Kathleen O. McCarthy, LICSW
Client Registration Information
Thank you for choosing my psychotherapy practice. Please provide me with the following information.
Please Print:
Client Name: ______Date: ______
(First Name)(Last Name)
Address:______
(Street) (Town/City) (State) (Zip Code)
Phone:______
(Home) (Work) (Cell)
*Please tell therapist if you do not want to be called, or have a voicemail message left,at any of the above numbers*
Social Security #: ______Gender: ____ Date of Birth: ______Age______
Relationship Status: ___Single ___Married ___ Separated ___ Divorced ___ Widowed ______Other
Emergency Contact Person: ______Phone: ______
How did you hear about my practice?:______
Name of Primary Care Physician:______
Address:______Phone:______
Name of Insurance Company:______
ID#:______Effective Date:______
Employer: ______Co-pay Amount: ______
Therapy in the past 12 months? ___Yes ___No
If patient is NOT policyholder, fill in below:
Policyholder Name: ______Date of Birth:______
Policyholder’s Address:______
(Street) (Town/City) (State) (Zip Code)
Social Security#:______Relationship: ___ Parent ___ Spouse ___ Child ___ Other Employer:______
*Do also you have a secondary insuranceor EAP benefits you also plan to use? ______Yes ______No
Assignment and Release
I hereby authorize Kathleen O. McCarthy, LICSW to release all information requested by my insurance carrier to secure payment of benefits and to mail patient statements. I hereby assign to the provider all payments rendered. I understand it is my responsibility to pay for any deductible amount, co-payment, or other allowable balance not paid for by my insurance.
Signature:______Date:______
(For therapist’s use only: DX______TX______OCR Yes / No)
Office & Privacy Policies
Welcome to my psychotherapy practice. I am pleased to have the opportunity to work with you, and hope these forms will provide helpful information about my services. Please read all of the information below carefully before signing. If you have any questions or concerns, I would be happy to discuss them with you.
How to Contact Me: You may leave a message for me on my private, confidential voice mail at 978-921-1088 at any time. Please be sure to leave your phone number and times you can be reached in your message. Due to the nature of my work schedule, I am often not immediately available by phone, however, I will make every effort to return your call as soon as possible during normal business hours on the days that I am in the office (as stated in my voicemail message). If you leave a message at a time when I am not in the office, I will return your call as soon as possible when I am back in the office. If I am going to be out of the office for an extended period of time, I will give you advance notice and my voicemail message will provide information regarding coverage during my absence.
Emergency/Crisis Situations: Please be aware that I am unable to provide 24-hour crisis or emergency services. In the event of a mental health emergency, such as being at risk of hurting yourself or someone else, please immediately do one of the following:
1.Go to your nearest hospital Emergency Room
2. Call the Lahey Crisis Team at 1-866-523-1216
3. Call 911
Please also call and inform me via voicemail of your situationif you are able, so that I am aware of your situation and so we may schedule a session as soon as possible. If Ifind that you are in need of more crisis type care than I can provide in this private practice, I will assist you in finding a therapist whose agency does offer on-call crisis service, andassist in the transfer of your care.
Confidentiality: Clients are assured of confidentiality, which is protected by ethical practice and law. In general, the law states that all communication between a licensed practitioner and his/her client are confidential. Any information shared will require your signed consent except where disclosure is required by law.
Some legal exceptions to maintaining confidentiality are:
●If I have reason to suspect a child, disabled person, or elderly person in your care is being abused or neglected, as a mandated reporter, I must inform the appropriate state agency.
●In circumstances in which, to the best of my professional judgment, I believe that you may be in danger of killing yourself, and you refuse to accept further appropriate treatment, I may contact members of your family or other individuals to take the necessary steps to ensure your safety.
●If you threaten to kill or seriously injure another person, or if I believe you will attempt to kill or seriously injure someone, I am required by the law to notify any potential victim and the police.
●If you were to make your own mental or emotional health an issue in a court case.
●If a court orders access to your records in a sexual assault or other criminal case.
●Federal regulations allow me to disclose necessary data from your record in order to obtain payment from your insurance company
●If necessary to use a collection agency or other process to collect overdue amounts you owe for services.
