Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the patient is the holder of the psychotherapist- patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $225.00 per 50-minute session. Sessions longer than 50- minutes are charged for the additional time pro rata. Couples sessions are $250.00 for 60-minute session. Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient or Patient’s guardian(s) for purposes other than scheduling sessions. Patient (or responsible party) is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than five minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patient (or responsible party) is expected to pay for services at the time services are rendered. Insurance Patient (or responsible party) is responsible for any and all fees. Therapist a considered an “Out of Network Provider.” Upon request client will receive a monthly statement for possible reimbursement by his/her insurance company, managed care organization, or any other third-party payer. Patient (or responsible party) is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments and deductibles. Cancellation Policy Patient (or re...
Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Informed Consent By signing below, each Patient acknowledges that he/she has reviewed and fully understands the terms and conditions of this Agreement. Patient has discussed such terms and conditions with Therapist, and has had any questions with regard to its terms and conditions answered to Patient’s satisfaction. Patient agrees to abide by the terms and conditions of this Agreement and consents to participate in psychotherapy with Therapist. Moreover, Patient agrees to hold Therapist free and harmless from any claims, demands, or suits for damages from any injury or complications whatsoever, save negligence, that may result from such treatment. NOTICE TO CLIENTS The Board of Behavioral Sciences receives and responds to complaints regarding services provided within the scope of practice of (marriage and family therapists, licensed educational psychologists, clinical social workers, or professional clinical counselors). You may contact the board online at xxx.xxx.xx.xxx, or by calling (000) 000-0000. Authorization to Treat Minor The below signed parent(s) authorize Therapist to treat their child(ren) listed below:
Patient Privilege. The information disclosed by Client, as well as any records created, is subject to the psychotherapist-client privilege. The psychotherapist-client privilege results from the special relationship between Therapist and Client in the eyes of the law. It is akin to the attorney-client privilege or the doctor-client privilege. Typically, the patient is the holder of the psychotherapist- patient privilege. If Kairos Counseling Inc or Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Kairos Counseling Inc. and Therapist will assert the psychotherapist-patient privilege on Client’s behalf until instructed, in writing, to do otherwise by Client or Client’s representative. Client should be aware that he/she might be waiving the psychotherapist-client privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Client should address any concerns he/she might have regarding the psychotherapist-client privilege with his/her attorney. F ee and Fee Arrangements The usual and customary fee for service is $160 per 50-minute session. Sessions longer than 50- minutes are charged for the additional time pro rata. Kairos Counseling Inc. reserves the right to periodically adjust this fee. Client will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. The agreed upon fee between Kairos Counseling Inc. and Client is $160/hr. Kairos Counseling Inc. reserves the right to periodically adjust fee. Client will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Client for purposes other than scheduling sessions. Client is responsible for payment for any telephone calls at the same rate as a regular therapy session. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Client’s request and with Client’s advance written authorization. Client is responsible for payment for any telephone calls. Therapist may also engage in correspondence with third parties in the form of letters, emails, text messages, and voicemails. Client is also responsible for the therapist time spent on such communication on the same rate charged for therapy sessions. Clients are expected to pay for services at the time services are rendered. Kairos Counseling Inc. accepts cash and...
Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. Typically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $175 per 55-minute session. This fee is increased by $5 on the first of each year. At times, Therapist may suggest sessions of other lengths, and if accepted by Patient, these are billed at $235 for 85 minutes or $290 for 115 minutes. Special extended sessions beyond two hours are billed at the hourly session fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. If Patient wishes to use insurance benefits, a separate insurance fee consent will outline the fees specific to the individual’s plan. If Patient does not wish to use insurance benefits, Patient may choose to begin using benefits, if available, at any time in the future. Benefits utilization will begin at the time Therapist is provided policy information; no back-billing will be done. Therapist will bill primary insurance when the therapist is contracted with the insurance panel. For out of network and secondary insurance benefits, Therapist will provide a superbill that Patient can use for reimbursement. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient’s request and with Patient’s ad...
