Tampa Psychology

Brian Nussbaum, Psy.D

Licensed Clinical Psychologist, FL license# PY6830

Tampapsychology.com

(813) 545-7754

Contract For Services

Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them. When you sign this document, it will represent an agreement between us.

PSYCHOLOGICAL SERVICES

Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and client, and the particular problems you discuss. I view therapy as a partnership. You define the problem areas to be worked on while I use specialized knowledge to help you make the changes you want to make. It is not like visiting a medical doctor. It requires your very active involvement and your best efforts to change thoughts, feelings, and behaviors. Change will sometimes be easy and quick, but more often it will be slow and require on-going effort. There are no instant cures or "magic pills." In order for the therapy to be most successful, you will have to practice new skills that you will learn in our meetings.

Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, langer, frustration, loneliness, and worry. On the other hand, psychotherapy has also been shown to have powerful benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, and an improved sense of wellbeing. But there are no guarantees of what you will experience.

Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a significant commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise.

EVALUATION & PSYCHOTHERAPY SESSIONS

I normally conduct an evaluation that will last from 1-2 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your therapy goals. If psychotherapy is begun, I will usually schedule one 45-minute session every 1-2 weeks at a time we agree on. You are responsible for coming to your sessions on time and at the time we have scheduled. If you are late, we may be unable to meet for the full time, as I may have another appointment after yours, however you will still be responsible for the full fee for the session. If I am unable to start on time, I assure you that you will receive the full time agreed to.

PROFESSIONAL FEES

Psychotherapy/Counseling

My regular fee for a 45-minute psychotherapy appointment is $150. In addition to weekly appointments, I charge this amount for most other services you may need. though I will break down the hourly cost if I work for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me (except as noted below).

 Psychological Testing/Evaluations

Fees for psychological testing and formal psychological evaluations such as personality testing vary based upon complexity, the psychological tests used, and the purpose of the evaluation. You will be informed of the costs associated with such an evaluation prior to any such services being rendered.

Forensic/Legal Services

Because of the difficulty of legal involvement, I charge $350 per hour for preparation and attendance at any legal proceeding. Additionally, any services rendered as part of a legal proceeding, such as disability hearings, expert witness testimony, or divorce/custody proceedings are billed at the rate of $350 per hour. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. I require a $1400 non-refundable retainer fee be paid in advance of any legal/forensic services or court appearances.

 

 

BILLING AND PAYMENTS

New Telehealth clients will be required to pay at the time of scheduling their initial appointment to reserve their time slot. This payment is refundable if the appointment is cancelled with at least 24 hours notice prior to the scheduled appointment time. Returning clients are expected to pay for each session in advance of their appointment date/time. Payment schedules for other professional services will be agreed to when they are requested. Psychotherapy sessions and other psychological services that have been provided are non-refundable. 

It is the policy of Tampa Psychology to not allow clients to accumulate a balance. If your account has not been paid for more than 15 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. [If such legal action is necessary, its costs will be included in the claim.] In most collection situations, the only information I release regarding a client's treatment is his/her name, the nature of services provided, and the amount due.

INSURANCE REIMBURSEMENT

I DO NOT accept insurance as a form of payment for services. Therefore, all fees are expected to be paid in full at the time the service is rendered. Some insurance policies include coverage for "out of network" care. If so, I will provide you with any necessary documents, forms, or other information needed for you to submit to your insurance company for possible reimbursement. However, please be aware that most insurance companies require you to obtain prior authorization for mental health services and may not reimburse for services they have not authorized. Additionally, most insurance providers require me to provide them with a clinical diagnosis in order for you to receive reimbursement. Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files. I will never release any information to your insurance company without your consent. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. 

CONTACTING ME

I am often not immediately available by telephone, but you may leave me a voicemail message at any time. Please keep in mind that I will not answer the phone when I am with a client. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. I typically return calls between 4:00p-

 

6:00pm. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and feel that you can't wait for me to return your call, contact your family physician, crisis center, 24-hour National Suicide Prevention Lifeline 1-800-273-8255, or go to the nearest emergency room. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. For non-urgent communication you may also contact me through email at brian@@tampapsychology.com, but be aware that I am often unable to check this email account until late in the evening, so please call if you are cancelling an appointment or otherwise need to speak with me in a timely fashion.

