Agreement for Psychological Consultation — First Step Session
This
Agreement contains important information about receiving a 45-minute initial
psychological consultation at Create Outcomes where a licensed therapist will
gather information to determine whether one of our therapists can meet your
treatment needs. If we do not have a therapist that is a match for your current
treatment needs, we may refer you to another therapist or treatment program
outside of our organization. This agreement also informs you about our business policies as well as provides a clear
framework for our work together. Please read the information carefully. You are
free to revoke this agreement or discontinue your work with our organization at
any time.
I.
Create
Outcomes offers an initial psychological consultation to aid you and/or family
in finding the treatment that is right for you. This session will be done over
video when possible, using the online secure and HIPAA-compliant platform Zoom. Consultation can cover a variety of questions regarding
your needs, presenting problem(s), current life circumstances, and your
history. However, the depth in which these topics can be explored is limited by
the very nature of consultation. The initial consultation is a one time-limited
meeting and does not include in-depth assessment, treatment interventions,
on-going therapy or any diagnostic procedures. Consultation with our
organization will be provided by a Licensed Therapist and sessions are
typically 45-minutes long.
We cannot promise that your particular situation will improve as a result of this initial consultation and sometimes the outcome of consultation may include specific recommendations regarding seeking services with a provider outside of our organization who can better meet your treatment needs. It is your choice and responsibility to follow through on those recommendations once consultation is over.
We cannot promise that your particular situation will improve as a result of this initial consultation and sometimes the outcome of consultation may include specific recommendations regarding seeking services with a provider outside of our organization who can better meet your treatment needs. It is your choice and responsibility to follow through on those recommendations once consultation is over.
II.
The law protects the privacy of all communications between a
client and a licensed therapist. All information disclosed within sessions is
confidential and may not be revealed to anyone without written permission
except where disclosure is required by law. Disclosure is required by law in
the following circumstances:
1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.
2. If a client threatens grave bodily harm or death to another person. If a client communicates an immediate threat of serious harm to an identifiable victim, we may be required to notify the potential victim, contact the police, and/or seek hospitalization for the client.
3. If the therapist has a reasonable suspicion that an adult client is the perpetrator, or, if the adult client or child client is the actual victim of physical, emotional or sexual abuse.
Suspected neglect of the parties named in items #3.
4. If a court of law issues a legitimate subpoena for information stated on the subpoena.
If information is obtained for the purpose of rendering an expert’s report to an attorney.
At Create Outcomes we are committed to professional growth and as such consult with each other on cases as well as provide supervision to interns and students. During these consultations, we will avoid revealing any information that may identify you personally. If any such situation arises, we will make every effort to discuss it with you fully before taking any action, and will try to limit disclosure to what is necessary.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, 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 in situations where specific advice is required, formal legal advice may be needed.
1. If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.
2. If a client threatens grave bodily harm or death to another person. If a client communicates an immediate threat of serious harm to an identifiable victim, we may be required to notify the potential victim, contact the police, and/or seek hospitalization for the client.
3. If the therapist has a reasonable suspicion that an adult client is the perpetrator, or, if the adult client or child client is the actual victim of physical, emotional or sexual abuse.
Suspected neglect of the parties named in items #3.
4. If a court of law issues a legitimate subpoena for information stated on the subpoena.
If information is obtained for the purpose of rendering an expert’s report to an attorney.
At Create Outcomes we are committed to professional growth and as such consult with each other on cases as well as provide supervision to interns and students. During these consultations, we will avoid revealing any information that may identify you personally. If any such situation arises, we will make every effort to discuss it with you fully before taking any action, and will try to limit disclosure to what is necessary.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, 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 in situations where specific advice is required, formal legal advice may be needed.
III.
Payment and Fees: Our initial consultation fee is $55. If on-going therapy with our practice is appropriate for your treatment need, fees range from $175 in Colorado, to $195 to $300 in New York for each 45-minute therapy session. Payment will be collected after your appointment from the debit or credit card you have provided to us. Please be aware there will be a 4% administration fee for each transaction. This fee is to securely hold your credit card information on file.
Health Insurance: We will provide you with an invoice for services rendered and any paperwork necessary should you wish to try and seek reimbursement from your insurance company through out-of-network benefits. You are ultimately responsible for determining what services are covered and to what degree.
Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges.
Cancellation Policy: All appointments require advance notice of cancellation, which allows us to serve all of our clients in an effective and timely manner. In the event that you need to cancel your appointment you must do so 48 hours before your appointment time. For example, if you have a 6pm appointment on Wednesday evening, you must call by Monday at 6pm to cancel. If you have a Monday appointment, you must call by the appropriate time on a Friday to account for the weekend. If you do not cancel by this time or do not show for your scheduled appointment, you will be responsible for the full session fee. If you need to cancel or reschedule a session, please do so by telephone at ︎︎︎(866) 232-7328. Cancellations via email will not be accepted.
Health Insurance: We will provide you with an invoice for services rendered and any paperwork necessary should you wish to try and seek reimbursement from your insurance company through out-of-network benefits. You are ultimately responsible for determining what services are covered and to what degree.
Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges.
Cancellation Policy: All appointments require advance notice of cancellation, which allows us to serve all of our clients in an effective and timely manner. In the event that you need to cancel your appointment you must do so 48 hours before your appointment time. For example, if you have a 6pm appointment on Wednesday evening, you must call by Monday at 6pm to cancel. If you have a Monday appointment, you must call by the appropriate time on a Friday to account for the weekend. If you do not cancel by this time or do not show for your scheduled appointment, you will be responsible for the full session fee. If you need to cancel or reschedule a session, please do so by telephone at ︎︎︎(866) 232-7328. Cancellations via email will not be accepted.
IV.
During the course of treatment, it may be useful for us to
communicate with you electronically, for example, via email or text messages
(unless you would prefer an alternate means of communication). The benefits of
electronic communication can include:
—Resolving scheduling and billing issues quickly and efficiently
—Allowing your therapist to send reminders and appointment confirmations
—Transmission of helpful resource material, worksheets, educational information, etc.
—Access to your therapist remotely in between scheduled sessions, if you and your therapist have determined that this is clinically appropriate
—We strive to provide you with convenient, timely means of communicating with us, and also make every effort to protect your privacy; however, electronic communication is never completely secure. Some potential risks of electronic communication include:
—Others accessing your device in case of loss/theft, or incidental contact at home/work
—Email accounts can be hacked
—Text messages are stored on servers
e-mails or text messages may be delivered to an incorrect address
—Resolving scheduling and billing issues quickly and efficiently
—Allowing your therapist to send reminders and appointment confirmations
—Transmission of helpful resource material, worksheets, educational information, etc.
—Access to your therapist remotely in between scheduled sessions, if you and your therapist have determined that this is clinically appropriate
—We strive to provide you with convenient, timely means of communicating with us, and also make every effort to protect your privacy; however, electronic communication is never completely secure. Some potential risks of electronic communication include:
—Others accessing your device in case of loss/theft, or incidental contact at home/work
—Email accounts can be hacked
—Text messages are stored on servers
e-mails or text messages may be delivered to an incorrect address
V.
You may reach us by telephone at ︎︎︎(866) 232-7328. You may also be
provided with additional contact information as necessary. Due to the nature of
our work, we may not always be available by telephone. When we are unavailable,
the telephone is answered by a confidential voicemail that is monitored
frequently. Every effort will be made to return your call within 2 business
days (excluding weekends and holidays).
Consultation does not provide any provisions for emergency situations. If you find yourself in an urgent situation, it is up to you to make a judgment about the prudence of waiting for a return call versus calling your primary care physician or 911. If you anticipate a need for emergency consultations or will be requiring more frequent contact then please be advised that consultation may not be a suitable service.
Consultation does not provide any provisions for emergency situations. If you find yourself in an urgent situation, it is up to you to make a judgment about the prudence of waiting for a return call versus calling your primary care physician or 911. If you anticipate a need for emergency consultations or will be requiring more frequent contact then please be advised that consultation may not be a suitable service.
By
electronically accepting this Agreement, it indicates that you have read this
agreement, agree to its terms and acknowledge that no therapeutic relationship
has been established between you and the assigned consultant. Your acceptance also
serves as an acknowledgment that you have received the HIPAA notice titled “Notice of Privacy Practices.”
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