PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT/CONSENT FOR TREATMENT
 

Welcome to Edwards Psychological Associates – we look forward to working with you. This document contains important information about our services and business policies. Please feel free to ask questions about this information before signing at the end of the document.

 

PSYCHOLOGICAL SERVICES

There is no “one way” to practice therapy or address specific concerns – we use evidence-based practices and are flexible in our approach. We welcome feedback as you go through the therapy process.

 

MEETINGS

We typically consider the first 1-4 sessions to be an “evaluation period.” During this time, you and your therapist can determine if she is the best person to provide the services you need in order to meet your treatment goals. If you decide not to work together, your therapist will make recommendations and/or provide referrals to other professionals as needed. If you decide to continue with therapy then you and your therapist will clarify an initial treatment plan, including how often to meet.

 

CANCELLATION POLICY

Once an appointment is scheduled, you will be expected to pay for it unless you provide 24 business hours advance notice of cancellation. Please be prepared to pay for the session even if you reschedule for that same week. If you need to cancel a Monday appointment, contact your therapist on the previous Friday to avoid being charged. It is important to note that insurance companies do not provide reimbursement for canceled or missed sessions.    

 

PROFESSIONAL FEES

The fee for the intake appointment (i.e., first session) range from $300-$425, which includes a clinical interview and consultation. The individual session fee is between $170-$290 (depending on which therapist you see) for each subsequent 45-50-minute psychotherapy session. Rates increase annually. Please note that these fees also apply to phone calls or other clinical time (i.e., providing documentation that you request). If you become involved in legal proceedings that require our participation, you will be expected to pay for all professional time at an hourly rate of $350, including preparation and transportation costs, even if we are called to testify by another party.

 

GOOD FAITH ESTIMATE

You have the right to receive a “Good Faith Estimate” (GFE) explaining how much your medical care is anticipated to cost. Under the law, health care providers will give patients who do not have insurance or who are choosing to not use insurance an estimate of the bill for services. You may request a Good Faith Estimate for the total expected cost of any non-emergency services. If you would like to receive a GFE, please let your therapist know and this will be provided to you in writing at least one day before your scheduled service and placed in your clinical file. If you receive a bill that is at least $400 more than your GFE, you can dispute the bill. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.

 

BILLING AND PAYMENTS

Payment is due at time of service and we require a credit card be kept on file for billing. We use the Square App to process card payments. Edwards Psych Associates is out-of-network for all insurance plans. We will provide you with a monthly statement of transactions including all of the information necessary for you to file a claim with your insurance company for out-of-network reimbursement, if you choose to do so. You should be aware that your contract with your health insurance company requires that your therapist provide a clinical diagnosis. 

 

CONTACT

You may contact Edwards Psych Associates by phone at any time. However, we only listen to voicemails and return calls during typical business hours, Monday-Friday, 9am to 5pm. We will make every effort to return your call within 48 hours, with the exception of weekends and holidays. If you are unable to reach your therapist and are experiencing a potentially life-threatening emergency, please call the GA Crisis and Access line 24 hours a day at 1.800.715.4225 or call 911 or proceed to your nearest emergency room.

You may also email or text regarding scheduling only. Emails and texts will only be viewed/read during business hours (Monday through Friday 9am to 5pm) and may not be used to address crises, communicate information related to personal and/or clinical issues, or to obtain treatment in any form. Information provided through electronic transmission, other than that pertaining to scheduling, will be placed into your clinical file and becomes a part of your confidential record. This type of communication should not be considered a secure form and the confidentiality of an electronic message cannot be guaranteed.

 

TERMINATION

Clinical services may be terminated under the following conditions:

• We agree that your treatment goals have been accomplished and there is no need for continued treatment.
• You wish to discontinue services for any reason.
• We believe another mental health provider or type of treatment would be more appropriate or that progress toward treatment goals has ceased. In this case, we will discuss relevant issues and come to a joint decision regarding termination of treatment and provide referrals.
• You do not adhere to treatment structure or do not follow through with essential recommendations made during treatment.
• You repeatedly miss or cancel sessions or do not schedule an appointment or make contact as previously planned. In such circumstances we will terminate services only after attempting to contact you without success.
   
  If you do not schedule an appointment for a consecutive 60-day period, then clinical services will be considered terminated and you will not be considered an active client.

 

MINORS & PARENTS

Clients under 18 years old and their parents/guardians should be aware that the law allows parents/guardians to examine their child’s treatment records unless the therapist believes that doing so would harm the child. Because privacy in therapy is often crucial to successful progress, particularly with children and teenagers, signatures below serve as agreement that you will give your child a degree of privacy in the relationship with his/her therapist and that you understand you will not be provided with specific details of what is discussed in therapy.

 As an alternate to full treatment record access, we will provide parents/guardians with general information about the progress of the child’s treatment and attendance at scheduled sessions. If requested, we are happy to provide parents/guardians with a summary of their child’s treatment when it is complete. During treatment, parents will be informed of any serious health or safety issues regarding likely risk to your child, with the understanding that the determination of risk will be made by the therapist. Before giving parents/guardians any information, we make every effort to first discuss the matter with the child and do our best to handle any objections he/she may have.

 
COUPLES & FAMILIES

In couple’s and family therapy the “client” is the couple/family and the emphasis of the work is on the couple/family as a unit. All participating members agree to share responsibility for the therapy process, including goal setting and termination. In order for any information to be released to a third party, both members of the couple/all adults must provide their written authorization - one member’s desire to have information released is not sufficient. If we decide that some individual sessions may help the process of the therapy, what you say in those individual sessions will be considered to be a part of the couple/family therapy (rather than separate individual therapy). Information discussed in couple’s/family therapy is for therapeutic purposes only and is not intended for use in any legal proceedings involving the partners or family members. Your signature below indicates agreement that our involvement will be strictly limited to that which will benefit you and your partner or family.

  
LIMITS OF CONFIDENTIALITY

The law protects the privacy of all communications between a client and a psychologist. This means that everything discussed in therapy is confidential and private, with the exceptions listed below. We can only share information about your treatment with others if you sign a written Release Form.

Your therapist is required to disclose information without your consent in the following situations:

• If there is reason to believe that a child, disabled adult, or elderly person (over 65) is currently being abused, neglected or exploited. We are required to report to the appropriate agency.
• If there is reason to believe that a client presents a serious danger of violence to him/herself or to another person, we are required to take protective actions. These actions may include notifying the potential victim, and/or contacting the police, and/or seeking hospitalization for the patient. 

If any of these situations arise, we will make every effort to fully discuss it with you before taking any action and will limit our disclosure to what is necessary.

Edwards Psychological Associates is a group practice. Please note that Dr. Lauren Edwards and any administrative personnel have access to information included in all files – this information will only be accessed for purposes of maintaining business and ethical standards. As a group we may discuss therapy cases for purposes of clinical consultation.

 

ADDITIONAL FORMS PROVIDED TO YOU
Your signature on this form also indicates that you have been provided with, read, and agree to the terms outlined in the Georgia Notice form (on the Edwards Psych Associates website).

 

YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS DOCUMENT AND AGREE TO ITS TERMS.