PROFESSIONAL RECORDS

The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of the records unless I believe that seeing them would be emotionally damaging, in which case I will be happy to send them to a mental health professional of your choice. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. I recommend that you review them in my presence so that we can discuss the contents. [I am sometimes willing to conduct a review meeting without charge.] Clients will be charged an appropriate fee for any time spent in preparing information requests.

MINORS

If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, parental involvement is essential. It is usually my policy to request an agreement with minors 13 and older and their parents about access to information. This agreement provides that during treatment, I will provide parents with only general information about the progress of the treatment, and the patient's attendance at scheduled sessions. I will also provide parents with a summary of their child's treatment when it is complete. Any other communication will require the child's authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. By signing this Agreement, you consent to treatment of yourself and/or minor child.

CONFIDENTIALITY

In general, the privacy of all communications between a client and a psychologist is protected by law, and I can only release information about our work with your written permission. But there are a few exceptions. In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it. There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a client's treatment. For example, if I believe that a child, elderly person, or disabled person is being abused, I am required to file a report with the appropriate state agency. If I believe that a client is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client. If the client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection.

 

These situations have rarely occurred in my practice. If a similar situation occurs, I will make every effort to fully discuss it with you before taking any action.

I may occasionally find it helpful to consult with other professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The consultant is also legally bound to keep the information confidential. If you don't object, I will not tell you about these consultations unless I feel that it is important to our work together.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have. I will be happy to discuss these issues with you if you need specific advice, but formal legal advice may be needed because the laws governing confidentiality are quite complex, and I am not an attorney.

CANCELLATIONS AND MISSED APPOINTMENTS

Once an appointment is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. My voicemail has a time and date stamp which will keep track of time of cancellation. Please understand that this appointment time has been reserved for you and it is very likely that another client would have liked to have had that appointment had they known it was available. I cannot keep my practice viable if I do not enforce this policy. Therefore, if you miss an appointment or fail to provide 24 hours advance notice as outlined in this section you are still responsible for and must pay the full appointment fee for the missed appointment. This fee must be paid prior to scheduling your next visit (additional appointments will not be scheduled if the fee is unpaid). If you choose not to schedule another appointment, you still maintain responsibility for paying this fee, which must be paid by credit card over the phone, check, or emailed invoice.

TELEHEALTH

Psychological services through Tampa Psychology, LLC with Dr. Nussbaum are provided using a video-conferencing platform. In some cases, appointments may be held via telephone call. Efforts are made to ensure the safety, privacy, and reliability of using telehealth. However, there are potential benefits and risks of telehealth services that differ from in-person services. Confidentiality still applies to telehealth services, and we mutually agree not to record appointments without permission from the other person. I will provide you options for video-conferencing platforms and instructions for how to use them. You will need to use a computer with a webcam or a smartphone during appointments. It’s important to be in a quiet, private space that is free of distractions during your appointments. You should use a secure internet connection, not public Wi-Fi. In the event of technical problems, I will contact you via telephone as a backup option. There are some circumstances where telehealth may not be the best options for treatment. In such cases I will discuss this with you and provide alternate recommendations for care.

CONSENT TO SERVICES

I have read the Tampa Psychology contract for services and HIPAA Notice. I have had sufficient time to be sure that I considered it carefully and agree to the terms.

I understand and agree to the cancellation policy and will provide at least 24 hours notice for any changes to my scheduled appointments or I will be charged the full fee for the service scheduled.

I consent to treatment with Tampa Psychology, LLC and Brian Nussbaum, Psy.D. I understand I can end therapy at any time I choose and that I can refuse any requests or suggestions made by Dr. Nussbaum.

I consent to the use of a diagnosis in billing when required. I agree to pay the fee of $150.00 per 45-minute appointment. unless otherwise specified and mutually agreed upon. I understand my rights and responsibilities as a client, and my therapist's responsibilities to me.