Geoff Bathje, PhD
(312) 505-2180
gbathje@gmail.com

This document (the Agreement) 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 client rights with regard to the use and disclosure of your Protected Health Information (PHI), which may be used for the purpose of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment, and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information. Although these documents are long and sometimes complex, it is very important that you read them carefully before we proceed. We can discuss any questions you have about the procedures at any time. When you sign this document, it will also represent an agreement between us. You may revoke this agreement in writing at any time. This revocation will be binding on me unless I have taken action in reliance on it; if there are obligations imposed on me by my health insurer in order to process or substantiate claims made under your policy (if applicable); or if you have not satisfied any financial obligations you have incurred.

Therapy is not easily described in general statements. It varies depending on the personalities of the psychologist and client, and the particular problems you are experiencing. There are many different methods I may use to deal with the problems that you hope to address. Therapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our 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, frustrations, loneliness, and helplessness. On the other hand, therapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. There are no guarantees of what you will experience. Our first session will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow if you decide to continue therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. 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.

I normally conduct an initial evaluation that lasts 60 minutes. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If we decide to begin therapy, I will usually schedule one 50-55 minute session per week at a time we agree on, although we may meet less frequently if you prefer. You are expected to attend all scheduled sessions. If you need to cancel a session, 24 hours' notice is required. Sessions that are missed with less than 24 hours' notice will be billed at $150.00 per session and cannot be billed to or reimbursed by insurance. You are responsible for paying this fee. If you miss an appointment with less than 24 hours' notice due to an emergency situation I may choose to not charge you for the missed appointment at my discretion.

The fee for an initial evaluation/intake session is $225. Subsequent therapy sessions are $200. Payment is due at the time of service, payable by Zelle, Venmo, or Paypal (Master Card, Visa, Discover, and American Express). I do offer a sliding scale based on financial hardship and experiences with systemic oppression on a case-by-case basis. Please discuss this PRIOR TO your first appointment. If you are using your insurance plan, please see the section below entitle Insurance Reimbursement and complete the Financial Policy Regarding Insurance form.

Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voicemail that I monitor frequently. I will make every effort to return your call promptly. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and feel that you cannot wait for me to return your call, then call 911 or proceed to the nearest emergency room. If I will be unavailable for an extended time, I will provide on my voicemail the name of a colleague to contact, if necessary.

The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA and Illinois law. However, in the following situations, no authorization is required:

• Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in the Agreement.
• If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-client privilege law. I cannot disclose any information without a court order or your written consent. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information.
• If a government agency is requesting the information for health oversight activities, I may be required to provide it for them.
• If a client files a complaint or lawsuit against me, I can disclose relevant information regarding that client in order to defend myself. Please be advised that in Illinois, a person filing a complaint against a professional waives his or her right to confidentiality.
• If you file a worker's compensation claim, and I render treatment or services in accordance with the provisions of Illinois Worker's Compensation law, I must, upon appropriate request, provide a copy of your record to your employer or his/her appropriate designee.
• I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep the information confidential.
• There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect you or others from harm and I may have to reveal some information about a client's treatment. These situations are unusual in my practice:
  • If I have reasonable cause to believe that a child under 18 known to me in my professional capacity may be an abused child or a neglected child, the law requires that I file a report with the local office of the Department of Children and Family Services. Once such a report is filed, I may be required to provide additional information.
  • If I have reason to believe that an adult over the age of 60 living in a domestic situation has been abused or neglected in the preceding 12 months, the law allows me to file a report with the agency designated to receive such reports by the Department of Aging. Once such a report is filed, I may be required to provide additional information.
  • If you have made a specific threat of violence against another, and if I believe that you present a clear, imminent risk of serious physical harm to another, and I may be required to disclose information in order to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking your hospitalization.

If I believe that you present a clear, imminent risk of serious physical or mental injury or death to yourself, I may be required to disclose information in order to take protective actions. These actions may include seeking your hospitalization or contacting family members or others who can assist in protecting you. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. Please be advised that if you threaten harm to yourself or another, I may be required by Illinois law to notify the State Police. This may result in the revocation of your Firearm Owner's Identification (FOID) card.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future.

The laws and standards of my profession require that I keep Protected Health Information (PHI) about you in your Clinical Records. You should be aware that, pursuant to HIPAA, I may keep documentation about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the way in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive for other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. In addition, I also may keep a set of Psychotherapy Notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They may also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. The Psychotherapy Notes are kept separate from your Clinical Record. While insurance companies (if applicable) can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes without your Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of both sets of records, if you request it in writing, unless any applicable law dictates otherwise. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of $1.00 per-page (and for certain other expenses).

HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you.

Clients under 12 years of age and their parents should be aware that the law allows parents to examine their child's treatment records. Parents of children between 12 and 18 cannot examine their child's records unless the child consents and unless I find that there are no compelling reasons for denying the access. Parents are entitled to information concerning their child's current physical and mental condition, diagnosis, treatment needs, services provided, and services needed. Since parental involvement is often crucial to successful treatment, in most cases, I require that clients between 12 and 18 years of age and their parents enter into an agreement that allows parents access to certain additional treatment information. If everyone agrees, during treatment, I will provide parents with general information about the progress of their child's treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of treatment when it is complete. Any other communication will require the child's authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.

You will be expected to pay for each session at the time it is held, unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a client's treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim.

Please confirm that I am in-network with your insurance provider prior to beginning services and discuss this with me if you would like to use insurnce for psychotherapy. If I am seeing you for psychotherapy on an out-of-network basis, I can provide a "superbill" for you to submit to your insurer for reimbursement if they provide out-of-network services. If you are insured by Medicare, please be aware that I have opted out of Medicare and will need you to sign a separate form stating that you understand that services will not be reimbursible prior to beginning treatment. If I am seeing you for coaching or consulting purposes, this is not reimbursible by insurance and a superbill cannot be provided as it is not psychotherapy. If you have questions about any insurance issue, please raise them before beginning services or as soon as is possible.

YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS. IT AUTHORIZES ME TO BILL YOUR INSURANCE (IF APPLICABLE), AND SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE OF PRIVACY PRACTICES DESCRIBED ABOVE.