise your privacy if monitored. Be careful with the use of password keepers on your computer that you might use to login to the patient portal if someone else has access to your computer, and to not use a publicly shared computer.
VIDEO RECORDING (FOR IN-OFFICE TREATMENT ONLY)
ISTDP is a treatment model that involves video recording the sessions for my review after we meet and to help tailor the treatment to your specific problem. Video recordings of your session are kept secure and no one else has access to them.
Therapy is confidential with the following exceptions:
Your health insurer has the right to access your medical records if they reimburse for my services. Once they have this data, I have no control over how it is used or who has access to it.
I must notify authorities if I believe you are at imminent risk of hurting yourself or someone else.
I am mandated by Vermont law to report suspected abuse of a child or protected adult.
I am legally required to release medical records when presented with a court subpoena.
If you would like me to discuss your information with someone else, you’ll be required to sign an information release; you are entitled to a copy. You have the right to restrict or revoke an information release at any time.
I routinely meet with other psychotherapists to consult about my current patients. Your name or any other identifying information will not be used to protect your privacy.
If you do not have insurance
Two hour trial therapy is $280
Standard 55-minute session of individual psychotherapy is $130.
If you have insurance and I am a credentialed provider for them
I accept their reimbursement as I have negotiated with them; you may be responsible for a co-pay, co-insurance, and/or a deductible. Please verify the details of your outpatient mental health benefits prior to your first appointment. If your insurer fails to pay, you are responsible for the full session charge as noted above.
If you have insurance but I am not a provider for them, known as “out-of-network”
I charge the full fee and will provide you with a receipt for services to seek reimbursement directly. You are responsible for determining from your insurance company prior to our first session if, and how much, they will reimburse you for my services.
If you have insurance but choose not to use it, you will be charged the full fee per session. If in an initial consultation a session ends early due to my assessment that no treatment is warranted, and therefore not reimbursable by insurance, the standard assessment fee of $140 will apply.
Case management services performed on your behalf (consultation with family, your attorney, DCF social worker, etc.) will be billed in quarter hour increments for an hourly rate of $130/hour. Minimal case management to facilitate the continuity of care (insurance authorizations, consulting with your PCP, discharge planners at a hospital or other treatment facility, etc.) is included in your normal session fee. Health insurers do not reimburse for case management.
I accept cash, checks, Health Savings Account (HSA) cards, Health Reimbursement Arrangement (HRA) cards, credit cards (Visa, MasterCard, American Express and Discover) and Apple Pay.
All out of pocket fees are due at the end of each session. Returned checks are subject to a $25 service charge.
Account balances over 30 days are subject to an interest rate of 1.5% (an APR of 18%). Account balances 90 days past due will be forwarded to a collection agency, which requires disclosure of medical information.
If you have a third party payer (e.g., Health Equity, DataPath, Healthy Dollars, Further) that covers a portion of your out-of-pocket costs, please have them reimburse you directly for the treatment you have previously paid for. If you need a statement to submit to them for reimbursement, I will gladly provide you one. You can also use your HRA/HSA credit card as the card on file.
CREDIT CARD AUTHORIZATION
Authorization for a valid credit or debit card is required. You authorize me to use your debit or credit card to charge any out of pocket expenses not covered by your insurer including co-pays, co-insurance, deductibles, no-show or late cancelation fees, the session fee if your insurance has lapsed or for an assessment where treatment is not recommended.
If you’re using a credit or debit card, you authorize me, in the event of a chargeback, to release the minimum amount of information necessary (including medical records, insurance statements or any other protected health information) to substantiate the provision of services.
Your credit card information will be verified by Square, who I use to process payment, and loads your information into my account. I do not have access to your full card number and when this form is transmitted, only the last four digits are shown.
CANCELATIONS & NO-SHOWS
If you need to cancel, please give 24 hours’ notice by calling me at (888) 313-5525. If you late-cancel (less than 24 hours’ notice), no-show, or you arrive 15 minutes late or more, you will be charged a $130 fee. This fee is not covered by your insurance. I reserve the right to end treatment at any time if cancelations, no-shows or late arrivals are impacting your treatment.
COURT SUBPOENAS AND FEES
I do not voluntarily appear in court to testify on a patient’s behalf except in the case of a state or federal court subpoena. If a subpoena is issued requiring me to testify, a flat fee of $1000 per day will apply.