Patient Privilege. Your information and records are subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between myself and you in the eyes of the law. It is akin to the attorney-client privilege or the doctor- patient privilege. Typically, you are the holder of the psychotherapist-patient privilege. If I received a subpoena for records, deposition testimony, or testimony in a court of law I will assert the psychotherapist-patient privilege on your behalf until instructed in writing to do otherwise by you or your representative. Please be aware that you might be waiving the psychotherapist-patient privilege if you make your mental or emotional state an issue in a legal proceeding. Please address any concerns you might have regarding the psychotherapist-patient privilege with your attorney. Fees and Sliding Scale The fee for individual therapy is $150.00 per 50-minute session. For couples, families and parent conferences, fee is 175.00 for a 60-minute session. I maintain a limited number of appointment times for patients needing a reduced fee. Sliding scale fees are determined upon appointment availability, income and means to pay. Sliding scale fees will be reviewed regularly with periodic increases. Active credit cards must remain on file, however I accept payment by cash or check at the beginning of each session. Please make checks payable to Xx. Xxxxx Xxxxxxxx. There is an ATM located in this complex, so please come to session prepared to pay for your session. I do request a credit card number to be kept on file, should you miss an appointment without cancelling, or forget to bring payment at the time of session. Credit card information is securely stored in your confidential file along with your signed payment authorization form located in this packet.
Patient Privilege. The information disclosed by patients, as well as any records created, is subject to the psychotherapist – patient privilege. The psychotherapist– patient privilege results from the special relationship between therapist and patient in the eyes of the law. It is akin to the attorney– patient privilege or the doctor– patient privilege. Typically, the patient is the holder of the psychotherapist – patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist – patient privilege on Patient’s behalf until instructed, to do otherwise by Patient or Patient’s representative. Patient should be aware that she/he might be waving the psychotherapist– Patient privilege if she/he makes mental or emotional state an issue in a legal proceeding. Patient should address any concerns she/he might have regarding the psychotherapist – patient privilege with his/her attorney. There are however exceptions to privilege, which includes, but is not limited to: 1) a patient is a danger to self or others, 2) a judge issues a court order, 3) a patient introduces his/her mental condition into testimony, 4) someone is under 16 and victim of a crime, 5) the court is using therapy to establish sanity or competence to stand trial, 6) a patient has treated information as though it is not confidential, 7) information pertaining to the Patriot Act, 8) information listed on the health insurance claim form or child abuse report, 9) a patient complaint or lawsuit against me.
Patient Privilege. All Patients over the age of 13, unless otherwise designated by law, hold their own privilege, or the right to choose whether or not to release confidential information about their treatment. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient‟s behalf until instructed, in writing, to do otherwise by Patient or Patient‟s representative. Patient should be aware that he/she might be waiving the psychotherapist- patient privilege with his/her attorney. Patient should also be aware that a court judge may also waive this privilege in certain cases. Fee and Fee Arrangements The usual and customary fee for service is $110.00 per 45 minute session. Sessions longer than 45 minutes are charged for the additional time pro rata. Therapist reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment at least 30 days in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is _. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than fifteen minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient‟s request and with Patient‟s advance written authorization. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than fifteen minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash and checks.
Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist- patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. If Therapist receives a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by a person with the authority to waive the privilege on Patient’s behalf. When a patient is a minor child, the holder of the psychotherapist-patient privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-patient privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-patient privilege with his/her attorney. Patient, or Representative, should be aware that he/she might be waiving the psychotherapist- patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Professional Consultation Professional consultation is an important component of a healthy psychotherapy practice. Therapist regularly participates in clinical, ethical, and legal consultation with appropriate professionals. Therapist will not reveal any identifying information regarding Patient or Patient’s family members or caregivers.
Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $145 per 55-minute session. This fee is increased by $5 on the first of each year. At times, Therapist may suggest sessions of other lengths, and if accepted by Patient, these are billed at $205 for 85 minutes or $255 for 115 minutes. Special extended sessions beyond two hours are billed at the hourly session fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. If Patient wishes to use insurance benefits, a separate insurance fee consent will outline the fees specific to the individual’s plan. If Patient does not wish to use insurance benefits, Patient may choose to begin using benefits, if available, at any time in the future. Benefits utilization will begin at the time Therapist is provided policy information. Therapist will xxxx primary insurance when the therapist is contracted with the insurance panel. For out of network and secondary insurance benefits, Therapist will provide a superbill that Patient can use for reimbursement. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third par...
Patient Privilege. The information disclosed by client, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and client in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. If I received a subpoena for records, deposition testimony, or testimony in a court of law, I will assert the psychotherapist-patient privilege on client’s behalf until instructed, in writing, to do otherwise by client or client’s representative. Client should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Client should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. _______ Initial Notice of Privacy Practices: This practice is HIPAA compliant. Please indicate that you have received and signed the document named “Notice of Privacy Practices.” _______ Initial
