Outpatient Services Contract
Welcome to TherapyCanHelp! We look forward to helping you reach your goals for therapy. Thisdocument contains important information about our professional services and business practices.Please read it carefully and feel free to discuss any questions you have with your therapist.
Psychotherapy Services We provide in office and TeleMental Health psychotherapy
services for early-adolescents, adolescents, adults, couples and families. The first appointment(s)serve as a consultation. By the end of the first appointment, we will give you some initialrecommendations on what we think will help. If you and your therapist decide to work together in therapy, you will collaborate on a treatment plan that incorporates effective strategies to help with whatever difficulties you are hoping to improve in therapy. Individual, couples and family sessions last 45-50 minutes unless otherwise arranged.
TeleMental Health Services The following information is provided to clients who are
seeking TeleMental Health therapy solely or as an adjunct to in-person sessions. TeleMental Healthmeans the remote delivering of health care services via technology-assisted media. This includes awide array of clinical services and various forms of technology. The technology includes but is notlimited to, a telephone, video, internet, a smartphone, tablet, PC desktop system or other electronic means. The delivery method must be secured by twoway encryption to be be considered secure. Synchronous (at the same time) secure video chatting is the preferred method of service delivery.
Limitations of TeleMental Health Therapy Services: While TeleMental Health offers several advantages such as convenience and flexibility, it is an alternative form of therapy or adjunct to therapy and thus may involve disadvantages and limitations. For example, there may be a disruption to the service (e.g., phone gets cut off or video drops). This can be frustrating and interrupt the normal flow of personal interaction. Primarily, there is a risk of misunderstanding one another when
communication lacks visual or auditory cues. For example, if video quality is lacking for some reason, your clinician might not see various details such as facial expressions. Or, if audio quality is lacking, your clinician might not hear differences in your tone of voice that they could easily pick up if you were in their office.
Additionally, the therapy office decreases the likelihood of interruptions.
However, there are ways to minimize interruptions and maximize privacy and effectiveness. Your clinician will take every precaution to insure a technologically secure and environmentally private psychotherapy session. As the client, you are responsible for finding a private quiet location where the session may be conducted. Consider using a “do not disturb” sign/note on the door. The virtual sessions must be conducted on a wifi connection
We understand that during a TeleMental Health session we could encounter a technological failure. Difficulties with hardware, software, equipment, and/or services supplied by a 3rd party may result in service interruptions. If something occurs to prevent or disrupt any scheduled appointment due to technical complications and the session cannot be completed via online video conferencing, please call the therapist directly. Please make sure you have a phone with you, and that your clinician has that phone number. You and your clinician may also reschedule if there are problems with connectivity.
Availability Between Sessions If necessary, you can leave your therapist a message on
their 24-hour voicemail. Please do not contact us through text/SMS messages or emails regarding clinical issues. If we are unavailable for an extended time, such as vacation, we will inform you and provide you with contact information for another therapist. If you are in an emergency situation and cannot wait for us to return your call, contact your psychiatrist, go to the nearest emergency room, or call 911. Do not contact us by email or text/SMS message in an emergency, as we may not get the information quickly. In order to maintain your confidentiality and our respective privacy, we do not interact with current or former clients on social networking websites.
Confidentiality: We have included a Notice of Privacy Practices in your intake paperwork outlining your rights and our responsibilities to help you. Please review it carefully. In general, federal and state law protects the confidentiality of all communications between a client and mental health clinician, and we can only release information to others with your written permission. Both the
Health Insurance Portability and Accountability Act (HIPAA) and the standards of our profession require that we keep appropriate and confidential treatment records. However, there are a number of exceptions, some of which are indicated below.
We are ethically and legally required to take action to protect others from harm even if taking this action means we reveal information about you. For example, if we believe a child, elderly person or disabled person is being abused or neglected, we may be mandated to report this to the appropriate state agency. If we believe a client is threatening serious harm to another person, we may have to take
protective action through notifying the potential victim, police and/or facilitating hospitalization of the client. If we believe a client is a serious threat to harming his or her self, we may have to take protective action (arranging for hospitalization, contacting family/significant others for notification and/or contacting the police).
We will make a reasonable effort to discuss any need to disclose confidential information about you and are happy to answer any questions you may have about the expectations to confidentiality. Please note that while we make proactive efforts to ensure the confidentiality of your
information, we cannot assure complete confidentiality when utilizing non-secure
Should you participate in TeleMental Health services, you agree to take full responsibility for thesecurity of any communications or treatment on your own computer or electronic device and in your own physical location. You are solely responsible for maintaining the strict confidentiality of your user ID, password, and/or connectivity link and will not allow another person to use your user ID or connectivity link to access the services. You are also responsible for using this technology in a secure and private location so that others cannot hear your conversation. TeleMental Health sessions will not be recorded and all information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law. Minors If you are under 12 years of age, please be aware that the law may provide your parents the right to examine your treatment records. If you are between the ages of 12 and 18, the law may provide your parents the right to examine your treatment records if, after being informed of your parents’ request to examine your records, you do not object or your therapist does not find that there are compelling reasons for ending the access to the records. Your parents are always entitled to the following information: current physical and mental condition, diagnosis, treatment needs, services provided and services needed.
Payment for Services Payment in full is expected at the time services are rendered. We will charge for any additional services, and will review charges at the time the services are requested. Cash, check, and credit/debit cards are all accepted forms of payment. You hereby assume financial responsibility for and agree to make payment in full to Therapy Can Help for any and all charges for services received by you and/or any dependents not otherwise authorized or paid by your insurance carrier.
Please remember that your insurance company may or may not cover therapy via phone or video. You and your clinician are responsible for understanding your mental health benefits. Please contact your insurance provider to verify coverage via TeleMental Health. You understand and agree to the credit/debit card on file being charged after 30 days of an amount outstanding. In the event of a check returned, unpaid from the bank, you acknowledge that a service charge of $35.00 will be incurred for each incident. If fees for services are not paid in a reasonable
amount of time, and attempts have been made to resolve the financial matter to no avail, a client account may be sent to a collection service. You agree to notify Therapy Can Help of any changes in your billing address, telephone, or insurance information as they occur. You certify that the financial information given is true, accurate, and complete to the best of your knowledge.
Insurance Reimbursement It is important for you to verify your mental health benefits so you can understand your coverage prior to your first appointment. We can provide you with documentation for you to submit to your insurance company for reimbursement. If you are using your insurance, this document serves as authorization for Therapy Can Help to provide to your insurance company a clinical diagnosis and, sometimes, additional clinical information, such as treatment plans or summaries before they will pay benefits.
Cancelled/Missed Appointments Cancellations or missed appointments without 24
hours’ notice will be subject to fee charge. You will be responsible for $75 per missed appointment. In cases of emergency or special circumstances where 24 hours’ notice is not possible, the late cancellation fee may be waived.
Questions/Complaints If you have a question or complaint about your treatment or about your billing statement, please talk to us about it. We will take your criticism seriously, openly, and respond respectfully. If you feel uncomfortable talking to your therapist about an issue, please contact the administrator of the office immediately, carol@therapycanhelp.org.
Signature Your signature below indicates that you have read and understand this
Outpatient Service Contract, have reviewed the Notice of Privacy, and that you are
making an informed choice to consent to enter therapy.