THERAPIST/CLIENT AGREEMENT & CONSENT FOR TREATMENT

NOREEN ESPOSITO EDD, PMHNP-BC

1829 EAST FRANKLIN ST, SUITE 100-A, CHAPEL HILL, NC, 27514 919-360-5929

In order to better serve you, please review the following. Please acknowledge your understanding and acceptance by providing your initials in the space provided after each individual statement and your signature at the end of the document.

Psychiatric & Psychotherapy Services and Guidelines

  • I offer a range of psychiatric/psychotherapy services for adults (over age 18).
  • Medication management session: New and continuing prescriptions based on an assessment of your needs and response to current treatments.
  • Psychotherapy: The psychotherapy provided may range from supportive therapy to assisting you in setting and working towards goals for desirable changes. There are minimal risks associated with these forms of psychotherapy. Potential benefits includepositive changes in individual functioning. These may result in decreases in general distress or specificsymptoms.

Initial: _____

Session Times

  • Medication management may range from once a week to once every few weeks.
  • Psychotherapy sessions will generally occur once per week for 45 minutes or occur on a schedule mutuallyagreeable to you and me. Every effort will be made to begin and end sessions on time. If I am latebeginning a session, then when possible, the session will be extended to allow for the full session time. If apatient is late for a session, then the session will usually have to end on time.

Initial: ______

Fees for out-of network clients:

  • Initial evaluation, 90 minutes $250
  • DBT GROUP Intake: $125
  • Therapy with medication management, 50 minutes varies based on complexity of vist
  • Brief therapy with medication management, 20 minutes
  • Individual therapy, 45 minutes $150
  • Sessions running over originally scheduled time, the fee will be $40 for each addition 15 minutes.
  • Equine-assisted psychotherapy: Fee will be dependent on current rates of additional team members. Please discuss with Dr. Esposito
  • Medication Check up, 15 minutes $60
  • Phone consultations are charged at $2.60 per minute after the first 10 minutes.
  • Fees for other services requested by you or someone else for you or your child’s benefit, such as writing lengthy letters, attending school meetings, lengthy phone calls, etc. will be charged as a percentage of my hourly rate
  • Returned Check Fee $ 25

Insurance and Payment

  • Please check with your insurance company to see if I am an eligible provider for your policy. If I am in-network, a co-pay may be due at the time of service. If I am an out-of-network provider for your insurance your full payment is due atthe time of service. I will provide receipt that you can then submit to your insurance company. You are responsible for contacting your insurance company to inquire about the amount covered for mentalhealth services. Once you submit, it may takesix to eight weeks for insurance claims to be processed and reimbursed toyou. You, not your insurance company, are ultimately responsible for all payment of fees. If you are notfiling insurance, there are a limited number of scholarship slots available per session based on need andavailability.

Initial _____

  • Cash, check or credit card areaccepted (a small additional fee for credit card), checks made payable to Noreen Esposito, PMHNP. You are personally accountable for insuring that your fee is paid ontime.
  • If for any reason an account balance has been accrued, the balance is due within 10 days of thestatement/invoice date. Accounts not paid within 14 days will have a finance charge of 10% added for eachtwo weeks of outstanding payment. I acknowledge responsibility for all fees incurred and should collection of my account become necessary I will be responsible for all costs of litigation including attorney’s fees. If payment for services is not received within 3 months of services rendered, then I understand that a collection agency will be notified.
  • If for some reason payment is not received for as many as twosessions, then further services will be discontinued until all unpaid charges are paid; however, in the case ofan emergency, I will make the necessary exceptions.

Initial______

  • Telephone Messages and Emergency Coverage: You may reach me by text or leave a voice-mail for me at 919-360-5929. I do my best to return telephone calls within 24-48 hours. I generally answer calls between 9am and 7pm. If I am away for an extended time period, the message will direct you as to who is providing coverage for my patients. In the event of an emergency, call 911 or go to the nearest emergency department.

Initial ______

  • Prescription Refills: Medication refills are normally written at the time of the appointment. It is your responsibility to monitor when you will need refills on medication. All refills not addressed during appointment times should be directed to your pharmacy. Please allow 2-3 business days for requests to be filled. Refills are not an emergency and will be handled between 9am and 5pm, Monday through Friday.

Initial ______

Cancellations/Missed Appointments

  • An appointment represents time reserved personally for you. Cancellation and/or rescheduling ofappointments must be done 24 hours in advance or the fee will be charged for the session. Cancellationsmust be made via phone call, text or voice mail, not through email correspondence. Note that insurance cannot bebilled for a missed or late appointment, so you will be responsible for the entire charge of the reserved time.The reason this policy is in place is to give me an opportunity to fill the slot you have reserved/cancelledwith another client who is available and in need of an appointment.

Initial____

Waiver of Liability and Confidentiality

I am aware that all statements I shall make are of a confidential nature, including all written information, and ethically may not be disclosed without my written consent with the following exceptions that will result in confidentiality being waived:

  1. A therapist working with an adult, adolescent, or a child is required by law to disclose to the appropriateperson, agency and, or civil authority any harm that a person may attempt or desire to do to one’s self or toothers, and is required to disclose any reasonable suspicion of physical or sexual abuse being done or havingbeen done to a minor child or a dependent person.
  1. Noreen Esposito EdD, Psychiatric Mental Health Nurse Practitioner reserves the right to consult with professionals regarding your treatment. To insure thehighest quality of service to you and for Dr. Esposito’s professional development, Dr. Esposito PMHNP meets regularlywith a consultation team of therapists. The consultation team may be privy to information obtained duringyour psychotherapy sessions, yet the team also upholds all of the aforementioned confidentiality agreementsin strict professional confidence.
  1. Although the courts usually hold psychiatric and psychotherapy records as privileged, therapists are professionally bound tocomply with subpoenas given by a court of law.

By providing my signature, I acknowledge that I have read, understood, and have agreed to the Psychotherapy Guidelines, the Waiver of Liabilityand Confidentiality, and that I accept the stated conditions and limits of confidentiality.

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Your Printed Name (or guardian of client)

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Your Signature (or guardian of client) Date

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Noreen Esposito EdD, Psychiatric Mental Health Nurse Practitioner Date

1

September 2016