Patient Registration

Cancellation Policy

Thank you for being a valued client in our practice! Our goal is to provide you with optimal care and to be mindful of your time during scheduled sessions. We respectfully ask that if a session needs to be canceled for any reason that you provide the office with 24 hours notice to avoid a cancellation fee for the missed session. Please be advised that there is a $75 cancellation fee. (If you are meeting with an intern, your cancellation fee will be the same as your quoted session fee; For example if you pay $20 a session, you will be charged a $20 cancellation fee). All sessions are reserved for you exclusively in advance. Without notice, it limits our ability to provide consistent treatment to you or to offer the time to another client in need. Our voicemail is available 24 hours/ 7 days a week at 631-296-1113, directly contact your therapist via phone/text or email, or you can email us at admin@northshorerelationshipcenter.com. Please note we will make every effort to re-schedule sessions within the same week as scheduling permits, however the canceled session fee will still apply. 

Please note that if there are declined charges, you will be notified by our billing department as well as your therapist via phone and email. There will be a one time courtesy for declined charges, however any other declined charges due to insufficient funds, card restrictions, fraudulent charges on a card that is no longer in use, or expired credit cards; you will be discharged from the practice. It is an important part of care to be responsible for your sessions, payments, and to contact the office if there are any changes to your credit card and/or payment situation. 

Cancellations with more than 24 hours notice. 

Please note that consistency in treatment is extremely important to our practice, your care as well as our providers schedules. If there are more than 2 canceled and/or missed appointments in a row, despite timing of cancellation; there may be potential discharge from treatment. This will be discussed with you by your therapist.

Credit Card on File

We require a credit card on file for late cancellations and any balance due past 30 days. Your credit card will be stored in a HIPAA compliant electronic health system and you will receive an email with receipt with any charges made to your card. Please note we will notify you of any balance due on your account prior to your card being charged except for the $75.00 cancellation fee which will automatically be charged to your card.

I authorize North Shore Relationship Center to charge my card $75.00 or my sliding scale fee for any session canceled less than 24 hours in advance and for any balance due past 30 days. I have read and understand the above policy and authorize North Shore Relationship Center (Alexandra Gleason, LMFT, PLLC)  to charge my card in the manner indicated by my initials above. I understand I will receive an email statement of all charges made to my credit card.

I authorize North Shore Relationship Center to charge the card listed below for ongoing session fees. I understand I can use a different form of payment or change my card on file at any time. 

Dear Valued Client,

 
I hope this message finds you well. I am writing to inform you of a small adjustment to our credit card processing fee.

 
Beginning March 1, 2026, the credit card processing fee will increase from 2.9% plus $0.30 per transaction to 3.1% plus $0.30 per transaction.

 
This adjustment reflects updated processing costs from our payment provider, and it helps us offset these expenses while maintaining the quality of care you expect from us. 

 
We understand that changes to financial policies can be inconvenient, and we appreciate your understanding and cooperation. As always, we continue to offer alternative payment methods, such as cash or Zelle, which do not incur any additional fees. 

 
Clients can submit payment for their sessions via Zelle (to: agleasonlmft@gmail.com) before or at the time of their appointment. Please include the name of the client and date of the appointment in the Memo section. If the payment is not received by the appointment time, the credit card on file will be charged. 

 
Should you have any questions or concerns, please do not hesitate to contact our billing department at 631-296-1113 x2 or via email at billing@ northshorerelationshipcenter. com. 

 
Thank you for your continued trust and support. 

INFORMED CONSENT FOR THERAPY SERVICES 

PSYCHOLOGIST-CLIENT SERVICE AGREEMENT

Welcome to my practice. This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.

PSYCHOLOGICAL SERVICES

Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in psychotherapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.

Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions.

The first 2-4 sessions will involve a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some initial impressions of what our work might include. At that point, we will discuss your treatment goals and create an initial treatment plan. You should evaluate this information and make your own assessment about whether you feel comfortable working with me. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. 

INSURANCE

In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. With your permission, my billing service and I will assist you to the extent possible in filing claims and ascertaining information about your coverage, but you are responsible for knowing your coverage and for letting me know if/when your coverage changes.

Due to the rising costs of healthcare, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. Managed Health Care plans such as HMOs and PPOs often require advance authorization, without which they may refuse to provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services
to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.

You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. (Diagnoses are technical terms that describe the nature of your problems and whether they are short-term or long-term problems. All diagnoses come from a book entitled the DSM-5. There is a copy in my office and I will be glad to let you see it to learn more about your diagnosis, if applicable.). 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 and will probably be stored in a computer. 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. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier if you plan to pay with insurance.

