Child and Adolescent Therapy Contract
Prior to beginning treatment, I would like to introduce you to my approach to child therapy and agree to some rules about your child’s confidentiality during the course of his/her treatment. Under HIPAA and the APA Ethics Code, I am legally and ethically responsible to provide you with informed consent. As we go forward, I will try to remind you of important issues as they arise. Therapy is most effective when a trusting relationship exists between the clinician and the patient. Privacy is especially important in securing and maintaining that trust. One goal of treatment is to promote a stronger and better relationship between children and their parents. However, it is often necessary for children to develop a “zone of privacy” whereby they feel free to discuss personal matters with greater freedom. This is particularly true for adolescents who are naturally developing a greater sense of independence and autonomy. By signing this agreement, you will be waiving your right of access to your child’s treatment records.
It is my policy to provide you with general information about treatment status. I will raise issues that may impact your child either inside or outside the home. If it is necessary to refer your child to another mental health professional with more specialized skills, I will share that information with you. I will not share with you what your child has disclosed to me without your child’s consent. I will tell you if your child does not attend sessions. At the end of your child’s treatment, you may request a treatment summary that will describe what issues were discussed, what progress was made, and what areas are likely to require intervention in the future.
If your child is an adolescent, it is possible that he/she will reveal sensitive information regarding sexual contact, alcohol and drug use, or other potentially problematic behaviors. Sometimes these behaviors are within the range of normal adolescent experimentation, but at other times they may require parental intervention. We must carefully and directly discuss your feelings and opinions regarding acceptable behavior. If I ever believe that your child is at serious risk of harming him/herself or another, I will inform you.
Although my responsibility to your child may require my involvement in conflicts between the two of you (parents), I need your agreement that my involvement will be strictly limited to that which will benefit your child. This means, among other things, that you will treat anything that is said in session with me as confidential. Neither of you will attempt to gain advantage in any legal proceeding between the two of you from my involvement with your children. In particular, I need your agreement that in any such proceedings, neither of you will ask me to testify in court, whether in person, or by affidavit. You also agree to instruct your attorneys not to subpoena me or to refer in any court filing to anything I have said or done.
Note that such agreement may not prevent a judge from requiring my testimony, even though I will work to prevent such an event. If I am required to testify, I am ethically bound not to give my opinion about either parent’s custody or visitation suitability. If the court appoints a custody evaluator, guardian ad litem, or parenting coordinator, I will provide information as needed (if appropriate releases are signed or a court order is provided), but I will not make any recommendation about the final decision.[ Furthermore, ]if I am required to appear as a witness, the party responsible for my participation agrees to reimburse me at the rate of $250 per hour for time spent traveling, preparing reports, testifying, being in attendance, and any other case-related costs.
One risk of child therapy involves disagreement among parents and/or disagreement between parents and therapist regarding the best interests of the child. If such disagreements occur, I will strive to listen carefully so that I can understand your perspectives and fully explain my perspective. We can resolve such disagreements or we can agree to disagree, so long as this enables your child’s therapeutic progress. Ultimately, you will decide whether therapy will continue.
There are a few instances when it may be appropriate to terminate therapy. These generally include: when your child attains his or her therapy goals; if we decide that it is best for another professional to provide services for your child; or if either of you decides that therapy should end. In any case, I will honor that decision; however I ask that you allow me the option of having a few closing sessions to appropriately end the treatment relationship.
SESSIONS AND CANCELLATION POLICY
Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of the cancellation unless we both agree that you were unable to attend due to circumstances beyond your control. Exceptions to this policy are generally what would be considered by reasonable people to be serious illness or emergencies and would not include professional demands or childcare accessibility. If possible, your therapist will try to find another time to reschedule the appointment, generally during the same week.
I/We, the parent(s), agree that if 24 hours’ notice is not given to cancel a session, we are responsible for payment for that session. ______(Initial)
PROFESSIONAL FEES
Please inquire with your therapist about his or her hourly fee (45-50 minute hour). In addition to weekly appointments, there will be a fee for other professional services at a prorated rate. Other services include report writing (not to include the standard record keeping of your child’s/teen’s sessions), telephone conversations, text and emails lasting longer than a brief administrative call of about 10 minutes (appointment rescheduling or quick questions), attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other services you may request of your provider.
