CONSENT TO TREAT

Frequency of Sessions? 

Weekly or bi-weekly 60-minute sessions are most common. The frequency of sessions is based largely on your needs and situation.

How Long is Therapy? 

The amount of sessions needed varies depending on the nature of each person’s concerns, the complexity of the issues involved, the strength of our working relationship, and each person’s commitment to work on the presenting issues. There is a direct relationship between effort applied between sessions and progress over time. Anywhere between 1 and 20 sessions are typical, though more sessions may be needed in some situations.

About Privacy:

All information you share with your therapist is private can confidential.
Your information will not be released to anyone without your written permission (with some exceptions as explained below):
• When information is to be released with your consent you will be consulted regarding what information is to be released.
• Your information will be kept on file and in a secure and private location.
• You may review the contents of your own counseling file upon request.

Exceptions to Privacy:

Your therapist offers confidential therapy in so far as allowed by the United States Government and the laws of the State of New York. This means that the therapists and supervisors at Treehouse Wisdom and Wellness Inc. have a responsibility to protect information received from you during treatment. In order for any information about you to be shared, you must first sign a HIPAA Release of Information form that allows us to communicate only with the person identified on the release and only regarding specific information identified by you.

From time to time, we discuss our clinical work with colleagues to make sure that we are providing our clients with the best care possible. During these consultations, we do not share our clients’ personally identifiable information. And even though our colleagues do not have any of our clients’ personally identifiable information, they are still ethically bound to keep the information addressed in our consultation discussions confidential.

A client’s confidential information can be released without their consent under the following conditions:

• When the purpose is to protect individuals (including a client) who are at foreseeable and imminent risk of bodily harm or death as a result of a client’s actions.
• Under the law, we are mandated reporters, which require reporting of child and elder abuse/neglect to authorities.
• Under subpoena from a court of law.
• There are exceptions to confidentiality that apply to personal information disclosed by minors. At the same time, NY has laws in place that allow your minor child to protect their information. Your therapist will discuss these with you in session, as applicable.
• If you disclose in confidence that you have done something illegal, your therapist is not obligated to report this to the authorities, unless the circumstances involve child abuse, abuse against a dependent adult, or a direct threat to another person (as outlined above).

Email & Texting Privacy:

Emailing and texting are quick and convenient methods of communication. Many of our clients use one or the other to correspond with us. Please be aware, however, that while every effort is made to safeguard your privacy, we cannot guarantee the confidentiality of email and text messages. If this is a concern for you, please do not use email or text to correspond with us.
• We will only use email or text to communicate with you: a) in response to an email or text you send us or, b) as you authorize it or otherwise request it.

Collaboration with Professional Referral Source: 

If you have been referred by another professional (i.e. mental health provider, lawyer, physician, psychiatrist, clergy, etc.), it is customary for your therapist to contact your referral source to acknowledge the referral at the beginning of treatment.

Consent to Release Information:

If you are submitting any health claims to your health insurance provider for the counseling services you receive here, your insurance provider may contact us to obtain information necessary to verify your claim.
• The type of information they would typically request includes: 1) date of service, 2) the nature of services provided, and 3) the names of individuals who received the service.
• Our experience has shown that verification checks are not common and that most health insurance providers will typically not request detailed diagnosis and treatment plan information, unless the insurance company was the referral source who previously contacted us on your behalf, and contracted with us to provide services to you.

Other Services:

Examples of such services include correspondence with other professionals, such as and not limited to: school personnel (i.e, school social workers, teachers, guidance), medical staff, probation officers, CPS workers, therapists, etc. All letters written on the behalf of clients will be subject to an out-of-pocket expense.  These services cannot be submitted to insurance for reimbursement. Please be aware that we are not trained for the purpose of child custody and will not make any claims, verbal or written, on either party's behalf. Please discuss this with your clinician prior to any request. 

