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    Adult
  • This document contains important information about our services and business policies. Please read it carefully and note any questions you may have. When you sign this document, it indicates that you understand and agree to the information in this document upon entering into therapy.

    Bay Area Clinical Associates is a group of independent mental health professionals who share office space, certain expenses, and administrative functions.  Each practitioner practices independently in their provision of clinical services and they alone are fully responsible for their services.  Treatment records are separately controlled, and no other practitioner has access to them without your specific written permission.

     

    Psychological and Counseling Services  

    Psychotherapy is not easily described in general statements. It varies depending on the personalities of both therapist and client and the particular problems you are experiencing. There are many different methods that can be used to deal with the issues you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active and ongoing effort on your part. In order for therapy to be most successful, you will have to work on the things you and your therapist discuss both during sessions and at home.

    Therapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, therapy often leads to better relationships, solutions to specific problems, and a significant reduction in feelings of distress. Unfortunately, there are no guarantees of what you will experience.

    Our first few sessions will involve an evaluation of your needs. By the end of this evaluation, your therapist will be able to offer you some first impressions of what treatment plan is recommended if you decide to continue therapy. You should evaluate this information along with your own opinions of whether or not you feel comfortable working with your therapist. Therapy involves a large commitment of time, money, and energy. If you have questions about any procedures, they should be discussed whenever they arise. If your doubts persist, your therapist will be happy to help you set up a meeting with another mental health professional for a second opinion.

     

    Meetings

    Your first meeting with your therapist will involve an evaluation of your needs and is an opportunity for you and your therapist to decide if they are the best person to provide the services you seek. If psychotherapy is undertaken, sessions are typically scheduled once a week or every other week and last 50-60 minutes (although they may be shorter or longer).

     

    Cancellations and Missed Appointments

    We generally see clients promptly at the appointment time. In order for you to achieve the most benefit from your counseling appointments, it is important that you arrive on time.

    In scheduling an appointment, a block of time has been reserved for you, and it is a time that will not be made available for other purposes without sufficient notice. Therefore, if you have scheduled an appointment and later wish to change or cancel it, we require notification 24 hours in advance. Last minute cancellations and appointments missed without just cause will be charged to you at a minimum of $100.00. Repeated no shows and/or last minute cancellations may result in you being charged the full amount or in termination of treatment. Should you need to leave a message after our regular office hours, we have a 24-hour answering service available to take your call.

    By contacting the on-call therapist for an emergency, you are authorizing that therapist to access your electronic medical record. The after hours answering service should only be used for emergencies and calls will be charged at a rate of $50 for each 15 minutes. These fees will be charged directly to you and will not be filed with insurance.

     

    Professional Fees

    Counselor, LPC:  
    Initial Visit $150
    Follow-up Visit $136
       
    Psychologist:  
    Initial Visit  $200
    Follow-up Visit $175
       
    Missed Appointment*: $100
    *without at least 24 hours' notice  

    Fees for the following services vary: 

    • Consultations/Observations (in or out of office)
    • Phone consultations lasting longer than ten minutes
    • Psychoeducational Testing
    • Forensic evaluations/court costs
    • Completion of forms for FMLA, accommodations, etc.

     

    Payments

    You will be expected to pay for each session at the time it is held unless we agree otherwise or unless you have insurance coverage that requires another arrangement. It is important to evaluate what resources, including insurance, you have available to pay for treatment. We will be happy to assist you in accessing the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment for your treatment. It is very important that you find out what mental health services your insurance policy covers.

    You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, we will provide you with whatever information we can based on our experience and will be happy to help you understand the information you receive from your insurance company. If it is necessary to clear up confusion, we will be willing to call your insurance company on your behalf.

    You should also be aware that if you decide to use insurance to pay for your treatment, you consent to our office providing the insurance company with whatever information they request. Typically, this is a diagnosis, dates of service, and general information about the type of services provided. In some cases, insurance companies request treatment notes or other information. By signing this document, you agree that we can provide the requested information to your carrier.

     

    Contacting Us

    Due to the nature of the services provided, we are typically not immediately available by telephone. You are welcome to leave a message for a return call, and we will get back to you as soon as possible. Discussion of clinical issues should generally be reserved for your scheduled therapy session unless it is an emergency. 

