Nu Day Therapy Services
THERAPIST-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.
COUNSELING 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. However, 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 1-3 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.
APPOINTMENTS
Appointments will ordinarily be 50 minutes in duration, at a time we agree on. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours’ notice. If you miss a session without canceling, or cancel with less than 24-hour notice, my policy is to collect $50 fee from you personally, not your insurance. If it is possible, I will try to find another time to reschedule the appointment. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.
PROFESSIONAL FEES/ INSURANCE
The standard fee for each session depends on whether you are a self-pay client, a client using one of the five (5) insurances under Headway, or if you are you using the Employee Assistance Program (EAP) benefits provided by your employer through Compsych or Lifeworks.
Self-pay clients fee = $150.00 a session - Health Savings Account Cards are accepting using Square. An invoice will be generated before the session with an expectation that payment is delivered before the end of the same day.
Headway Platform clients (accepted insurance – Aetna, United, Cigna, Oxford, and Oscar) co-pay that was calculated through the Headway platform. Following each session, I will confirm the session with Headway for the copay transaction to occur. Please notify immediately if your coverage should lapse so that different arrangements or scheduling can occur.
Compysch and Lifeworks EAP clients – At the completion of the limited number of sessions allowed by your employer, you have the option to continue with my services or terminate counseling.
If you miss a session without canceling, or cancel with less than 24-hour notice, my policy is to collect $50 fee from you personally, not your insurance.
If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required even if another party compels me to testify.
INSURANCE
This business accepts self-pay clients, as well as, Aetna, Cigna, Optum, Oscar, and United through participation with Headway Outsource paneling. I am also paneled with Compsych and Lifeworks-for EAP services. Payments for self-pay clients are accepted by cash, check (Nu Day Therapy Services, LLC), credit card, Zelle (ayneal3@yahoo.com), or CashApp (727-434-0766) transactions.
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.
CONFIDENTIALITY
My policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled Notice of Privacy Practices. You have been provided with a copy of that document and we have discussed those issues. Please remember that you may reopen the conversation at any time during our work together.
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 text me an urgent message or 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. 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) call 911. 2) You may also go to your Local Hospital Emergency Room, or 3) Go directly to PEHMS. 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.
LIABILITY
You may need special services from Nu Day Therapy Services, such as consultation with your school or place of employment. You may also request services related to acquiring special accommodation at your school or place of employment. While we are happy to provide that service, the service does not guarantee that you will get the requested accommodations. There may be consequence related to the acquisition of special accommodations. You agree to hold Nu Day Therapy, LLC harmless from any liability related to the outcome of your ADA request
OTHER RIGHTS
If you are unhappy with what is happening in therapy, I hope you 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.
TREATMENT AGREEMENT:
You will be charged $50.00 for not giving us 24 hours’ notice, when canceling an appointment.
There are no guarantees with psychotherapy. however, we are committed to applying therapy techniques that are proven in research. furthermore, we tailor treatment plans to the client’s needs and based on assessment results.
I have received the treatment agreement and Disclosure statement I understand and agree to abide by my financial responsibilities. I understand that information will be released to my insurance company if necessary, and any charges that my insurance company will not cover I am responsible for.