Valerie Andersen, PSYD

Licensed Psychologist || PY9730

 

Client’s Rights and Responsibilities, Professional Fees, and Consent for Treatment

 

IMPORTANT:  Please read carefully and initial or sign where indicated

As a client, you have the right to receive available services individualized to your specific needs and provided in the least restrictive manner. You have the right to seek information about and to approve of therapeutic practices. You also have the right, at any time and for any reason, to decide you do not wish to continue counseling. With limited exceptions, information discussed is confidential. You will be asked to provide written consent if information is to be released to third parties.

The exceptions to this written consent and strict maintenance of confidentiality include:

1) Imminent physical danger to self or others and/or active state of psychosis.

2) Suspected child / elder abuse

3) Information legitimately ordered by a court of law

4) Information required by your insurance company to process claims.

It is important for you to know that engaging in psychotherapy has potential emotional risks. Approaching feelings or thoughts that you have tried not to think about for a long time may be painful. Making changes in your beliefs or behaviors can be scary, and sometimes disruptive to the relationships you already have. You may find your relationship with me to be a source of strong feelings. It is important that you consider carefully whether these risks are worth the benefits to you of changing. Most people who take these risks find that therapy is very helpful.

I am away from the office a few times a year for short vacations. I will tell you well in advance of any absences. If you are experiencing an emergency when I am out of town, or outside of my regular office hours (after 7 pm weekdays or over the weekend), you can call The Crisis Center of Tampa Bay at 2-1-1. In emergency situations you can also go to your local emergency room and ask for the Psychologist or Psychiatrist on call, or you can call 9-1-1. If you call my office number when I am out of town, outside of my regular office hours, or over the weekend, I cannot guarantee I will be able to get back to you until I return to work.

Dr. Valerie Andersen, PSYD. Licensed Psychologist | #PY9730 | 10300 49th Street North, Clearwater, FL 33762 | 321.368.9646

Appointments can be scheduled as my time becomes available. Sessions last for 55 minutes unless we agree otherwise. If you are late, we will end on time and not run over into the next person's session. If you miss a session without canceling, or cancel with less than 24 hours notice, your authorized credit card on file will be processed for the session cost in full and in accordance with my cash-pay rate ($175/hr). My voicemail, email and text messages record the time and date of messages, which will keep track of the time of cancellation.

You are responsible for the fees that you incur with Dr. Valerie Andersen, PSYD., and not your insurance company or other third party. Parents/guardians are responsible for payment of a minor. If you fail to pay on your account, I reserve the right to turn your account over to a collection agency or attorney for collection. If this account is assigned to an outside collection agency, an additional fee of 20% of the total amount owed will be added.

Payment is due in full at the time of service. Payments may be made in cash, check, or credit card. There is a $35.00 charge for declined credit card transactions due to insufficient funds.

My cash-pay fee for the first session and ongoing sessions is $175/ hr (standard duration 50 minutes), unless otherwise agreed upon. If we decide to meet for a longer session, you will be billed prorated, rounded to the next quarter hour, and in accordance to the appropriate session fee (Example: $45 for 15 minutes of individual/couples counseling). Initial 20-minute phone consultations and emergency phone calls/text messages of less than 10 minutes are normally free. However, if we spend more than 10 minutes in a week on the phone/text, if you leave more than 10 minutes worth of phone messages/texts in a week, you will be billed on a prorated basis (rounded to the next 15 minutes) for that time. *If you are using insurance to cover therapy services, your insurance company will be billed for the first 60 minutes of our therapy session. Should our session exceed the 60 minutes allowable by insurance your authorized credit card on file will be processed for payment with the fee prorated, rounded to the next quarter hour, and in accordance to the appropriate session fee (i.e. $45 prorated for 15 minutes of exceeded time). Any copays that are required by your individual insurace plan will be invoiced directly from my billing agency, Alma, within 24 hours of services being rendered.*

Requests for medical records, by insurance companies or otherwise, will not accept a claim for services without a mental health diagnosis. Like any medical diagnosis, your mental health diagnosis and treatment will become a permanent part of your medical records. If you have concerns about your confidentiality or how this might affect you, please consult with your therapist.

Dr. Valerie Andersen, PSYD. Licensed Psychologist | #PY9730 | 10300 49th Street North, Clearwater, FL 33762 | 321.368.9646

I have read the above statement of "RIGHTS AND RESPONSIBILITIES AND PROFESSIONAL FEES” for Valerie Andersen, Psy.D. I understand its contents and conditions, give my consent to such, and agree to be bound by them. I, the undersigned, have voluntarily sought and agree to participate in counseling and/or psychotherapy services.

Please indicate your understanding and acknowledgement of the preceding information by signing below:

Dr. Valerie Andersen, PSYD. Licensed Psychologist | #PY9730 | 10300 49th Street North, Clearwater, FL 33762 | 321.368.9646