USE OF EMAIL
E-mail can be an unsafe method for communicating protected health information (PHI) if you are using free, commercially available accounts such as Gmail, or if you are using employer-sponsored email. If you send me an email, I will understand it as your consent to use email and will reply in kind. Please use email solely for the purposes of
scheduling appointments or facilitating payment
receiving receipts or invoices for services
automated appointment reminders
If the content is clinical in nature, it is added to your clinical file.
I use ProtonMail, an encrypted Swiss-based email provider.
I offer text message, email and/or phone call reminders through TherapyNotes, my electronic medical record. By electing to have appointment reminders, you consent to receiving communication in this way, and understand the limits to privacy of each method and in your particular circumstance. Reminders are a courtesy - you are responsible for the appointment time even if an automated reminder fails. You can also check upcoming appointment times and adjust reminder settings through my patient portal.
Please turn off or silence your phone during our sessions. If you must be available to someone in extenuating circumstances, please let me know ahead of time. I also will honor this by not accepting calls during our sessions except for rare situations, which I will let you know about ahead of time.
I do not answer the phone or respond to emails when I'm with a patient. You can leave me a message in my confidential voicemail and I will respond as soon as possible within my normal business hours (no later than 24 hours).
Please call 911 or proceed to your nearest hospital emergency room in the event of a mental health emergency.
You have the right to review your clinical information with advanced, written notice.
MEETING OUTSIDE OF THERAPY
I expect that our paths will cross outside of my office. In the event we meet I will do as much as possible to protect your privacy by following your lead. If you do not acknowledge me, I will do the same.
SOCIAL MEDIA POLICY
I do not interact with current or former patients via any social media accounts. Additionally, I do not search for patients online to learn more about them or view their social media accounts. I will know nothing about you other than what you choose to disclose in our professional work together.
PROFESSIONAL QUALIFICATIONS (as required by the Vermont Office of Professional Regulation)
I am a Licensed Independent Clinical Social Worker (LICSW) in the state of Vermont. I abide by the legal and ethical guidelines set forth by the Vermont Office of Professional Regulation and to my professional Code of Ethics. I hold a Master’s Degree in Social Work (MSW) from the University of Vermont.
My experience and expertise pertains to the assessment, diagnosis and treatment of mental health conditions. The following paragraph is an excerpt from Vermont statute defining unprofessional conduct:
§ 3210. Unprofessional conduct
A. The following conduct and the conduct set forth in section 129a of Title 3 by a licensed social worker constitutes unprofessional conduct. When that conduct is by an applicant or a person who later becomes an applicant, it may constitute grounds for denial of a license:
failing to use a correct title in professional activity
conduct which evidences unfitness to practice clinical social work
engaging in any sexual conduct with a client, or with the immediate family member of a client, with whom the licensee has had a professional relationship within the previous two years
harassing, intimidating, or abusing a client or patient
practicing outside or beyond a clinical social worker's area of training, experience or competence without appropriate supervision
engaging in conflicts of interest that interfere with the exercise of the clinical social worker's professional discretion and impartial judgment
failing to inform a client when a real or potential conflict of interest arises and to take reasonable steps to resolve the issue in a manner that makes the client's interest primary and protects the client's interest to the greatest extent possible
taking unfair advantage of any professional relationship or exploiting others to further the clinical social worker's personal, religious, political or business interests
engaging in dual or multiple relationships with a client or former client in which there is a risk of exploitation or potential harm to the client
failing to take steps to protect a client and to set clear, appropriate and culturally sensitive boundaries, in instances where dual or multiple relationships are unavoidable
failing to clarify with all parties which individuals will be considered clients and the nature of the clinical social worker's professional obligations to the various individuals who are receiving services, when a clinical social worker provides services to two or more people who have a spousal, familial or other relationship with each other
failing to clarify the clinical social worker's role with the parties involved and to take appropriate action to minimize any conflicts of interest, when the clinical social worker anticipates a conflict of interest among the individuals receiving services or anticipates having to perform in conflicting roles such as testifying in a child custody dispute or divorce proceedings involving clients
B. After hearing, and upon a finding of unprofessional conduct, an administrative hearing officer may take disciplinary action against a licensed clinical social worker or applicant.
Contact the Vermont Office of Professional Regulation should you wish to file a complaint at 802-828-2396.
Your signature is an indication that:
You have read and agree with the above policies.
You have received and read the Notice of Privacy Practices.
You authorize payment of medical benefits for services provided.
You authorize the release of any medical information necessary to process insurance claims for services provided.