In addition, if you plan to use your insurance, authorization from the insurance company may be required before they will cover therapy fees. If you did not obtain authorization and it is required, you may be responsible for full payment of the fee. Many policies leave a percentage of the fee ( which is called co-insurance ) or a flat dollar amount ( referred to as a co-payment ) to be covered by the patient. Either amount is to be paid at the time of the visit by check or cash. In addition, some insurance companies also have a deductible, which is an out-of-pocket amount, that must be paid by the patient before the insurance companies are willing to begin paying any amount for services. This will typically mean that you will be responsible to pay for initial sessions with me until your deductible has been met; the deductible amount may also need to be met at the start of each calendar year. Once we have all of the information about your insurance coverage, we will discuss what we can reasonably expect to accomplish with the benefits that are available and what will happen if coverage ends before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above, unless prohibited by my provider contract.

If I am not a participating provider for your insurance plan, I will supply you with a receipt of payment for services, which you can submit to your insurance company for reimbursement. Please note that not all insurance companies reimburse for out-of-network providers. If you prefer to use a participating provider, I will refer you to a colleague.

PROFESSIONAL RECORDS

I am required to keep appropriate records of the psychological services that I provide. Your records are maintained in a secure location in the office. I keep brief records noting that you were here, your reasons for seeking therapy, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records I receive from other providers, copies of records I send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and / or upsetting to untrained readers. For this reason, I recommend that you initially review them with me, or have them forwarded to another mental health professional to discuss the contents. If I refuse your request for access to your records, you have a right to have my decision reviewed by another mental health professional , which I will discuss with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request.

CONTACTING ME

I am often not immediately available by telephone. I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a message on my confidential voice mail and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters. You can also contact me via email or through my website. If, for any number of unseen reasons, you do not hear from me or I am unable to reach you, and you feel you cannot wait for a return call or if you feel unable to keep yourself safe, 1) contact your local community mental health services, 2) go to your Local Hospital Emergency Room, or 3) call 911 and ask to speak to the mental health worker on call. I will make every attempt to inform you in advance of planned absences, and provide you with the name and phone number of the mental health professional covering my practice.

OTHER RIGHTS

If you are unhappy with what is happening in therapy, I hope you will will talk with me so that I can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist and are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect that I will not have social or sexual relationships with clients or with former clients.

CONSENT TO PSYCHOTHERAPY

Your signature below indicates that you have read this Agreement and agree to their terms.

COMPREHENSIVE PATIENT CONSENT FOR SERVICES DURING TRANSITION PERIOD

PURPOSE AND ORGANIZATIONAL STRUCTURE DISCLOSURE
Alexandra Gleason, LMFT, PLLC d/b/a North Shore Relationship Center (“NSRC”) has been acquired by CS Medical Associates, P.C. d/b/a Victory Recovery Partners (“Victory”). During this transition period, services are being integrated across affiliated entities.

During this time:

Therapy services will be provided through NSRC
Psychiatric evaluation and medication management services, if clinically indicated, will be provided by licensed psychiatric providers affiliated with Victory
These entities are legally distinct, but are collaborating to ensure:

Continuity of care
Timely access to services
Integrated clinical treatment
I understand that I may receive services from one or both entities depending on my clinical needs.

CONSENT TO PARTICIPATE IN TREATMENT
I, ______________________________________ (patient name), voluntarily consent to participate in mental health treatment services, which may include:

Diagnostic evaluation
Individual, family, or group therapy
Care coordination
Referral to psychiatric services, if clinically indicated
I understand that:

Participation in treatment is voluntary
I may withdraw from treatment at any time, subject to clinical recommendations and safe discharge planning
I have the right to ask questions and receive information about my treatment at any time
No guarantees have been made regarding outcomes

NATURE OF THERAPY SERVICES
I understand that therapy involves the assessment and treatment of emotional, behavioral, and psychological conditions.

Potential risks may include:

Emotional discomfort
Recollection of distressing experiences
Temporary worsening of symptoms
Potential benefits may include:

Improved coping skills
Symptom reduction
Improved relationships and functioning
I understand that my progress depends in part on my active participation.

 

REFERRAL TO PSYCHIATRIC SERVICES
If clinically appropriate:

I may be referred for psychiatric evaluation and/or medication management
These services may be provided by CS Medical Associates, P.C. d/b/a Victory Recovery Partners, which is a separate legal entity
I understand that:

Participation in psychiatric services is voluntary
I will be required to complete a separate informed consent for psychiatric evaluation and medication management prior to receiving those services

 

HIPAA ACKNOWLEDGMENT AND AUTHORIZATION FOR USE AND DISCLOSURE OF HEALTH INFORMATION
I understand that my protected health information (“PHI”) is protected under the Health Insurance Portability and Accountability Act and applicable New York State laws.

