WELCOME TO LIFT!

When completing paperwork for a MINOR child, the parent/guardian must fill paperwork out in the name of the MINOR child (the client.) When completing paperwork for a COUPLE, BOTH parties should submit informed consent to treat. When completing paperwork for an ADULT individual client, paperwork must be completed in the name of the individual seeking treatment. When completing paperwork for multiple children, each child will need a completed informed 
consent document of their own. In situations of divorce, it is our strong request and expectation that parents will receive either verbal or written authorization from their co-parenting partner(s) for children to receive treatment, prior to commencing care.

Our office policies dictate that an updated credit card, HSA, or FSA, be kept on file for efficient weekly billing processes. As a practice, we are unable to split bills between parties, or carry forward balances.

Your informed consent document will not be considered complete if it does not include a credit card, HSA, or FSA card. If you plan are uninsured or do not plan to submit for OON reimbursement, you will need to let our team know prior to the intake appointment, so that we may prepare a GFE on your behalf (see below, “NSA/GFE.”)

What Does It Mean To Give Informed Consent?

Informed consent means that you have been informed of our office practices, and understand the following: 1.) the nature of the services we provide, 2.) how we will safeguard your personal information, 3.) the cost involved in obtaining services, 4.) our policies related to no-show appointments and appointments cancelled without 48 hour notice.

We will note that therapy, medication management, and nutrition services can be a transformative process over time, and that full participation requires that you discuss experiences and events in your life that may be unpleasant. This may, for a period of time, increase feelings of sadness, anger, fear, shame, or other unpleasant feelings. Making changes in your life can be difficult. You may find that your relationship with a therapist, prescriber, or dietitian raises strong feelings, some of them painful. It is up to you to decide whether these potential risks are worth the benefits.

Limits to Confidentiality:

Our sessions, and the information you share with us, are confidential. We will require your written permission to share information regarding your treatment and/or your attendance for treatment. However, by law, there are some instances which permit us to disclose confidential information. Those instances are as follows: a) if you appear to be in imminent danger of doing serious harm to yourself or another person, we are legally required to intervene (ie, call an emergency contact or family member, contact the police and/or the potential victim) b) if we have a reasonable suspicion based on your report, that you or a child have been the victim of physical, sexual, or emotional abuse or neglect, by you or any other person, c) if there is a court order or summons presented for our attendance in court and/or release of your records, d) if you reveal that you have been abused by a health care provider, or e) if the need arises for us to contact a relative, friend, or potential substitute decision-maker, if you are injured, incapacitated, ill, or unable to personally provide consent.

Emergency Situations:

If you are experiencing an emotional crisis that requires immediate attention, you may call the office to see if an emergency appointment is available. If we are not available, or if you are calling outside of regular office hours, please do one of the following: contact your family physician, dial 911, and/or report to the nearest Emergency Room.

Cost of Services:

Our psychotherapy sessions consist of 45 minutes of contact, typically occurring 1-3 times per week. The FREQUENCY and DURATION of your sessions will be determined together in partnership between you and our clinical team, during your initial one-hour case assessment.

Our dietary sessions consist of 30-60 minutes of contact, typically occurring between 1-3 times per week. The FREQUENCY and DURATION of your sessions will be determined together in partnership between you and our clinical team, during your initial one-hour dietary assessment.

Our group therapy appointments consist of 30-45 minutes of contact, typically occurring between 1-3 times per week. The FREQUENCY and DURATION of your sessions will be determined together in partnership between you and our clinical team, during your initial onehour dietary assessment.

We cannot estimate the LENGTH of time for your particular treatment, as the course depends on individual circumstances and/or additional issues that may arise. If you ever wish to determine the total estimated cost over the course of a year, you could simply multiply the fee per session by the number of anticipated sessions. For example, if you see a clinician biweekly, then you would multiply session fee x 26 weeks to get a total annual estimated cost (not including missed 
sessions for illness, holidays, vacation, etc.).

Case Management Fees:

We may be requested to provide additional professional services on your behalf that you have authorized, including preparation of treatment summaries, writing of written reports, or making telephone calls to you, or to other providers, on your behalf. There are fees involved in these case management requests. Our office charges a $80 consulting fee for phone calls or emails in between appointments that run over 10 minutes in length, and a $160.00 consulting fee for phone calls or emails in between appointments that run over 25 minutes in length. Case management fees for calls/emails are generally NOT reimbursable by your insurance carrier, as they occur outside of the scope of treatment.