    We do not provide after-hours phone communication. If you call during regular business hours (Monday through Thursday, 8:00am - 5:00pm) and have an emergency and cannot contact us or cannot wait for a return call, please stay safe and call 988 or 911. Another therapist may return your phone call. By leaving an emergency message you are authorizing another therapist to review your record and contact you.

    If you have an emergency when our office is closed, please call 911 or go to an emergency room. You can also call the the Suicide and Crisis Lifeline at 988. 

    Please review our Electronic Communication Policy for policies regarding other forms of contact.

     

    Limits on Confidentiality

    The law protects the privacy of all communications between you and us. In most situations, we can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide advance written consent. Circumstances in which we cannot, by law, maintain confidentiality of communication include those where you communicate that you are a serious threat to your own safety or the safety of an identifiable third party, or that a child or vulnerable adult is being abused or neglected. In these cases, an appropriate party who can intervene will be notified, and only information relevant to the situation will be discussed. Certain legal situations may also limit the confidentiality of your records.

     

    Couples/Family Therapy
    All information obtained during couples or family therapy will be kept in a single chart. Therefore, to release information, we must have authorization from all parties. If an individual requests access to the chart, a redacted (edited) chart, with all the other members’ information removed, could be requested.

  • Please initial each item below. All items must be initialed before you can be seen.

  • *      I hereby consent to enter into treatment with my clinician. I understand that no promises have been made to me as to the results of treatment or of any procedures provided. I am aware that I may stop my treatment with my clinician at any time.
      
    *     I agree to pay for all services provided. I understand that I am responsible for any charges that are not paid by my insurance company., Not all services are covered and I understand that it is my responsibility to know the limits of my coverage and to pay any fees denied by my insurance company. 
     
    *     I assign any and all rights or payments that may be due under my insurance policy directly to me clinician. I authorize the release of any information necessary to process my claims.  
     
    *      I understand that insurance copays, deductibles, and charges not filed with insurance are due at the time or service. 
       
    *      I understand that it is my responsibility to notify my clinician of any charges to my insurance company, I will be responsible for any claims denied due to incorrect insurance information.
      
    *      I have read the policies regarding cancellations, no shows, and arriving late to my appointments. 
     
    *     I have read and understand the information regarding contacting my clinician outside of the therapy hour, including how emergencies will be handled.
     
    *     I am aware that the practice has a Notice of Privacy Practices that contains a section on Patient RIghts. I have been given the opportunity to review this Notice and a copy will be provided upon my request.  

    *     I have read and fully understand all information about the limits of confidentiality.   


    Signature   *   Date   Pick a Date*   

          

  • Notice of Privacy Practices

  • Privacy is a very important concern for all those who come to this office. It is also complicated because of federal and state laws and our profession. Because the rules are complicated, some parts of this Notice are quite detailed.

    This Notice will tell you how we handle information about you. It tells how we use this information here in this office, how we share it with other professionals and organizations, and how you can see it. We want you to know all of this so that you can make the best decisions for yourself and your family. We are also required to tell you about this because of the privacy regulations of a federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

     

    What We Mean by Your Medical Information

    Each time you visit this practice or any doctor's office, hospital, clinic, or any other healthcare provider, information is collected about you and your physical and mental health. It may be information from your past, present, or future health/conditions. It may also be information of the treatment or other services you received from your therapist or from others or about payment for healthcare. The information we collect from you is called, in the law, Protected Health Information (PHI). This information goes into your medical or healthcare record or file at the office. In this office, this PHI is likely to include these kinds of information:

    • Your History - as a child in school, at work, marital, and other personal history.
    • Reasons you came for treatment - your problems, complaints, symptoms, needs, and goals.
    • Diagnoses - medical terms for your symptoms.
    • A treatment plan - services that are designed to best help you.
    • Progress notes - written account of what occurs during our sessions.
    • Records we obtain from other providers.
    • Educational or Psychological Testing - results and interpretations.
    • Information about medications you took or are taking.
    • Legal matters.
    • Billing and insurance information.

     

    We use this information for many purposes:

    • To plan your care and treatment.
    • To decide how well the treatments are working for you.
    • To discuss your treatment with other healthcare providers who are also treating you.
    • To show that you actually received the services for which we have billed your or your health insurance company.

