If you will be using insurance, we will need the following information.
CONSENT TO TREAT CHILD
Prior to beginning treatment, it is important for you to understand our approach to child therapy and agree to some rules about your child’s confidentiality during the course of his/her treatment. The information herein is in addition to the information contained in the Treatment Consent.
Therapy is most effective when a trusting relationship exists between the therapist and a child. Privacy is especially important in securing and maintaining that trust. It is necessary for children to establish a “zone of privacy” with their therapist that allows them to feel free to discuss personal matters. Therefore, it is our policy to provide you with general information about the treatment of your child, but we will not share with you what your child has disclosed to you without your child’s consent. However, if we ever believe that your child has been abused or is at serious risk of harming him/herself or another, we will inform you. This “zone of privacy” extends to information contained in treatment records as well. By signing this agreement, you are waiving your right of access to your child’s treatment records. We will be happy to provide a written treatment summary upon request.
Adolescence is a time when children need to develop a greater sense of independence and autonomy. If your child is an adolescent, it is possible that he/she will reveal sensitive information during therapy sessions regarding sexual contact, alcohol and/or drug use, or other potentially problematic behaviors. In order for a therapist to effectively work with your child, it is necessary for to maintain confidentiality about these behaviors unless they involve imminent risk of harm to self or others, such as driving while under the influence of alcohol or drugs. We will also inform you if your child does not attend sessions or if it is necessary to refer your child to another mental health professional.
One risk of child therapy involves disagreement among parents and/or disagreement between parents and a therapist regarding the best interests of the child. If such disagreements occur, we will strive to listen carefully and try to understand your perspectives, while fully explaining mine. We can resolve such disagreements or we can agree to disagree, so long as this enables your child’s therapeutic progress. If either parent decides that therapy should end, we ask that you allow the option of having a few closing sessions with your child to appropriately end the treatment relationship.If conflicts arise between parents, you understand and agree that our role is strictly limited to providing psychotherapy for the benefit of your child. This means, among other things, that you will treat anything said in session as confidential and you will not attempt to gain advantage in any legal proceeding from our involvement with your child. You agree that you will not involve Treehouse and its' clinicians in any legal dispute, especially a dispute concerning custody or visitation arrangements. You will not ask our clinicians to testify in court, either in person or by affidavit. You also agree to instruct your attorneys not to subpoena Treehouse and/or its' clinicians or to refer in any court filing to anything we have said or done.
If a court appoints an evaluator, mediator, or guardian ad litem, Treehouse will provide information as needed, if appropriate releases are signed or a court order is provided. Therapists are ethically bound not to give their opinion about either parent’s custody or visitation suitability. If, for any reason, Treehouse and its' clinicians are required to participate in a legal dispute, the party responsible for this participation agrees to reimburse the clinician for time spent testifying, being in attendance at hearings, or any case-related costs including phone calls and preparing emails to lawyers and parental parties. Additional fees will be incurred for preparing reports, telephoning, and travel time. It is highly advised you to review the financial policy.
Thank you for your understanding and cooperation. If you have any questions about the information contained in this contract, please discuss them with your clinician before your first session. Your signature indicates legally-binding agreement with the terms set forth in this contract.
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.
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.
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.
CONSENT TO COUPLES THERAPY
Relationship therapy works best when the focus of my work is on your relationship. When working with you, it is expressly understoodthat my patient is both your relationship and each of you as individuals. In order to maintain fidelity to both of you and to your relationship, I ask for your consent on the following agreements.
ConfidentialityAll information disclosed within sessions is confidential and may not be revealed to anyone without written permission except where disclosure is permitted or required by law. Those situations include but are not limited to: (a) when there is reasonable suspicion of abuse to a child or to a dependent or elder adult; (b) when the client communicates a threat of bodily injury to others; (c) when the client is suicidal; (d) when the client has been physically injured due to violence; (e) when disclosure is required pursuant to a legal proceeding.I receive occasional professional consultation. In such cases, neither your name nor any identifying information about you is revealed.
No Secrets PolicyWhen a couple enters into counseling, it is considered to be one unit. This means that my allegiance is to the couple “unit,” and not to either partner as individuals. I find this is particularly important in creating a space where both partners can feel safe. Therefore, I adhere to a strict “No Secrets” policy. This means that I will not hold secrets for either partner. This policy is intended to allow me to continue to treat the couple by preventing, to the extent possible, a conflict of interest to arise where an individual’s interests may not be consistent with the interests of the unit being treated.
On occasion during the counseling process, individual partners may be seen for an individual counseling session. In this case, the individual session is still considered as part of the couple’s counseling relationship. Information disclosed during individual sessions may be relevant or even essential to the proper treatment of the couple. If an individual chooses to share such information with me, I will offer the individual every opportunity to disclose the relevant information and will provide guidance in this process. If the individual refuses to disclose this information within the couple’s session, I may determine that it is necessary to discontinue the counseling relationship with the couple. If there is information that an individual desires to address within a context of individual confidentiality, I will be happy to provide referrals to therapists who can provide concurrent individual therapy. This policy is intended to maintain the integrity of the couples/marital counseling relationship.
Court Proceedings/Subpoena of RecordsIt is understood that the purpose of marital/couples therapy is for the amelioration of distress within a relationship. Therefore, if both partners request services with a couples therapist, they are expected not to use the information given to the therapist during the therapy process against theother party in a judicial setting of any kind, be it civil, criminal, or circuit. Likewise, neither party shall for any reason attempt to subpoena the therapist's testimony or records to be presented in a deposition or court hearing of any kind for any reason, such as a divorce case.
Release of RecordsBoth partners must provide their consent to release marital/couples counseling records. If one partner does not provide consent, records will not be released.
Course of TreatmentThe continued participation by each person is voluntary. Either participant may suspend or terminate the therapy at her or his individual request.
I certify by my signature below represents both parties and that we have read, fully understand, and agree to abide by the stated policies.
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 havebeen seen for 8 sessions or longer.
Court AppearanceClients 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/hourPhone calls $220/hourDepositions $250/hourEmail or written letters $200/hourTime required for being present at court and giving testimony $250/hourMileage $0.54/mileTime away from office due to depositions or testimony $220/hourFiling a document with the court $100 (Plus court fees)The minimum charge for a court appearance $1500Any 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.