Requests for services will begin with a consultation/assessment usually taking one to three sessions, depending on the situation. Feedback will be provided with suggestions given as to the course of treatment in terms of type (i.e., individual or couples therapy), length, and general approach. Referrals to other professionals may be made.

CONFIDENTIALITY

Sessions with your provider and the information discussed in them are confidential and are protected by state law and the ethical principles of your provider’s profession. That is, the contents of a session, or even whether or not you attend, will not be revealed to outside sources unless you have provided written permission to do so, or as required by law.
There are several important circumstances under which confidentiality may not be legally and/or ethically guaranteed, and which may require your provider to initiate hospitalization for you, notify the police or other government agency, or notify your family members to help protect you. Such circumstances include:
(1) when your provider believes you intend to harm yourself or another person;
(2) when your provider believes a child or elderly person or dependent person has been or is in danger of being abused or neglected; (3) if a judge subpoenas your mental health records—a rare but possible circumstance if you are involved in or become involved in litigation; and
(4) if your provider consults with another mental health professional regarding your case, in which case none of your personal identifying information will be used.
Otherwise, your provider will not disclose anything about your treatment, diagnosis, history, or even that you are a client without your full knowledge and consent.

BILLING/INSURANCE REIMBURSEMENT

We do not accept insurance as payment. However, you may be able to receive reimbursement from your insurance company for seeing an “out of network provider.” It is your responsibility to determine whether or not your insurance company will reimburse you and to what extent you will be reimbursed. If you wish to seek reimbursement from your health insurance company, your provider will complete any reasonable forms to enable you to do so. If required to provide clinical information, your provider will make every effort to release only the information about you that is necessary for the purposes requested. By signing this agreement, you agree that your provider can provide required information to your insurance carrier in order to help you receive reimbursement. However, ultimately you are responsible for all incurred fees. If you have an outstanding balance for more than 2 months, we reserve the right to use legal matters including hiring a collection agency and/or using small claims court to receive payment. Should this occur, certain information pertaining to your treatment will be released.

CONTACTING YOUR PROVIDER

All calls to your provider’s office number are answered by confidential voice mail. Your provider will check for messages frequently throughout the workday, and will make every effort to return your call within 48 hours, with the exception of weekends and holidays. Your provider can also be reached by email. Email is the preferred method of communication for non-urgent logistical questions, such as those pertaining to scheduling. Email is not a secure form of communication and confidentiality cannot be guaranteed.

WHAT TO DO IN A PSYCHIATRIC EMERGENCY

Sometimes people experience an emotional crisis that requires immediate attention. In such a case, you may call the office first to see if an emergency appointment can be arranged. Please note that we do NOT provide emergency services. Your provider may not be immediately available during the day, evenings, or on weekends. However, your provider will return your call as soon as possible, usually on the same business day. Often, an appointment can be made on short notice, but this cannot be guaranteed. If you feel you cannot wait, or if it is outside office hours, you should contact your family physician, or go to the Emergency Department of your nearest hospital and ask for the psychiatrist on call.

FEES

The therapy hour involves fifty minutes of direct contact, with the remaining ten minutes being used for notes, reports, and treatment planning. There is usually no charge for: (i) treatment planning outside the session; (ii) brief telephone contacts (15 min. or less) with you, family members where appropriate, and other professionals; and (iii) other brief and incidental involvements of your provider’s time. However, when tasks and consultation require considerable time, fees may be charged. Administrative fees will be charged for requests for file notes (for time and duplication costs), reviewing files/notes and writing reports.
Payment for therapy is normally expected at each session (check, Visa, MasterCard, PayPal, or American Express). Receipts will be sent to you at the end of each month. Please retain these receipts for your insurance or income tax claims, if applicable.

PROVIDER INVOLVEMENT IN LEGAL PROCEEDINGS

In the event you should require your provider’s testimony or involvement in legal or court proceedings, client consent will be required. Your provider will be unable to disclose any information pertaining to other family members or parties in counseling without each person’s specific consent. Court appearances, either requested or subpoenaed, as well as depositions and settlement conferences are billed at an hourly rate of $400.00. These rates will be charged at a minimum of four hours which includes time spent on preparation, travel, waiting, and testimony. The initial minimum four-hour charge of $1600 is due at the time of the subpoena. These charges are not allowable charges for insurance and are the sole responsibility of the client. Because it is often difficult to accurately determine the time needed to appear in court, there is a need for the therapist to clear his or her appointment schedule for the entire day. Such scheduling makes it necessary to charge in this manner.

RECORD KEEPING

Your provider’s profession requires that treatment records be maintained after discontinuation of treatment. You may submit a request in writing to receive a copy of your records. Your provider will honor your request, unless your provider considers your records to be potentially dangerous, in which case we will forward them to another mental health provider of your choice.

