If you are not using insurance, please skip Insurance Policy and Primary Policy Holder sections.

PLEASE NOTE:  We apologize if this questions creates discomfort for you. You only need to indicate your administrative sex if you are using insurance to pay for your appointments. Insurance companies require we provide the administrative sex of the patient in order to allow us to submit claims. Failure to do so may result in out of pocket costs to you. 

 

In order to protect the health and wellbeing of clients and staff, the following policies are being enacted. 

1.      If you are having any signs or symptoms of illness including sinus/chest congestion, gastrointestinal upset, fever/chills, sore throat, loss of smell/taste, or cold/flu symptoms, you must make arrangements to cancel your in-person appointment and to meet via telehealth with your therapist. Please be mindful of the well-being of others you may be in contact with, including those with underlying health issues, as you consider whether to attend your sessions in person.
 
 
2.      All therapists within our practice will also observe these policies to keep themselves and others well and to avoid spread of illness to our patients and others within the practice.

 

By signing below, you are agreeing that you have read, understand and agree to the above policies and requirements. You also agree that in the case you do contract Covid 19 or any other illness, you will not hold Manifest Psychotherapy & Wellness or the individuals of this practice, responsible.

This Informed Consent for Teletherapy contains important information concerning engaging in electronic psychotherapy or teletherapy. Please read this carefully and let me know if you have any questions. This consent shall only apply to clients physically within the State of Pennsylvania seeking therapeutic treatment within the State of Pennsylvania. This Informed Consent shall be signed in conjunction with Manifest Psychotherapy and Wellness’s Patient Rights and Responsibilities form.

Benefits and Risks of Teletherapy

Teletherapy refers to the remote provision of psychotherapy services using telecommunications technologies such as video conferencing or telephone. One of the benefits of teletherapy is that the client and therapist can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the client or therapist moves to a different location, takes an extended vacation, or is otherwise unable to continue to meet in person. It can also increase the convenience and time efficiency of both parties. 

Although there are benefits of teletherapy, there are some fundamental differences between in-person psychotherapy and teletherapy, as well as some inherent risks. For example: 

 Risks to confidentiality. Because teletherapy sessions take place outside of the typical office setting, there is potential for third parties to overhear sessions if they are not conducted in a secure environment. I will take reasonable steps to ensure the privacy and security of your information, and it is important for you to review your own security measures and ensure that they are adequate to protect information on your end. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation. 

 Issues related to technology. There are risks inherent in the use of technology for therapy that are important to understand, such as: potential for technology to fail during a session, potential that transmission of confidential information could be interrupted by unauthorized parties, or potential for electronically stored information to be accessed by unauthorized parties. 

Crisis management and intervention. As a general rule I will not engage in teletherapy with patients who are in a crisis situation. Before engaging in teletherapy, we will develop an emergency response plan to address potential crisis situations that may arise during the course of our teletherapy work. 

Efficacy. While most research has failed to demonstrate that teletherapy is less effective than in person psychotherapy, some experienced mental health professionals believe that something is lost by not being in the same room. For example, there is debate about one’s ability when doing remote work to fully process non-verbal information. If you ever have concerns about misunderstandings between us related to our use of technology, please bring up such concerns immediately and we will address the potential misunderstanding together. 

 

Electronic Communications

Your provider will use Zoom’s HIPAA Compliant program. You may access the platform via a link given to you by your provider on your smartphone, computer, or tablet. I will make my best efforts to comply with the American Counseling Association’s Ethics Code guidance on Distance Counseling as well as the Pennsylvania’s Department of Regulatory Agency’s Teletherapy Policy, and I will provide you with a copy of these guidelines upon request. You may be required to have certain system requirements to access electronic psychotherapy via the method we choose. You are solely responsible for any cost to you to obtain any additional/ necessary system requirements, accessories, or software to use electronic psychotherapy. For communication between sessions, I 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 my office should be limited to things like setting and changing appointments, billing matters, and other related issues. You should be aware that I cannot guarantee the confidentiality of any information communicated by email or text. Therefore, I will not include any clinical material by email and prefer that you do not as well. Treatment is most effective when clinical discussions occur at your regularly scheduled sessions, however if an urgent issue arises, you should feel free to attempt to reach me by phone. 