If you become involved in legal proceedings that require your clinician’s participation, you will be expected to pay for all professional time spent, even if the therapist is called to testify by another party. Because of the difficulty of legal involvement, we charge $220 per hour for preparation and attendance at any legal proceeding and $220 per hour for travel. It is highly recommended that you review our financial policy for further details. 

All correspondence including letter writing, phone calls, and all emails will be subject to $220 per hour (payable prior to receipt of such letter, email, phone) minutes of work and will be charged separately. 

 

I have read this letter in full, and I have been informed of the procedures and conditions as outlined in this letter. I accept the help offered with full knowledge and understanding of the relevant procedures and conditions. By selecting YES at the bottom of this form, this is your consent for treatment.

FINANCIAL POLICY

1. You have been asked to upload a picture of your insurance card. This is your verification of the correct insurance and consent to bill them on you or your child’s behalf. IF THE INSURANCE COMPANY THAT YOU DESIGNATE IS INCORRECT, YOU WILL BE RESPONSIBLE FOR PAYMENT OF THE VISIT AND TO SUBMIT THE CHARGES TO THE CORRECT PLAN.

2. Insurance companies will only reimburse one therapist per individual client. For example, if John Doe, a client of Treehouse, is using his insurance to see another therapist outside of Treehouse, John Doe will be required to pay privately for our services at the rate of $200 a session. Individual family members are excluded. For example, this does not pertain to John Doe's wife or child/ren. Claims to insurance companies are specific to an individual.

3. According to your insurance plan, you are responsible for any and all co-payments, deductibles, and coinsurances.

4. We do not submit to secondary insurance plans. If you have secondary insurance, we will provide you with a receipt to submit for reimbursement. Your secondary insurance will send the reimbursement check directly to you. YOU ARE RESPONSIBLE FOR ANY BALANCE ON YOUR ACCOUNT.

5. It is your responsibility to understand your benefit plan. It is your responsibility to know if a written referral or authorization is required to use our services, if preauthorization is required prior to a session, any coinsurance or deductible, and what services are covered.

6. If our practice does not participate in your insurance plan, payment in full is expected from you at the time of your office visit. For scheduled appointments, prior balances must be paid prior to the visit.

7. If you have no insurance, payment for an office visit is to be paid at the time of the visit. A credit card on file is required for private pay sessions.

9. Patient balances are billed immediately on receipt of your insurance plan’s explanation of benefits. Your remittance is due within 10 business days of the receipt of your bill.

10. If previous arrangements have not been made with our finance office, any account balance outstanding greater than 14 days will be charged a $25 re-bill fee. Any balance over 60 days will be forwarded to a collection agency.

11. If you participate with a high-deductible health plan, we require that a copy of the health savings account debit/credit card or a personal credit card remain on file. 

12. We require 24-hour notice for canceling any appointments. There is a $75 charge for weekday appointments and $100 charge for Saturday appointments if they are not canceled OR if 24-hour notice is not given.

13. A $50 fee will be charged for any checks returned for insufficient funds, plus any bank fees incurred.

14. Not all services provided by our office are covered by every plan. Any service determined to not be covered by your plan will be your responsibility.

15. Treehouse Wisdom and Wellness, Inc. does not provide disability letters, or letters regarding your ability to work, or any letters that would inform providers of your mental health history. You must discuss these needs with your mental health provider. If a letter is required attesting the client’s needs the therapist will provide it for a fee of $75 per one-page letter and $25 for each additional page. Letters are only provided to clients who have
been seen for 8 sessions or longer.

Court Appearance
Clients are discouraged from having the therapist subpoenaed. Though the client's attorney, who initiates the subpoena request is responsible for the court appearance and testimony fees, and it does not mean that the therapist's testimony will be solely in the client's favor. The therapist will only testify their professional opinion and to the facts of the case.