    Although your health record is the physical property of the healthcare practitioner or facility, the information belongs to you. You can inspect, read, or review it. If you want a copy, we can make one for you, but you may be charged the cost of copying (and mailing if you want it mailed to you or someone else). In some very unusual situations you cannot see all of what is in your records. If you find anything in your records that you think is incorrect or something important is missing, you can ask us to amend (add information to) your record, although in some rare situations, we do not have to agree to do that.

     

    Couples/Family and Therapy
    All information obtained during couples or family therapy will be kept in a single chart. Therefore, to release information, we must have authorization from all parties If an individual requests access to the chart, a redacted (edited) chart, with all other members’ information removed, could be requested.

     

    Privacy and the Laws About Privacy
    The HIPAA law requires us to keep your PHI private and to give you this notice of our legal duties and our privacy practices, which is called the Notice of Privacy Practices (NPP). We will obey the rules of this notice as long as it is in effect, but if we change it, the rules of the new NPP will apply to all PHI we keep. If we change the NPP, we will provide you with a new Notice.

     

    How Your Protected Health Information Can Be Used and Shared

    When your information is read by personnel in this office, this is called, in the law, “use.” If information is shared with or sent to others outside this office, that is called, in the law, “disclosure.” Except in special circumstances, when we use your PHI here or disclose it to others, we share only the minimum necessary PHI needed for the purpose. The law gives you the right to know about your PHI, how it is used, and to have a say in how it is disclosed.


    We use and disclose PHI for several reasons. Mainly, we will use and disclose (share) for routine purposes. For other uses, we must have written authorization from you unless the law allows or requires us to make the use of disclosure without your authorization. The law also says that we are allowed to make some uses and disclosures without your consent.


    Uses and disclosures of PHI in healthcare with your consent - After you read this Notice, you will be asked to sign a separate consent form to allow us to use and share your PHI. In almost all cases, we intend to use your PHI here or share your PHI with other people or organizations to provide treatment to you, arrangement for payment for our services, or some other health care operation (TPO). Together, these routine purposes and the Consent form, allow us to use and disclose your PHI for treatment, payment, and healthcare operations (TPO).

     

    For Treatment
    We use your medical information to provide you with psychotherapy and evaluation services. These might include individual, couples, or family therapy, educational or psychological testing, and treatment planning.


    We may share or disclose your PHI to others who provide treatment to you. We are likely to share your information with your physician. If you are being treated by a team, we can share some of your PHI with them so that the services you receive will be coordinated. We may refer you to other professionals or consultants for services we cannot offer such as special testing or treatments. When we do this we need to tell them things about you and your condition. We will receive their findings and opinions, and that information will go into your records here. If you receive treatment in the future from other professionals, we can also share your PHI with them.

    For Payment
    We may use your information to bill you, your insurance, or others to be paid for treatment we provide you. If you indicate that you wish your therapist to assist in insurance reimbursement for her services, she may contact your insurance company to verify your coverage. Your therapist may have to tell them about your diagnoses, what treatments you have received, and what your therapist expects as she treats you. Your therapist will need to tell them about when your sessions occurred, your progress, and other similar things.

    For Health Care Operations
    There are some other ways we may use or disclose your PHI, which are called health care operations. For example, your therapist may use your PHI to see where she can make improvements in the care and services she provides. We may be required to supply some information to some government health agencies so they can study disorders and treatment and make plans for services that are needed. If we do, your name and identity will be removed from what we send.

     
    Other Uses in Healthcare

    Appointment Reminders: We may use and disclose medical information to reschedule or remind you of appointments.


    Treatment Alternatives: We may use and disclose your PHI to tell you about or recommend possible treatments or alternatives that may be of interest to you.


    Other Benefits and Services: We may use and disclose your PHI to tell you and health-related benefits or services that may be of interest to you.

    Uses and Disclosures Requiring Your Authorization
    If we want to use your information for any purpose besides the TPO or those we described above, we need your permission on an Authorization Form. If you authorize us to use or disclose your PHI, you can revoke (cancel) that permission, in writing, at any time. After that time, we will not use or disclose your inforain for the purposes to which we agreed. Of course, we cannot take back any previously discussed information for which we had authorization.

    Uses and Disclosures NOT Requiring Consent or Authorization
    The laws allow us to use and disclose some of your PHI without your consent or authorization in some cases. We may use or disclose PHI without your consent or authorization in the following circumstances:

    Child Abuse:  If a therapist is treating a chid and that therapist knows or suspects that chid to be a victim of child abuse or neglect she is required to report the abuse or neglect to a duly constituted authority.