Confidentiality:

 I have a legal and ethical responsibility to make my best efforts to protect all communications, electronic and otherwise, that are a part of our teletherapy. However, the nature of electronic communications technologies is such that I cannot guarantee that our communications will be kept confidential and/or that a third party may not gain access to our communications. Even though I may utilize state of the art encryption methods, firewalls, and back-up systems to help secure our communication, there is a risk that our electronic communications may be compromised, unsecured, and/or accessed by a third party. The extent of confidentiality and the exceptions to confidentiality that I outlined in my Disclosure Statement and Informed Consent for Services still apply in teletherapy. Please let me know if you have any questions about exceptions to confidentiality. 

Appropriateness of Teletherapy

 If at any time while we are engaging in teletherapy, I determine, in my sole discretion, that teletherapy is no longer the most appropriate form of treatment for you, we will discuss options of engaging in face-to-face in-person counseling or referrals to another professional in your location who can provide appropriate services. You as the patient also have the right to refuse telehealth services. Refusal will not limit your access to in-person services. 

Emergencies and Technology 

Assessing and evaluating threats and other emergencies can be more difficult when conducting teletherapy than in traditional in-person therapy. In order to address some of these difficulties, I will ask you where you are located at the beginning of each session and I will ask that you identify an emergency contact person who is near your location and who I will contact in the event of a crisis or emergency to assist in addressing the situation. I will ask that you sign a separate authorization form allowing me to contact your emergency contact person as needed during such a crisis or emergency. If the session cuts out, meaning the technological connection fails, and you are having an emergency do not call me back, but call 911, the Re:Solve Crisis Hotline at 1-888-796-8226 or go to your nearest emergency room. Call me after you have called or obtained emergency services. If the session cuts out and you are not having an emergency, disconnect from the session and I will wait two (2) minutes and then re-contact you via the teletherapy platform on which we agreed to conduct therapy. If you do not receive a call back within two (2) minutes then call me on the phone number I provided you. If there is a technological failure and we are unable to resume the connection, you will only be charged the prorated amount of actual session time. 

Fees: 

The same fee rates shall apply for teletherapy as apply for in-person psychotherapy. However, insurance or other managed care providers may not cover sessions that are conducted using electronic psychotherapy. If your insurance, HMO, third-party payer, or other managed care provider does not cover electronic psychotherapy sessions, you will be solely responsible for the entire fee of the session. Please contact your insurance company prior to our engaging in teletherapy sessions in order to determine whether these sessions will be covered. 

Informed Consent: 

This agreement is intended as a supplement to the general informed consent that we agreed to at the outset of our clinical work together. Your signature below indicates agreement with its terms and conditions. This agreement is supplemental to my general informed consent and does not amend any of the terms of that agreement.

 

 

If you are using your insurance benefits your plan requires the patient portion be paid by credit card . This is due to the high incidence of unreported deductibles and the fact that insurance may not cover certain services (such as Marriage Counseling, Family Counseling, Hypnotherapy, etc.) or other charges such as late-cancel or no-show fees.

By paying via credit card, you acknowledge that this credit card information will be automatically kept on file via PCI-compliant encrypted code with the following credit card processor: Finix. Health Savings Account cards may also be kept on file as the primary form of payment, but you must still have a back-up credit card in case HSA funds are depleted.

You further agree and understand that if insurance does not pay the contracted rate for services within 60 days of your session date, any remaining balance due that is the legal patient responsibility and will be charged to the Health Savings Card or Credit Card on file. This amount typically includes, but is not limited to, co-pays, co-insurance, and deductibles that have not yet been met or were quoted incorrectly by the insurance company but may also include late-cancel or no-show fees. You are responsible for understanding the terms between you and your insurance company.

Manifest Psychotherapy and Wellness contracts a billing service, Advanced Mental Health Billing, to process insurance claims and copays. Your signature below represents an understanding that employees of Advanced Mental Health Billing are responsible for charging your card and may contact you in the event of a card being denied, your information needing an update, or other needed information regarding credit card payments or insurance claims.

Manifest Psychotherapy and Wellness will provide you access to the TherapyAppointment patient portal where you can view your account, request statements, or update your information. Clicking on the payment line will allow you to view or print the receipt.

PLEASE NOTE: Appointments can only be scheduled with a current card on file and with all previous appointments paid in full. We do not offer payment plans.

By signing my name below, I authorize Manifest Psychotherapy and Wellness to keep my credit card on file and to charge my credit card. I have the right to request my credit card to be removed via written or verbal request.