The following fees apply for all court and legal (including phone calls with other providers, CPS, lawyers, responding parties, etc.) appearances:

Preparation time (including submission of records) $220/hour
Phone calls $220/hour
Depositions $250/hour
Email or written letters $200/hour
Time required for being present at court and giving testimony $250/hour
Mileage $0.54/mile
Time away from office due to depositions or testimony $220/hour
Filing a document with the court $100 (Plus court fees)
The minimum charge for a court appearance $1500
Any and all legal fees and costs incurred by the therapist as a result of the legal action.

PLEASE NOTE: A retainer of $1500 is due in advance. If a subpoena or notice to meet attorney(s) is received without a minimum of 48-hour notice there will be an additional $250 “express” charge. If the case is reset with notice of less than 72 business-hours, the client will be charged $500 (in addition to the retainer of $1500). All fees are doubled if the therapist has to postpone or interrupt personal plans where they would be out of town.

 

I have read and understand this office financial policy and agree to comply and accept the responsibility for any payment that becomes due as outlined previously.

A canceled appointment hurts three people: you, your therapist, and another client who could have potentially used your time slot. Therapy sessions are scheduled in advance and are a time reserved exclusively for our clients.

When a session is canceled without adequate notice, we are unable to fill this time slot by offering it to another current client, a client on the wait list, or a client with a clinical emergency. In addition, we are unable to bill your insurance company for sessions that are not kept.

Without a cancellation fee policy in place, your therapist will lose the opportunity to schedule another client if you late cancel or do not show up.

Our cancellation policy is this: Clients can cancel or reschedule an appointment anytime if they provide 24 hours’ notice. If you cancel an appointment with less than 24 hours’ notice or fail to show up, you will be charged a $75 fee for the appointment.

Some practices have a 48-hour policy. Some even have a 72-hour policy. Ours is 24 hours, and we are firm at 24 hours.

Our cancellation policy is not a penalty or punishment. Most clients understand this. Very rarely, there will be a client who will feel that he or she is being punished when they are charged a late cancellation fee. We want to make sure that you don’t feel this way, if someday you miss an appointment.

It is likely, if you are in counseling long enough, at some point you might forget about an appointment, or something will come up in your schedule that will result in you missing an appointment. Maybe you’ll need to work late. Maybe you’ll get a sudden onset of the flu. Maybe your kids will have doctor appointments, or your car will break down, or something unavoidable will come up.

We are not upset with clients when they miss an appointment. We know that’s life. In return, our clients understand that scheduling an appointment with one of us is like buying tickets to an event. If you miss the event, it doesn’t matter why you missed it, or even if it was your first time, you can’t turn in your tickets for a refund.

A fee of $75 will be charged when you miss or cancel an appointment without giving 24 hours advanced notice. This means that if an appointment is scheduled for 3:00 pm on a Tuesday, notice must be given by 3:00 pm on Monday at the absolute latest. *For Saturday or Sunday appointments, a $100 late fee will be charged.

You can cancel your appointment by calling, texting, or emailing your specific therapist. If you are more than 15 minutes late for your appointment time, it will be treated as a late cancellation. It’s important to remember that insurance will not pay for missed appointments, so you will be responsible for the full $75 fee, not just a co-pay.

The only time we will waive this fee is in the event of serious or contagious illness or extreme weather or other unavoidable circumstance. If you are unsure, please contact your therapist for further guidance.

Please understand that therapy should be viewed as any other important medical appointment would be viewed. This cancellation policy is important for our counseling practice because while a medical doctor can see 35 patients in a day, a therapist generally sees a maximum of 6 to 8 clients a day.

While it is a time commitment, this is for your personal growth and consistency is key in order to achieve this. If you miss three scheduled appointments within a six-month time period without canceling or rescheduling in accordance with the cancellation policy of 24 hours’ advance notice, the therapeutic relationship will be terminated and appropriate referrals to other practices will be offered.

Clients who are unsure if they can commit to therapy appointments scheduled for them should seek services elsewhere.

You may return to therapy at any time should you so choose; however, you may be placed on a waiting list if your therapist doesn’t have openings on their schedule at the time. This is standard practice with most therapy agencies and private practice offices.