Long Grove Psychological Associates
Roseanne Boldt, Psy.D.
4160 RFD Route 83, Suite 307
Long Grove, IL 60047
(847) 951-7673
THERAPIST-CLIENT SERVICES AGREEMENT
This document contains information about our services and business policies and a summary of the Health Insurance Portability and Accountability Act (HIPAA). This federal law provides privacy protections and patient rights regarding the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that we provide you with a Notice of Privacy Practices and disclosure of PHI for treatment, payment and health care operations. The Notice 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. Although these documents are long and sometimes complex, it is very important that you read them carefully. When you sign this document, it will represent an agreement between us. You may revoke the Agreement in writing at any time. That revocation will be binding on us unless we have taken action in reliance on it; if there are obligations imposed on us by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.
PSYCHOLOGICAL SERVICES
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the therapist and client, and the particular problems you or your family is experiencing. There are many different methods we may use to deal with the problems you hope to address. Psychotherapy calls for a very active effort on your part. In order for the therapy to be most successful, you will be asked 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. Though there are no guarantees of what you will experience we will work together to avoid additional stress if possible.
Our first session or two will involve an evaluation of your needs. By the end of this 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 any questions about our work, we should discuss them as soon as 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
We typically schedule one 50-minute session per week. However, depending upon the circumstances, some sessions may vary in length and frequency.
CANCELLATION POLICY
Once an appointment is scheduled, you are expected to pay for it unless you provide 24 hours advance notice of cancellation (unless we both agree that you were unable to attend due to circumstances beyond your control). It is important to note that insurance companies do not provide reimbursement for cancelled session.
PROFESSIONAL FEES
Our hourly therapy rate is $200 for the initial evaluation session and $150.00 for subsequent sessions. All phone conversations or written correspondence exceeding 5 minutes will be billed at our hourly therapy rate.
IN-NETWORK INSURANCE REIMBURSEMENT
There is great variance in mental health insurance benefits. While the insurance company may quote a certain benefit, there is no guarantee of payment. We do not know how much the insurance company will pay until an actual claim is processed. Due to this uncertainly, my policy is to have you pay the entire fee for the session, not to exceed the maximum allowed by the insurance company. I will then file a claim with the insurance company. Once the claim has been processed, if we find that you have overpaid, you can choose to be reimbursed or have the excess applied to future sessions.
OUT-OF-NETWORK INSURANCE REIMBURSEMENT
If I am not in-network with your insurance carrier, my regular hourly rate, listed above, applies. If you choose to file a claim with your insurance carrier, I will give you the form to do so.
CHANGE IN ABILITY TO PAY
If, after therapy has begun, your situation changes and you are no longer able to pay your portion of the fee, I will work out a payment plan with you. If that is not possible, I may refer you to an agency that provides a sliding scale fee structure.
CONTACTING ME
My cell phone number is 847-951-7673. I return phone calls within 24 hours Monday-Friday. Keep in mind that cell phones are not a secure form of communication. If you prefer that I only call you from a “land line” phone, please indicate this preference on the last page of this document. If you are in an emergency situation, call 911 or go to the nearest hospital emergency room.
LIMITS ON CONFIDENTIALITY
The law protects the privacy of all communications between a patient and a therapist. 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 Illinois law. When more than one person is involved in therapy all persons must sign a written Authorization before I can release information. However, in the following situations, no authorization is required.
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 patient. The other professionals are also legally bound to keep 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. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information).
Disclosures required by health insurers or to collect overdue fees.
If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot disclose any information without a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court 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 them.
If you file a complaint or lawsuit against me, I may disclose relevant information about you in order to defend myself.
If you file a worker’s compensation claim, and I am rendering treatment or services in accordance with the provisions of Illinois Workers’ Compensation law, I must, upon appropriate request, provide a copy of your record to your employer or his/her appropriate designee.
There are some situations in which I am legally obligated to take actions, which I believe are necessary to protect 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 a child under 18 known to me in my professional capacity may be an abused child or a neglected child, the law requires that I file a report with the local office of the Department of Children and Family Services. Once such a report is filed, I may be required to provide additional information.
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. Once such a report is filed, I may be required to provide additional information.
If you have made a specific threat or violence against 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 your 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 fully discuss it with you before taking an action and I will limit my disclosure to what is necessary.
it is important that we discuss any questions or concerns about confidentiality that you may have now or in the future.
PROFESSIONAL RECORDS
The laws and standards of my profession require that I keep PHI about you in your Clinical Record. You may examine it with me or receive a copy of your Clinical Record, if you request it in writing. I will charge $0.25 per page.
Your Clinical Record includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress toward these goals, your medical and social record, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including your insurance carrier.
PATIENT RIGHTS
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 an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discus any of these rights with you.
MINORS AND PARENTS
Clients under 12 years of age and their parents should be aware that the law allows parents to examine their child’s treatment records. Parents of children between 12 and 18 cannot examine their child’s record unless the child consents and unless I find that there are no compelling reasons for denying access. If I feel that the child is in danger or is a danger to someone else, I will notify the parents immediately of my concern.
COURT PROCEEDINGS
I will not testify in court regarding therapy, even if all parties have given the necessary written consent. Such action could create a conflict of interest between the roles of creating a therapeutic relationship and providing an expert opinion.
CONTACT INFORMATION
Please enter phone number(s) where I can leave a confidential message:
______circle one (cell, home, work)
namenumber
______circle one (cell, home, work)
namenumber
______circle one (cell, home, work)
namenumber
Keeping in mind that cell phones and email are not secure forms of communication, check the boxes below if you agree to use either or both of these forms to communicate with me.
I agree that you may contact me using a cell phone. ______
initials of all clients who agree
I agree that communicating with you via email and text messages is acceptable to me.
______initials of all clients who agree
Also, even if this box isn’t checked, I understand that sending an email or text message to
you implies my consent to this form of communication. I understand that email will be used
for purposes such as scheduling appointments and dealing with administrative issues
related to making insurance claims. Therapy is not provided via email or text message.
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initials of all clients regarding understanding of sending an email or text to me
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nameemail address
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nameemail address
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nameemail address
PAYMENT INFORMATION
For your convenience, you may enter credit card information below for payment of co-pay or amounts due after insurance benefits have been paid.
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Credit card numberExpiration DateSecurity code
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Name on the Card, PrintedSignature
I/We,______,give my/our permission and consent to Roseanne Boldt, Psy.D. to provide psychotherapeutic treatment to us and/or ______who is/are our ______.
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.
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Client/Guardian Date
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Client/Guardian Date
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Child (ages12-18) Date