●I may consult with other professionals for clinical consultation, but your identity will never be revealed in such cases.
●If you bring legal action against me and disclosure is necessary or relevant to a defense.
My HIPAA Notice of Privacy Practices further explains in detail how medical information about you may be used and disclosed.
Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves clients making full disclosure about personal matters of a confidential nature, you should be aware that in situations involving the courts I may be required by the court to disclose all information pertaining to your treatment. Therefore,by signing this disclosure statement, you are agreeing that if you become involved in legal proceedings (such as, but not limited to, divorce and custody disputes, lawsuits, etc.), neither you (client) or your attorneys, nor anyone else acting on your behalf, will request me to testify in court or any other proceedings, provide letters to the court, nor will a disclosure of the psychotherapy records be requested.
Fees: Appointments are 45-50 minutes in length. The out-of-pocket fee for an Initial Evaluation is $175, Individual Therapy is $125, and Family/Couples Therapy is $150. Fees for phone calls 15 minutes or more are $125/hour prorated; letters/legal reports $200/hour prorated; and court appearances $250/hour plus expenses with a 4 hour minimum paid in advance.
Billing and Payment: Payment is expected at the time of your appointment unless other arrangements have been discussed and agreed upon in advance. Your health insurance company may reimburse me for your psychotherapysessions. However, you are responsible for any deductible, co-payment or balance applicable to your individual policy, payable at each visit.Payments are accepted by check, cash, credit/debit card or flexible spending/health savings account cards.If your check is deposited with insufficient funds, you will be charged the additional bank penalty fees. I reserve the right to suspend scheduling further appointments if an outstanding balance is not paid and/or payment arrangements are not made and complied with.
Late Cancellation & Missed Appointment Policy: A 24-hour cancellation policy applies to all appointments. Please call me as soon as you know that you need to cancel your appointment. Since your appointment involves the reservation of time specifically for you, and insurance companies will not reimburse for missed/late cancelled appointments, a minimum of 24 hours’ notice from the time of your appointment is required. I understand that, occasionally, circumstances beyond your control may unexpectedly arise and prevent you from attending your appointment. For this reason, I do not charge for the first appointment that is missed or cancelled late. However, after your first missed appointment, if 24 hour notice is not provided, you will be charged a $75 missed appointment/late cancellation fee. The only exception to this policy is if the driving conditions are so poor that it is not safe for you to drive to your appointment, please call me as soon as possible. If you do not call to cancel, regardless of weather conditions, you will still be charged.
Repeated cancellations or no-shows may result in the termination of therapy.Additionally, if you are running more than 5 minutes late for your appointment, please call and let me know. If I have not heard from you after 15 minutes into your appointment time, it will be assumed that you are not coming and you will be charged for the missed appointment.
Please note that the reason behind this policy is not to penalize you financially, but to protect the therapist’s time as therapists in private practice are paid by insurance companies per client session. Providing adequate advance noticealso gives me the opportunity to offer that time to other clients.
Client Records: The laws and standards of my profession require that I keep treatment records. These records are securely kept. I keep brief therapy notes of each session. If a third party such as an insurance company is paying part of your bill, I am required to give a diagnosis to that third party in order to be paid. As a client, you have the right to review or receive a summary of your records, upon your written request, except in certain circumstances or when I determine that releasing such information might be harmful in any way. In such a case, I will provide a summary of your records to you, or an appropriate mental health professional of your choice. As per current standard of care, I will keep your records for seven years following termination of treatment and then shred them.
Professional Boundaries: I have an ethical responsibility to not develop personal relationships with clients that would create a conflict of interest or dual relationship. Therefore, our relationship will be limited to formal professional contact, with no other social, online, or other outside activity. If we meet on the street or socially, I will not engage in conversation with you in an effort to protect your confidentiality in a public environment. Limiting our relationship to the therapy office keeps your therapeutic environment safe and free from outside complications that could interfere with our work.