THIS AUTHORIZATION EXPIRES 12 MONTHS FROM THE DATE OF OUR FINAL THERAPY SESSION

Please complete the following form prior to your first session, as it will contain information that will be useful to your treatment.

If you ARE NOT the patient (for example if you are filling this out for a child or relative) please fill in the form about the patient to the best of your knowledge.

Insurance companies now require Social Security Numbers for Initial Verification of Benefits. Our practice requires an initial verification of your benefits in order to minimize the possibility of needless out of pocket costs for you, and to ensure that we are able to provide services to you based on the parameters of your policy and benefits of your insurance plan.

Please note that we are reliant on the representatives of your insurance company to give us accurate information regarding your coverage. You are ultimately responsible for understanding and confirming the accuracy of this information by contacting your insurance company directly.

By signing below you consent to allow our contracted biller to contact your insurance company and to request relevant information and verification of benefits, based on the services you are asking us to provide.

 

As a person receiving mental health services you have the right to:

Be treated in a professional, respectful, and ethical manner with a safe environment, consistent with all applicable states laws of the PA Board of Social Workers, Marriage and Family Therapists and Professional Counselors regardless of race, age, sex, religion, national origin, sexual orientation, disability or marital status.
Receive information about your therapist’s knowledge, skills, experience, and credentials

All therapists receive regular training, consultation, and case feedback in order to provide the best care possible. Information regarding cases may be discussed but all information will be deidentified and kept confidential by all parties involved.
Participate meaningfully in the planning, implementation, termination or referral of your treatment. Refuse treatment or services unless mandated by a court of law.
Be informed of the risks and benefits of the proposed treatment.

Benefits of therapy can include improvement in a range of mental health symptoms, improvement in an overall general sense of well-being, feeling heard and respected by a trusted professional Risks can include mental, emotional, and physical distress related to discussing upsetting material

EMDR Therapy

Your therapist may be trained in EMDR Therapy. Eye Movement Desensitization and Reprocessing (EMDR) therapy is an approach that is widely validated for the treatment of PTSD and has been shown to decrease treatment time and improve therapeutic gains. It has also been shown as helpful for other trauma-related issues and is currently being researched for other applications.

In the process of EMDR therapy you may experience distressing, unresolved memories. Some clients have experienced reactions during session that neither they nor the clinician expected including a high level of emotional distress and physical sensations. After treatment sessions you may continue to process material, which could lead to other dreams, memories, flashbacks, emotions, sensations, etc. 
Before beginning EMDR, in order to help you plan for and cope with any distress, your therapist will work with you to make sure you have appropriate resources and coping skills.

Be informed about the situations that can lead to discharge from treatment. Your therapist has the right to discontinue services if your attendance in treatment is inconsistent; if you do not contact your therapist for over 30 days; if you make threats or act out aggressively toward the property, therapist, staff, or other clients; or if you have a substance abuse issue that begins to impede the treatment process (sessions will not occur if you are under the influence of alcohol or drugs). You have a right upon discharge from treatment to be referred to other appropriate services.
Provide feedback about treatment and, if needed, make complaints to your therapist. 
Receive prompt responses when corresponding with your therapist via phone or email (see attached info on communication and scheduling).

NOTE- Your therapist does not provide crisis support services. If you are having a crisis please call Resolve (1-888-796-8226), 911, or present to an Emergency Room
To have the information you disclose to your therapist kept confidential within the applicable limits of state and federal law. All information shared between therapist and client are considered confidential except for the following scenarios-

Client discloses plan to kill self or someone else
Client reports child abuse or suspected child abuse
Client reports abuse of an incapacitated adult
Health Information Portability and Accountability Act (HIPAA) regulation compliance
Court ordered disclosure of information

Information required in the course of third-party insurance reimbursement 
Other situations where I am permitted or required to disclose information without consent or authorization include-

If you are involved in a court proceeding and a request is made for information concerning your evaluation, diagnosis or treatment, such information is protected by the privilege of law. I cannot provide any information without your (or your personal or legal representative's) written authorization, or a court order.  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 you file a complaint or lawsuit against me, I may disclose relevant information about you in order to defend myself.
If you file a worker's compensation claim, you must sign a release so that I may release the information, records or reports relevant to the claim.

