Significant other's age blanks and gender blank .
Your rightsAs a client of CrossPoint Clinical Services, you are an active participant in treatment, and should be involved in the development of treatment goals for yourself or your child. Services provided by CrossPoint are voluntary, and you have the right to discontinue services at any time. We recommend that this in done in consultation with your clinician.
Detailed information about your rights can be found at:http://www.mass.gov/eohhs/docs/dmh/publications/human-rights-handbook.pdf
After hours helpIf you experience an emergency and are unable to reach your therapist, there are resources available:
Privacy of your informationCrossPoint will maintain an electronic record of your treatment, which is, and remains, the property of CrossPoint Clinical Services, Inc. You may examine and/or receive a copy of your file if you request it in writing. If you wish to review your record, this is best done with the clinician, who can explain and clarify what is written. There may be a charge for writing reports or for copying materials.
Your private health information is protected by a federal law known as the Health Insurance Portability and Accountability Act (HIPAA). CrossPoint will not release any of your personal information unless you provide specific written authorization for us to do so. There are, however, a limited number circumstances in which we may be obliged to release information without your prior written consent. These include:
1. If necessary to protect your safety or the safety of others. a. If you are clearly dangerous to yourself, your therapist may take steps to seek involuntary hospitalization and may also contact members of your family or others. b. If you threaten to kill or seriously hurt someone and your therapist believes you may carry out that threat, or if the therapist believes you will attempt to kill or seriously hurt someone, your therapist may tell any reasonable identified victim, notify the police, or arrange for you to be hospitalized.
2. If necessary for you to be hospitalized for psychiatric care.
3. If a judge thinks the therapist has evidence about your ability to provide care and custody in a child custody or adoption case.
4. In court proceedings involving the care and protection of children or to dispense with the need for parental consent to adoption.
5. If the therapist believes a child, a disabled person, or an elderly person in your care is suffering abuse or neglect.
6. To provide information regarding your diagnosis, prognosis and course of treatment to an insurance company or government agency paying for these services.
7. In legal proceedings where you introduce your mental or emotional condition.
8. If you bring an action against the therapist and disclosure is necessary or relevant to a defense.
9. If necessary to use a collection agency or other process to collect amounts you owe for services.
10. If a court orders access to your records in a sexual assault or other criminal case.
CrossPoint Clinical Services may present disguised case material in seminars, classes, or scientific writings. In this situation, all identifying information and Protected Health Information is removed and client confidentiality and anonymity is maintained.
For more information about privacy laws, see:http://www.hhs.gov/ocr/privacy/hipaa/understanding/index.html
Insurance billing and patient responsibility for services not covered by insuranceIf you have a health insurance plan that covers treatment, CrossPoint will bill your insurer using plan information that you provide to us. Any costs not covered by insurance, including co-pays and deductibles, are your responsibility. Failure to notify CrossPoint of any changes in your insurance coverage, including loss of coverage, could result in charges that will be your responsibility as the recipient of services.
If you do not have a plan that covers our services, you may pay a fee that is agreed to by both parties based our standard rate and your ability to pay. Payment is expected on the date of service, by cash, check or money order. We reserve the right to terminate services and refer you to another provider if you have an uncollected balance greater than $300.00.
Self PayThe standard fee for psychotherapy at CrossPoint is $75 per 45-minute session.
A session is generally 45 minutes in length with 15 minutes for record keeping. Longer sessions are charged as a prorated fee.
Fee increasesOccasionally, CrossPoint Clinical Services may increase its standard fee. If you are in therapy when an increase is to occur, you will be notified in advance. At that time, your fee will be adjusted to the new fee, this fee agreement will be terminated, and you will be asked to sign a new agreement which reflects the new fee. Any prepaid sessions will continue to be honored at the original rate until they are used.
Payment arrangementAll fees, including co-pays, are payable in full at the time of service. Established clients may be offered an account arrangement at the discretion of CrossPoint Clinical Services. Overdue accounts may be charged interest at the rate of 10% per year. Payment may be made in cash, by check, or by money order.
Collections proceduresCrossPoint Clinical Services reserves the right to collect any unpaid balance due to it. If a client is not making regular monthly payments on the account balance, CrossPoint Clinical Services may use a collection agency or take legal action to secure payment, as authorized by state or federal law, and the collections action will become a part of your credit record. Clients will be notified in writing before CrossPoint Clinical Services takes action to collect.
Limit on unpaid balanceCrossPoint Clinical Services may terminate treatment and refer the client elsewhere for continued care if any unpaid balance exceeds $300.00.
Appointment cancellation policy
Active participation in treatment is essential to your progress. If something unexpected occurs and you need to reschedule an appointment, please make arrangements with your clinician as soon as possible.
If you cancel an appointment less than 24 hours in advance, or do not show up for a scheduled appointment, you may be charged a fee of $50.
Consent to treatment
I hereby give my consent to CrossPoint Clinical Services, Inc. to provide counseling, consultation, or psychotherapy services as deemed appropriate, to myself or my child. I have read the information above and I understand and agree to its contents.
I understand that I may be charged $50 for an appointment cancelled less than 24 hours in advance.