BILLING AND PAYMENTS
The hourly fee is set individually by your clinician. This should be covered during your initial contact with the office or your provider. You will be expected to pay for your child’s session at the time of service, unless we agree otherwise. Fees include payments for cancellations that are made with less than 24 hours’ notice unless they are agreed upon emergencies. If you choose to pay for your child’s services with a credit card, debit card or PayPal account, you will be billed by our office manager weekly. We will have you fill out paperwork necessary for this service. There is no additional fee for this option. In some cases, monthly billing is available upon request. Payment schedules for other professional services will be discussed when they are requested. You should ensure your account remains up-to-date in order to continue receiving services.
Due to confidentiality concerns, monthly receipts will be provided upon request and in your preferred format: either an electronic mail attachment or through the postal service.
If your account has not been paid for more than 60 days and arrangements have not been agreed upon, Kentlands Psychotherapy has the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations the only information that will be released is a patient’s name, the nature of the services provided and the amount due.
With regards to billing for my child/adolescent’s services, my son/daughter gives Kentlands Psychotherapy permission to share my attendance status with my parents for billing purposes. ______(Patient Initials)
INSURANCE REIMBURSEMENT
In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. If you have insurance that allows you to see out-of-network providers, we will provide you with a super bill (a treatment receipt) to assist you in receiving the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of fees at the time of service. You may also use your super bill to utilize a flexible spending or health savings account if you have such an option. Finally we can provide you an annual summary of treatment dates and total payments should you choose to use such a receipt in your personal income tax preparations for annual uncovered medical expenses.
You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course we (your therapist and our office manager) will provide you with whatever information can based on our experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, we can call the company on your behalf.
Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPO’s often require authorization before they provide reimbursement for mental health services. Sometimes they require you see a provider on their list in order for you to utilize your benefits. Our providers are not participants in any HMO or PPO programs. As licensed psychologists/psychiatrists/social workers, we are approved for reimbursement as “Out of Network” providers assuming your coverage includes that option. That said, these plans are often limited to short-term treatment approaches designed to work out specific psychiatric conditions that interfere with a person’s usual level of functioning. As such you may find that the therapy you desire is not considered medically necessary by your carrier and therefore not covered by your health care insurance coverage.
You should also be aware that most insurance companies require you to authorize your clinician to provide them with a clinical diagnosis (this will be on the super bill receipt). Sometimes we have to provide additional clinical information such as treatment plans or summaries, or could be asked to provide copies of the entire record (in rare cases). Keep in mind that, since you are paying for your services, you always retain the right to refuse to release such information. But refusal to release it to your insurance company might cause you to forfeit seeking reimbursement. You maintain control of your private information at all times. Once released to an insurance company, the information will become part of the insurance company files and will probably be stored electronically. Though all insurance companies claim to keep such information confidential, we have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. We can provide you with a copy of any report submitted, if you request it.
CONTACTING YOUR THERAPIST
Our clinicians are not always immediately available by telephone. When unavailable, our therapists monitor their messages frequently. We will make every effort to return your call on the same day you place it, with the exception of weekends and holidays. Your therapist MAY give you or your teen her personal cell phone number for additional support in certain specific situations (for very brief calls or texts). Please make sure you are clear with your therapist on when to use this cell number. Most calls are to be made to the office line and not your therapist's personal cell phone. If you are difficult to reach, please inform us of times when you will be available. You are also welcome to contact us through e-mail. Although we do not offer therapy services via e-mail, this format can be useful for discussing appointment changes, billing matters, and for asking clarification questions. If you are unable to reach your therapist and feel that your situation is an emergency, please go to the nearest emergency room or call 911. If your therapist will be unavailable for an extended time, our clinical staff serves as back-up and you may reach them on the main office line.
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Parent SignatureDate
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Child/Teen SignatureDate
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