    Adult and Domestic Abuse:  If a therapist has reasonable cause to believe an adult, who is unable to take care of himself or herself, has been subjected to physical abuse, neglect, exploitation, sexual abuse, or emotional abuse, that therapist must report this belief to the appropriate authorities.

    Health Oversight Activities:  If the state licensing board is conducting an investigation into our practice, then we are required to disclose PHI upon receipt of a subpoena from the Board.

    Judicial and Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and we will not release information without written authorization of you or your legally appointed representative or court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. The privilege also does not apply in child custody issues.

    Serious Threat to Health or Safety :  Your therapist may disclose your PHI to the appropriate individuals if your therapist believes in good faith that the disclosure is necessary to prevent or lessen a serious and imminent threat to the health and safety of you or another identifiable person.

     

    Uses and Disclosures Requiring You to Have an Opportunity to Object

    Your therapist can share some information about you with your family or close others that you choose. She will ask you about who you want to tell what information about your condition or treatment. You can tell your therapist what you want, and she will honor your wishes as long as it is not against the law.

    If an emergency occurs - such that we cannot ask you if you disagree- we can share information if we believe that it is what you would have wanted and if we believe it will help you if we share it. If we share information in an emergency, we will tell you as soon as we can. If you don’t approve, we will stop as long as it is not against the law.

    An Accounting of Disclosures
    When we disclose your PHI, we will keep some records of whom we sent it to, when we sent it, and what we sent. You can get an accounting (a list) of these disclosures.

    If You Have Questions or Problems
    If you need more information or have questions about the privacy practices described above, please ask us to explain it in further detail. If you have a problem with how your PHI has been handled, or if you believe your privacy rights have been violated, discuss this with us, so that we can correct the problem. You have the right to file a complaint with the Secretary of the Federal Department of Health and Human Services. We promise that we will not in any way limit your care here or take actions against you if you complain.

     

    HIPAA ACKNOWLEDGEMENT

    Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. If you wish a copy of the HIPAA Notice Form, it will be provided to you. 

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  • *   Signature of Client (or authorized representative)

  • Electronic Communication Policy

  • In order to maintain clarity regarding our use of electronic modes of communication during your treatment, we have prepared the following policy. This is because the use of various types of electronic communication is common in our society, and many individuals believe this is the preferred method of communication with others, whether their relationships are social or professional. Many of these common modes of communication, however, put your privacy at risk and can be inconsistent with the law and with the standards of our profession. Consequently, this policy has been prepared to assure the security and confidentiality of your treatment and to assure that it is consistent with ethics and the law.


    If you have any questions about this policy, please feel free to discuss this with your clinician.

    Email Communications
    We will use email communication and text messaging only with your permission and only for administrative purposes unless we have made another agreement. That means that email exchanges and text messages with our office should be limited to things like setting and changing appointments, billing matters, and other related issues. If we have agreed to the use of email communications for clinical matters, you need to be aware that this is not always a secure method of communicating. Further, emails will not be checked on weekends and when our office is closed.

    Text Messaging
    Because text messaging is a very unsecure and impersonal mode of communication, we do not text message nor do we respond to text messages from anyone in treatment regarding clinical matters. Text messaging through our electronic records system may be used by your therapist to communicate with you regarding appointments and scheduling. It is also used to remind you of your appointments and for you to confirm or cancel your appointment. It is important to note, however, that you should not use this system as a means to communicate with the office, as the electronic system will not alert us that you have texted. If you and your clinician have agreed to use text messaging, you should remember that text messaging is not always reliable and/or secure.

    Social Media
    Our clinicians do not communicate with, or contact, any  clients through social media platforms like Instagram, Twitter, Facebook, etc. In addition, if we discover that we have accidentally established an online relationship with you, we will cancel that relationship. This is because these types of casual social contacts can create significant security risks for you.

    EMERGENCIES
    Electronic communication (messaging, text, email) should never be used to communicate in an emergency situation. These communications may not be received or read in a timely manner. Use of these methods of communications for these purposes may result in a termination of services.

     

    I have read the above electronic communications policy and agree to abide by it in my communications with my therapist. I understand that electronic communications are not to be used for emergency situations:

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  • *   Signature of Client (or authorized representative)

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