Insurance/OON Reimbursement:

Most of our clients at the practice submit ‘superbill receipts’ for out-of-network reimbursement from their insurance carriers, after sessions have taken place. Prior to the onset of treatment, we ask that you call the number on the back of your insurance card in order to gather information (a “benefit check”) for our out-of-network services. A superbill receipt can be requested after each service at LIFT. Please note that provision of the superbill receipt is not a guarantee of insurance 
reimbursement. It is the responsibility of the client to request the superbill receipt from their clinician on a weekly, monthly or quarterly basis, and submit it to their insurance company.

Payment is due in full at the time of services rendered. Our rates are transparent and are clearly listed here for your review.

The clinical team at LIFT has been hand selected for their exceptional talent, unique specializations, proven success outcomes in mental health treatment, and profound dedication to continuing education, research and practice in their respective fields.

Our fees for clinical services are outlined below.

90791: Your initial visit at LIFT will be a 60-minute meeting with our clinical admissions directors. You can attend this meeting virtually or in person at our Westport campus. If you are the parent of a minor seeking care for your child, this initial visit will be conducted with you and without your child present. During your initial visit, we will take a complete health history, discuss your goals, assess and determine the level and frequency of care appropriate for your treatment and who will need be involved in it, decide on the modality of therapy you will most benefit from, and select the appropriate provider on our team to meet your needs. You will leave this meeting with a collaborative treatment planning document, Prescription for Wellness ™️, which will contain a plan with detailed instructions for next steps and recommendations for you going forward. A Psychotherapy Acuity and Placement Intake Assessment is coded for insurance as 90791, and is $310.00.

90834: The cost of 45 minute psychotherapy, nutrition, psychiatric and coaching visits vary by level of provider experience, training and years of expertise. Each LIFT provider is uniquely qualified and possesses distinctive skills and knowledge. We hand-match providers with clients because our pre-vetting process has a 99% rate of guaranteeing client/clinician rapport, which is the most integral component of successful treatment. The provider recommended to you will be chosen because they possess qualities that make them a personality, temperament, and clinical match for you and your family.

Visit:

Senior-Level Clinicians:

Tier A

Mary Dobson: $385

 

Andrea Ciarlelli: $385

Tier B

Allison Golfis: $285

Megan Freyer: $285

Shannon Broderick: $285

Krista Rodgerson: $285

Mikala Coppolella: $285

Christine Sacane: $285

Rachael Weir: $285

 

Tier C

Chelsea Hanock: $260

Niyosha Arthur: $260


Masters Level Clinicians:

Stasia Timan: $220



Special Intern Rate: $75
*LIFT interviews interns and selects two per year to join our team on their road to full licensure. Interns are masters level clinicians who are receiving weekly supervision and consults from our senior team. LIFT interns are trained in a variety of therapy models and have the skills to deliver effective outcomes. Seeing a LIFT intern provides a family with access not only to their clinician, but to the observation, supervision, attention, and case management of the entire senior leadership team.

Coaching Services:

Dennis Dobson: $195

Our rates for dietary visits are as follows:

97802: 60 minute Dietary Intake Assessment: $310.00

97803: 45 minute dietary follow-up:

Kelsey Riesbeck: $285


Our rates for medication management visits are as follows:

99215 Psychiatric Intake: $410

 

90833 Psychiatry Session 45-minute: $385

99213 Medication Management Follow Ups 15-minute: $135

99214 Medication Management Follow Up 30-minute: $260

 

As of 12/1/2022, LIFT has instituted a policy for initial intake appointments. Our billing team now requires a method of payment to be held on file in order for an initial session to be confirmed, and intake sessions will be billed 48-90 hours in advance of the session, or at time of booking, in order to hold the appointment.

 

Our office policies dictate that an updated credit card, HSA, or FSA, be kept on file for efficient weekly billing processes. As a practice, we are unable to split bills or carry balances.

 

LIFT’s informed consent states clearly that payment for services are due by or at time of visit, that we have a stringent 48 hour cancellation policy, and that our office is unable to carry balances. Going forward, should a client with a history of nonpayment wish to schedule an appointment, payment in full will be required in order to hold that requested appointment time. This pre-payment will signify the client’s confident commitment to upholding their scheduled appointment.