THE THERAPY PROCESS

Your provider will conduct an initial comprehensive evaluation, and use an approach that your provider believes will be most effective in attaining the goals that you both have established. It is crucial for you to actively participate in this process by attending regular sessions, preparing for them, and practicing any between session exercises. Your input is essential in establishing treatment goals, issues, risks and benefits of change, the time commitment involved, costs, and other pertinent aspects of your situation. Periodically, you and your provider will evaluate your progress and, if necessary, redesign the treatment plan, goals, and/or methods.
As with any successful intervention, there are both benefits and risks associated with psychotherapy. Risks may include experiencing uncomfortable levels of feelings such as sadness, guilt, shame, anxiety, anger, frustration or conflicts with other people. Some changes may lead to feeling worse in the short run. However, long term benefits may include improvement in mood and distress, better relationships, and solutions to personal problems.
Evaluations and therapy are completely voluntarily. You may discontinue treatment at any time. However, it is important to discuss terminating treatment with your provider and to make subsequent plans for referral or discontinuation of treatment.

CONSENT OF NON-SECURE FORMS OF ELECTRONIC COMMUNICATION

Electronic communication, via email and text, between you and your therapist may not be secure. Email and text communication does not provide a completely secure means of communication. While your therapist will take reasonable efforts to protect your confidentiality, there is some risk that any protected health information contained in email or text may be disclosed to or intercepted by unauthorized third parties.

Your treatment will not depend on you giving consent. You also have the right to terminate this agreement at any time. Use of more secure communications, such as phone or fax, are always an alternative that are available to you if you elect to not give consent to the following forms of communication.

TELEHEALTH (REMOTE SERVICES)

“Telehealth” involves consultation, treatment, transfer of medical data, emails, telephone conversations, and education using interactive video, audio, or voice communications.
1. Unless we explicitly agree otherwise, our telehealth exchange is confidential. The same regulations governing face-to-face interactions remain in effect for telehealth.

2. Regardless of your location, our telehealth occurs in the state of California, and is governed by the laws of that state. In a manner of speaking, you use this modality to visit our office in California.
3. You understand that telehealth is neither a universal substitute, nor the same as, face-to-face psychotherapy treatment. You accept the distinctions made using telehealth vs. face-to-face psychotherapy. In particular, you accept that telehealth does not provide emergency services. Your signature indicates that you understand that you may choose to engage in telehealth at your own discretion.

4. You are responsible for information security on your computer. If you decide to keep copies of our emails or communication on your computer, it is up to you to keep that information secure.
5. The risks involved with telehealth include the potential release of private information due to the complexities and abnormalities involved with the Internet. Viruses, Trojans, and other involuntary intrusions have the ability to grab and released information you may desire to keep private. Furthermore, there is the risk of being overhead by anyone near you if you do not place yourself in a private area and open to other’s intrusion.
Signature:

CANCELLATION POLICY
PAYMENT IS EXPECTED FOR ANY MISSED SESSION, UNLESS RESCHEDULED OR CANCELLED 24 HOURS IN ADVANCE.

Please remember that insurance will not reimburse you for fees incurred for missed appointments. This is your responsibility. If you arrive late for an appointment, you will be charged the full session fee. If another client is not waiting and your provider is able to take the time, the hour may be extended so that you receive the full 50 minutes.

NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

OUR COMMITMENT TO YOUR PRIVACY

Our practice is dedicated to maintaining the privacy of your personal health information as part of providing professional care. We also are required by law to keep your information private. These laws are complicated, but we must give you this important information. This document is a shorter version of the full, legally required NPP. However, we can’t cover all possible situations so please inquire if you have any questions.
We will use the health information that we get from you or from others mainly to provide you with treatment, to arrange payment for our services, and for some other business activities which are called, in the law, health care operations. If we or you want to use or disclose (send, share, release) your information for any other purposes, we will discuss this with you and ask you to sign an Authorization form to allow this.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

1. You can ask us to communicate with you about your health and related issues in a particular way or at a certain place which is more private for you. For example, you can ask us to call you at home, and not at work to schedule or cancel an appointment. We will make every effort to respect your wishes.
2. You have the right to look at the health information we have about you such as your medical and billing records.* You can even get a copy of these records but we may charge you.
4. If you believe the information in your records is incorrect or missing important information, you can ask us to make some kinds of changes (called amending) to your health information. You must submit a written request and provide a justification for the desired change.
5. You have the right to a copy of this notice. We will inform you of any updates or changes to this policy.
6. You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with our Privacy Officer and with the Secretary of the Department of Health and Human Services. All complaints must be in writing. Filing a complaint will not change the health care we provide to you in any way.
If you have any questions regarding this notice or our health information privacy policies, please contact us at info@sfstress.com.