Ross L. Mayberry Ph.D., LLC WA Licensed Psychologist #1297
2800 East Madison St., Suite 306 (206) 323-7323
Seattle, WA
Fax (206) 323-7324
Office Policies and General Information Agreement
for Psychotherapy Services
Welcome to my psychotherapy practice. Before you begin your work with me there are several pieces of information that are relevant to you. I've broken it down into sections so you may review it in the future, as it is a lot to take in on your first visit. Please read the following carefully and feel free to ask as many questions as you'd like.
MY BACKGROUND: I am a Psychologist licensed in the State of Washington since 1989. I completed American Psychological Association-approved doctoral and internship programs in adult and child psychology, as well as spending six months studying at the C.G. Jung Institute in Zurich, Switzerland. I am also listed on the National Register of Health Service Providers in Psychology. I have been a member of the American Psychological Association since 1986 and adhere to the ethical code established by the APA, as well as the professional standards as described in the Washington State Psychology Licensing Laws (RCW 18.83, 18.130, and WAC 308-122.) Throughout most of the 1980'sI worked with Vietnam combat veterans and their families, including five years as Clinical and Administrative Director of two Vietnam Veteran Outreach Programs. I have also been the President of two health care corporations in the past. I entered private practice in 1989. In addition to my expertise in trauma disorders, I have special interest and expertise in several areas including diagnosing and treating Attention Deficit Hyperactivity Disorder in adults and teenagers, issues in adolescence, anger, anxiety and depression. My working style draws deeply from the cognitive restructuring model, as well as from Psychodynamic and Gestalt schools. I also work with imagery and dreams in a variety of treatment contexts. I am a proactive therapist and will make suggestions and give homework to help you facilitate the changes you desire.
THE PROCESS OF THERAPY/EVALUATION AND SCOPE OF PRACTICE: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. I will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc.I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy I am provide neither custody evaluation recommendation nor medication or prescription recommendation nor legal advice, as these activities do not fall within my scope of practice.
CLIENT'S RIGHTS: As a psychotherapy client you have many rights. You are entitled to select the type of treatment that best suits your needs. You are therefore encouraged to ask questions and gather as much information as you need to make an informed decision. You are entitled to see, copy, and/orask that I correct factual errors in records kept regarding your health care. You also have the right to request in writing that no treatment records be kept. If at any time you are uncomfortable with the direction our treatment is taking, you have the right to object. Please discuss this with me so that we can make adjustments which might include a change of therapy approach, a referral to another therapist, or discontinuing therapy. You have the right to restrict certain disclosures of private information to your insurer if you have paid out-of-pocket in full for that service. You have the right to be notified if there is a breach of your unsecured (non-encrypted) records. Lastly, if you believe that I have acted in an unprofessional or unethical manner you have the right to contact the WA State Division of Professional Licensing in Olympia.
CONFIDENTIALITY: Whatever we discuss in our sessions is confidential (for any client 13 years or older) and generally cannot be disclosed without your written permission, or release. However, you should know that there are a few exceptions provided by law. If there is a suspicion of abuse or neglect of a child, developmentally disabled adult, or a dependent/vulnerable adult, I must report it to the Department of Social and Health Services. If you or your dependent child appear to be at risk for harming yourself or someone else, I must take appropriate action to protect you. In most judicial proceedings, you have the right to prevent me from providing any information about your treatment. However, in circumstances such as child custody proceedings and legal proceedings in which your emotional condition is an important element, a judge may require my testimony if he/she determines that resolution of the issues demands it. While the law permits me to disclose information about your care to your other health care providers without your permission, I nevertheless ask for your specific release to do so on your New Client Information sheet. I believe this communication insures continuity of care and is therefore in your best interests. You have the right to see this communication and discuss it with me.
In addition, it is important that you understand that in order to have your care authorized by your insurance company I may be required to submit information that could include some or all of the following: psychiatric diagnosis, description of the problem, personal background information, treatment goals and therapy methods. Once this information is submitted, I have no further control over it. Signing the New Client Information sheet indicates that you are waiving your right to confidentiality for that purpose. If you have concerns about this, please feel free to bring it up with me.
CONSULTATION:Like other clinicians, I consult regularly with other professionals for feedback and supervision and you are therefore also releasing me to do so with the understanding that I will make every effort to disguise any information about you. The consultant is also legally bound to keep the information confidential. Finally, please be aware that the office space I use is shared with other professionals who, like me, are independent practitioners. This means that our practices are completely unrelated.
E–MAILS, CELL PHONES, COMPUTERS AND FAXES: It is very important to be aware that computers and email communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. Faxes can easily be sent erroneously to the wrong address. Emails, in particular, are vulnerable to unauthorized access due to the fact that Internet servers have unlimited and direct access to all emails that go through them. It is important that you be aware that emails, faxes, and important texts are part of the medical records. Additionally, my emails are not encrypted. My computers are equipped with a firewall, a virus protection, and a password and s/he also backs up all confidential information from his/her computers on a regular basis. Please notifyme if you decide to avoid or limit in any way the use of any or all communication devices, such as email, cell phone, or faxes. If you communicate confidential or private information via email, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via email. Please do not use email or faxes for emergencies.