Your informed consent document will not be considered complete if it does not include a credit card, HSA, or FSA card. If you plan are uninsured or do not plan to submit for OON reimbursement, you will need to let our team know prior to the intake appointment, so that we may prepare a GFE on your behalf (see below.)

No Surprises Act/Good Faith Estimate:

We at LIFT desire for treatment to be accessible for those who seek our services. For individuals who are uninsured or who are unable to submit a superbill receipt for reimbursement, we will work to attempt to arrange a financial situation that will work within what a family is able to allocate towards treatment. Congress recently (January 1, 2022) passed the No Surprises Act. Among other things, this act requests that medical providers issue a Good Faith Estimate to patients who are self-pay, uninsured, and/or do not submit superbills for reimbursement. This act appears to be intended to reduce unexpected medical bills for medical patients.

While its application and implementation in outpatient practices remains unclear, if you are selfpay, uninsured, and/or will not be submitting superbills for reimbursement, then we at LIFT will be providing you with a Good Faith Estimate, in order to help you prepare and plan for the cost of treatment. In the spirit of this new law, we also clearly state our session rates for our clients and prospective clients to see and we discuss them openly with clients at the onset of treatment.

Moving forward, we will continue to be closely tracking the development of this new and evolving Act, and what may be required of practices like ours. We will remain vigilant in ensuring that we are acting within our ethical and legal requirements while serving you in the best way possible.

With regard to the concept of providing a Good Faith Estimate: we feel very good about our communication with clients. Our rates are clear, straightforward, and spelled out plainly in our practice policies, which is a document provided to, and completed by, each client prior to scheduling any sessions.

Finally: as our client, you stay in charge of when and how often you wish to meet. This inherently means clients are not surprised by amounts charged, and that any additional requirements are likely to be redundant. If you have questions about billing practices, or this new Act, please email Mary Dobson directly at mary@liftupwellness.com.

Cancellation Policy:

Our office presently requires 48 hours notice of cancellations. If you miss an appointment without providing adequate notice, you will be charged for your session. When you schedule an appointment, you own your time. If you do not give us an adequate opportunity to extend that time to another patient, you have denied another patient the opportunity to receive our help. Arriving late to an appointment will still result in full responsibility for the session fee, as well as the same agreed upon end-time. Cancelled session fees are not reimbursable through insurance, as they do not constitute a clinical service.

Legal/Records Release:

It is important to note that at times, patients may find themselves in a legal situation and wish to engage us in proceedings as a witness or expert on their situation. If you become involved in legal proceedings and believe that our participation is warranted, you will be expected to pay for all of our professional time, including preparation of a treatment summary (we keep a lean clinical record for internal purposes and do not under any circumstances release case notes), as well as loss of income (time allocated outside of the office) and transportation costs. Due to the complexity and difficulties related to such involvements, our billable fee for such requests is $1,000 per hour.

Our of respect for privileged communication, our clinicians keep a lean clinical record for internal purposes only, and we do not, for any reason, release our treatment records to third parties, with OR without patient consent.

Electronic Communication, Social Media, & Online Policy:

It is our preference to use email only for initial inquiries and arranging or modifying appointments. Please do not email us any content related to your treatment, as email is not completely secure or confidential. Text messaging can be utilized, and we sometimes provide clients with our work cell phone numbers for both scheduling and “check-in” purposes. With that said, it must be understood that a) we are not always able to respond promptly to text messages, b) text messaging is not a secure or confidential way to communicate, c) service issues may prevent your text message from being received, d) information sent or received via text can be misread or misunderstood, and cannot be utilized as therapeutic advice or feedback, e) text messaging ought NEVER be utilized in the case of an emergency, including self harm/suicidal ideation/homicidal ideation/risk of impulsive, dangerous or irrational behavior. These situations ALWAYS warrant use of 911, a call to one’s physician, and/or proceeding to the nearest emergency room. It is our policy not to accept friend requests or contact requests on social networking sites from any current or past clients. We believe that adding clients on social networking sites may compromise your privacy and blur the boundaries of our relationship.

In addition to indicating your informed consent to participate and to receive services, your signature below indicates you have understood that in providing psychotherapy, dietary or medication management services, we will collect some personal information about you (e.g., reasons for seeking services, address, phone number, family information, etc.)