Fee Agreement and No-Show/ Cancellation Policy

As a client seeking services you are agreeing to make a commitment to the selected appointment time. This commitment on the part of you, the client, and your therapist, is for the appointment time to be reserved for you. In addition, as part of your commitment to therapy, you (and your insurance company if applicable) are responsible for the fees for the services provided. If appointment times are missed this leads to other clients missing out on that time and the therapist facing financial consequences. 

Insurance

For clients using insurance, you are responsible for any copay, coinsurance, and/or deductible at each session.  Please be sure to bring your insurance card with you to your first session, and be sure to call your insurer to verify your benefits before we meet.  It is very important that you are responsible for understanding your insurance plan and that you rely on your insurer for the final word on your benefits.  As a courtesy, I will submit your in-network claims to your insurer and will ascertain the basics of your plan regarding financial responsibility.  However, it is up to you to be in direct contact with your insurer to be absolutely certain you have the most accurate information regarding your benefits
Out of Pocket

For clients who do not have insurance coverage we have an hourly out of pocket fee with sliding scale available for those who qualify

You are required to pay in full for each session at the time it is held.  Payment for other professional services will be due at your next appointment or by the due date of your bill, whichever is sooner.  If your account has not been paid for more than 30 days and payment arrangements have not been agreed upon, I may use 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 is demographic information (i.e., name, nature of services provided, amount due), completely unrelated to the details of treatment. If such legal action is necessary, these costs will be included in the claim.

FEE SCHEDULE

 

STANDARD APPOINTMENT $150 NO SHOW/LATE CANCEL/ Full fee

REPEATED CANCELS

 

FAMILY/COUPLES SESSION $150 PHONE/EMAIL/TEXT $150/hr

COMMUNICATION includes crisis calls

(with you or collateral contacts)

 

FAMILY/ COUPLES SESSION  $150.00

  

LETTERS/TREATMENT $150/hr

 

LEGAL PROCEEDINGS $150 hr

Sliding Scale:

Please Note: If you have signed a contract for accommodations for a sliding scale fee, all associated fees (session fees, late fees, additional correspondence) will be adjusted to honor that contracted amount.

Sufficient Notice of Cancellation

You, the client, must provide sufficient notice of cancellation to your therapist 
Sufficient Notice is defined as:

Providing notice (call, text, or email) to your therapist AT LEAST 48 hours prior to your scheduled appointment time. Any notice provided in less than 48 hours will result in an out-of-pocket fee

 

Late Cancellation/ No-Show Fee

The fee for failing to provide sufficient notice (at least 48 hours in advance of your appointment) is the full cost of your session (i.e. the amount agreed upon by you with your therapist or between your therapist and your insurance) which will be charged directly to you, the client, as an out-of-pocket fee. This fee will be due prior to, or at the time of, your next appointment. 

If you no-show your appointment (with no call prior to the appointment time) you will be billed for the full fee of the session. You are considered a no-show if you are more than 10 minutes late to your appointment

If you cancel several sessions consecutively without attending, your therapist reserves the right to charge the full fee for those sessions even if you cancelled 48 hours in advance.

You must pay this amount in full before scheduling your next appointment.

Information Regarding Online Services

For your convenience and to assist the functioning of our practice we use an online service through www.therapyappointment.com to help with the following

Online intake/ scheduling (most information is gathered through online portal)
Appointment Reminders- This service provides appointment reminders 1 day prior sent via email or text message

Secure Message Center- Messages sent through therapyappointment.com are confidential and HIPAA compliant, you will need to create an account to login and view these messages

Online Medical Record Storage- We use therapyappointment.com to store the majority of our records and billing information. This online system is HIPAA approved and all patient information is encrypted. However, web-based record-keeping may be at risk for hacking, viruses, etc. If you have any concerns about these risks you are welcome to discuss them with your therapist. 

Please note that implementation of this service is in good faith by Manifest Psychotherapy and Wellness in order to provide more convenient, secure, and confidential services to you, the client. In addition you have the right to be informed of any security breaches that may occur online and to refuse usage of the online payment features.

By signing below you indicate that you have read and been informed about the above services, including the risks and benefits, provided through www.therapyappointment.com.

By signing below you agree to not hold Manifest Psychotherapy and Wellness liable for any breach, theft, misuse, or damages that result from online security breaches beyond their control.

 
By signing below I agree that I have read and understand the above details regarding the rights, responsibilities, risks, benefits, limits to confidentiality, fee agreement and the no-show/ cancellation policy. I agree to abide by these policies and understand the consequences should I fail to do so.