RECORDS AND YOUR RIGHT TO REVIEW THEM: Both the law and the standards of my profession require that I keep treatment records for at least eight years. Unless otherwise agreed to be necessary, I retain clinical records only as long as is mandated by Washington statelaw. If you have concerns regarding the treatment records, please discuss them withme. As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when I assesses that releasing such information might be harmful in any way. In such a case, I will provide the records to an appropriate and legitimate mental health professional of your choice. Considering all of the above exclusions, if it is still appropriate, and upon your request, I will release information to any agency/person you specify unless I assesses that releasing such information might be harmful in any way. When more than one client is involved in treatment, such as in cases of couple and family therapy, I will release records only with signed authorizations from all the adults (or all those who legally can authorize such a release) involved in the treatment.
HEALTH INSURANCE: If you have insurance coverage through a plan with which I am a provider, I will bill your primary insurance directly and bill you monthly for any unpaid portion that is your responsibility. If you are insured through a plan with which I am not affiliated, I ask that you pay me directly and I will provide you with statements which you may submit for reimbursement. Most insurers can let you know in advance whether your yearly deductible has been met and what you will owe for each session. I urge you to contact your insurance carrier to determine the extent and limits of your coverage and, if required, to obtain a preauthorization for our sessions. You should know that I no longer contract with any managed care companies because I believe that their decisions sometimes do not reflect the best interests of their subscribers; therefore, please make sure your policy is not through a managed care entity. Ultimately you are responsible for staying abreast of applicable deductibles and the number of visits that your policy allows. In addition, not all issues/conditions/problems, which are dealt with in psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage. If your counseling benefit is limited, it may not be possible to address all of your current concerns. If we are approaching the maximum number of visits allowed, we can discuss whether to taper off treatment, make a referral or proceed under a different financial arrangement.
CONFIDENTIALITY OF HEALTH INSURANCE RECORDS:It is important for you to know that disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. If you so instructme, only the minimum necessary information will be communicated to the carrier. Please be aware that I haveno control over, or knowledge of, what insurance companies do with the information I submit or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy or to future capacity to obtain health or life insurance or even a job. The risk stems from the fact that mental health information is likely to be entered into big insurance companies' computers and is likely to be reported to the National Medical Data Bank. Accessibility to companies' computers or to the National Medical Data Bank database is always in question as computers are inherently vulnerable to hacking and unauthorized access. Medical data has also been reported to have been legally accessed by law enforcement and other agencies, which also puts you in a vulnerable position.
TERMINATION: As set forth above, after the first couple of meetings, I will assess if I can be of benefit to you. I do not accept clients who, in my opinion, I cannot help. In such a case, I will give you a number of referrals whom you can contact. If at any point during psychotherapy, I assesses that I am not effective in helping you reach the therapeutic goals or that you are non-compliant, I am obligated to discuss it with you and, if appropriate, to terminate treatment. In such a case, I would give you a number of referrals that may be of help to you. If you request it and authorize it in writing, I will talk to the psychotherapist of your choice in order to help with the transition. If, at any time, you want another professional's opinion or wish to consult with another therapist, I will assist you with referrals, and, if I have your written consent, I will provide her or him with the essential information needed. You have the right to terminate therapy at any time. If you choose to do so, and if appropriate, I will offer to provide you with names of other qualified professionals.
APPPOINTMENTS AND CANCELATIONS: Your appointment time is an hour that has been reserved exclusively for you. If for any reason you are unable to keep a scheduled appointment, I ask that you give me 24 hours noticevia voice mailonly so that I may offer that hour to another client. If you do not provide 24 hours notice of cancellation, my policy is to charge full fee for the missed session. All cancellations must be by voice mail only to my (206)323-7323 number! I do not conduct sessions over the phone without prior agreement to do so. If you should miss a session, payment in full is due at the next appointment.
PAYMENT POLICY: Clients are expected to pay the standard fee of $170.00 per 55 minute session, or co-pays, at the time of service or at the end of the month unless other arrangements have been made. Intake sessions are billed at a higher rate ($240.00) to reflect the additional time and work involved in opening a case, dealing with insurance issues, etc. Telephone conversations, legal work, writing and reading reports, consultation with other professionals, release of information, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed upon otherwise. Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance companies. Balances over $300 must be dealt with before further appointments can be made, unless other arrangements are agreed upon. Should an outstanding balance linger on your accountpast 60 days, it is my policy that we must agree on a payment plan to deal with that balance. After 60 days, 1% interest will be charged per month and/or a $20.00 monthly rebilling charge will be assessed. If your account is overdue (unpaid) and there is no written agreement on a payment plan, I can use legal or other means (courts, collection agencies, etc.) to obtain payment.
TELEPHONE & EMERGENCY PROCEDURES: If you need to contact me between sessions, please leave a confidential message at my voice mail at (206) 323-7323 and your call will be returned as soon as possible; however, I cannot guarantee an immediate response. I checkmy messages often during the daytime only, unless I am out of town. If an emergency situation arises, indicate it clearly in your message and if you need to talk to someone right awayeither cal1 911 or the King County Crisis Line at (206) 461-3222 . Please do not use email or faxes for emergencies. I do not always check my email or faxes daily.
OTHER EMERGENCIES: If there is an emergency during therapy, or in the future after termination, where I become concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, I will do whatever I can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care.
I have read the aboveOffice Policies and General Information Agreement for Psychotherapy Services carefully (a total of 3 pages); I understand them and agree to comply with them:
Client's Name (print) ______
Signature ______Date ______
I look forward to working with you.
Ross L. Mayberry, Ph.D.
9/23/2013