Therapist’s Emergency Plan: I have made arrangements for you to be contacted by another licensed therapist in the event of a sudden illness or emergency leading to my inability to keep our appointments. You would be contacted to inform you of the situation and to also inform you of options for the continuation of your treatment. Your identity and contact information will not be shared until such an occurrence, and then only accessed by the designated therapist(s) according to my emergency plan.
I have read this Office and Privacy Policies statement and understand its contents. I understand the limits to confidentiality required by law. I agree to pay my co-pay, deductible, or any other fees not covered by my insurance company, including missed-appointment/late cancellation feesif applicable. I voluntarily consent topsychotherapy with Kathleen O. McCarthy, LICSW under the terms described above, and understand that I have the right to terminate therapy at any time.
Signature:______Date:______
Health Insurance Portability and Accountability Act (“HIPAA”) Notice of Privacy Policies
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how I may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act (“HIPAA”), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules, the NASW Code of Ethics and Massachusetts statutes and regulations. It also describes your rights regarding how you may gain access to and control your PHI.
I am required by law to maintain the privacy of PHI and to provide you with notice of my legal duties and privacy practices with respect to PHI. I am required to abide by the terms of this Notice of Privacy Practices. I reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time. I will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on my website, sending a copy to you in the mail upon request or providing one to you at your next appointment.
I. USES AND DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS, REQUIRING CONSENT
I may use or disclose your PHI for treatment, payment and health care operations purposes with your consent as discussed below:
For Treatment: Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. An example of treatment would be when I consult with another health care provider, such as a family physician or another social worker. I may disclose PHI to any other consultant only with your authorization.
For Payment: I may use and disclose PHI so that I can receive payment for the treatment services provided to you. This will only be done with your consent. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, I will only disclose the minimum amount of PHI necessary for purposes of collection.
For Health Care Operations: I may use or disclose, as needed, your PHI in order to support my business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, I may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided I have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.
II. USES AND DISCLOSURES REQUIRING AUTHORIZATION
Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that I have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization:
●most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record;
●most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications;
●disclosures that constitute a sale of PHI; and
●other uses and disclosures not described in this Notice of Privacy Practices.
III. USES AND DISCLOSURES WITH NEITHER CONSENT NOR AUTHORIZATION
I may use or disclose PHI without your consent or authorization in the following circumstances:
Child Abuse or Neglect: If I, in my professional capacity, have reasonable cause to believe that a minor child is suffering physical or emotional injury resulting from abuse inflicted upon him or her which causes harm or substantial risk of harm to the child's health or welfare (including sexual abuse), or from neglect, including malnutrition, I must immediately report such condition to the Massachusetts Department of Children and Families.
Elder Abuse: If I have reasonable cause to believe that an elderly person (age 60 or older) is suffering from or has died as a result of abuse, I must immediately make a report to the Massachusetts Department of Elder Affairs.
Abused of a Disabled Person: If I have reasonable cause to suspect abuse of an adult (ages 18-59) with mental or physical disabilities, I must immediately make a report to the Massachusetts Disabled Persons Protection Commission.
Health Oversight: The Board of Registration of Social Workers has the power, when necessary, to subpoena relevant records should I be the focus of an inquiry.
Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law and I will not release information without written authorization from you or your legally-appointed representative, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. You will be informed in advance if this is the case.
Serious Threat to Health or Safety: If you communicate to me an explicit threat to kill or inflict serious bodily injury upon an identified person and you have the apparent intent and ability to carry out the threat, I must take reasonable precautions. Reasonable precautions may include warning the potential victim, notifying law enforcement, or arranging for your hospitalization. I must also do so if I know you have a history of physical violence and I believe there is a clear and present danger that you will attempt to kill or inflict bodily injury upon an identified person. Furthermore, if you present a clear and present danger to yourself and refuse to accept further appropriate treatment, and I have a reasonable basis to believe that you can be committed to a hospital, I must seek said commitment and may contact members of your family or other individuals if it would assist in protecting you.
Worker’s Compensation: If you file a workers’ compensation claim, your records relevant to that claim will not be confidential to entities such as your employer, the insurer and the Division of Worker’s Compensation.
Specialized Government Functions: I may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious harm.