Acknowledgment of Privacy Practices
I acknowledge that:

I have received or have been offered a copy of the Notice of Privacy Practices
The Notice explains how my health information may be used and disclosed
I have the right to ask questions regarding these practices

 

Use and Disclosure for Treatment, Payment, and Healthcare Operations
I understand that my health information may be used and disclosed, without additional authorization, for purposes of:

Treatment
Payment
Healthcare operations

 

Authorization for Inter-Entity Sharing
I specifically authorize the use and disclosure of my health information between:

Alexandra Gleason, LMFT, PLLC d/b/a North Shore Relationship Center
CS Medical Associates, P.C. d/b/a Victory Recovery Partners
for purposes of:

Coordination of care
Diagnosis and treatment
Referral and consultation
Billing and healthcare operations related to my care
I understand that:

These entities are separate legal organizations
This authorization is necessary to ensure continuity and integration of my care

 

Sensitive Information Disclosure
I understand that this authorization may include disclosure of sensitive information, including but not limited to:

Mental health information
HIV/AIDS-related information
Alcohol and substance use information (to the extent applicable)
Sexually transmitted diseases
Genetic testing information
Such information will be disclosed only as permitted by applicable federal and New York State laws.

 

Right to Revoke
I understand that:

I may revoke this authorization at any time in writing
Revocation will not apply to information already disclosed
Revocation may impact the ability of providers to coordinate my care

 

TELEHEALTH CONSENT
I understand that services may be provided via telehealth, which involves communication through electronic systems.

I acknowledge that telehealth may include risks such as:

Technical failures
Interruptions
Potential unauthorized access, despite reasonable safeguards
I understand that:

Telehealth is voluntary
I may withdraw consent at any time
I am responsible for being in a private, safe environment during sessions
In the event of an emergency, I agree to call 911 or go to the nearest emergency room.

 

FINANCIAL RESPONSIBILITY AND BILLING DISCLOSURE

 

Separate Billing Entities
I understand that:

Therapy services will be billed through NSRC
Psychiatric services, if provided, may be billed through CS Medical Associates, P.C. d/b/a Victory Recovery Partners
I may receive separate bills depending on services rendered

Insurance and Payment Responsibility
I agree that I am responsible for:

Copayments
Coinsurance
Deductibles
Non-covered services
I understand that:

Insurance coverage is not guaranteed
I am financially responsible for any balance not paid by insurance

Assignment of Benefits
I authorize:

Release of necessary information to insurance carriers
Direct payment of benefits to the provider/entity rendering services

 

LIMITS OF CONFIDENTIALITY
I understand that confidentiality may be limited in situations including, but not limited to:

Risk of harm to myself or others
Suspected abuse or neglect
Court orders or legal requirements
Providers may be required to disclose information in accordance with applicable laws.

 

RECORDS AND DOCUMENTATION
I understand that:

My medical record will be maintained securely
Records will be retained in accordance with New York State requirements
I may request access to my records in accordance with applicable law

VOLUNTARY CONSENT AND RIGHT TO REVOKE
I understand that:

This consent is voluntary
I may revoke this consent at any time in writing, except where action has already been taken
Revocation may impact the ability to coordinate care or continue certain services

ACKNOWLEDGMENT AND SIGNATURE
I acknowledge that:

I have read and understand this document in its entirety
I have had the opportunity to ask questions and receive satisfactory answers
I understand the structure of services during this transition period
I voluntarily consent to receive services as described above

 

 

Introduction

To ensure I can fully focus on you during our sessions and provide the best care possible, I now use a virtual scribe that generates the necessary documents for me, eliminating the need for note-taking throughout the sessions. This ensures our time together flows smoothly and without interruption.

Privacy:

The documents produced by the scribe are derived from session recordings, which are not stored and are automatically deleted after processing. The scribe complies with HIPAA regulations, with all data encrypted both in transit and at rest. Additionally, notes can be manually deleted at any time.

Benefits

Enhanced Focus: Fully concentrate on the session without the interruption of note-taking.

Effortless Documentation: The service eliminates the need for manual documentation, ensuring seamless capture of information. 

Reduced Workload: Mitigates workload and potential burnout, contributing to an improved quality of care.

While the use of the virtual scribe is designed to optimize the session, it is important to note that choosing not to utilize this service will not have any negative impact on the therapeutic process. Your comfort and autonomy in our sessions remain our top priority.

Consent Confirmation

By signing below, I confirm my consent to the use of virtual scribe during my sessions.