Admin Forms-archive Name Email Date of Birth Address Phone Number (Home) Okay to leave message? Yes No Cell Number Okay to leave message? Yes No Last 4 digits of your social secruity Emergency Contact/Relationship/Phone Psychiatrist Name/Phone Priamary Physician/Name/Phone Office Policies - Please read and complete 1. Initial Evaluation - The initial evaluation will be for consultation and not for treatment. I will review your history and pinpoint the kinds of problems you want help with. This will require at least two sessions. If I feel that I have the tools and skills to help you, I will share my treatment recommendations with you. This will probably involve talk therapy (CBT) along with psychotherapy homework assignments between sessions. In some cases, medications might be helpful as well. In such a case I will refer you to a psychiatrist. If you decide that you would like to work with me along the lines that I suggest, I will be pleased to accept you as my client at that time. If I feel taht I do not have the tools to help you, or if the treatment methods I suggest do not appeal to you, you will be free to explore other treatment options and you will not become my client. If you pursue treatment with another therapist, I will be happy to share the results of my evaluation with that therapist if you provide written permission for me to do so. I agree Needs discussion 2. Scheduling - I accept phone calls for initial session scheduling, then I typically schedule ongoing appointments at the end of each session. For online sessions please schedule through VirtualTherapistNetwork.com It is possible and may be a good idea to schedule a couple appointments at a time so as to claim convenient time slots. I agree Needs discussion 3. Length and frequency of sessions - Clients who are using Health Insureance, sessions are scheduled for 50 minutes. Private clients are welcome to request 90 minute sessions that I find to be more productive, my hourly rate will be increased by one half. Initially I recommend weekly sessions, then as you are showing mastery of therapeutic techniques, sessions will move to every other week. I agree Needs discussion 4. Psychotherapy Homework - I will ask you to do homework between sessions, including written assignments. These assignments can significantly increase progress toward your goals. The fact is that I have rarely had successful results when the client has refused to do homework. I agree Needs discussion 5. Insurance and Billing - Clients pay for each session at that session. My fee is $125 per 50 minute hour. I provide a receipt for all money received I would recommend that you keep your receipts to present to your insurance company if needed. If someone else, like a parent wants to pay for your treatment, that's fine, however they will have to pay you, so you can pay me at each session. I'm working for you, not someone else. If I do not have a contract with your insurance, it will be your responsibility to submit forms to your company for reimbursement. It might be a good idea to call them and ask questions like; "How much will I be reimbursed for each therapy session? How many sessions will I be covered for?" If your insurancee company wants me to complete any forms about the treatment, I will be happy to do so. If an extensive amount of time is required (greater than 60 minutes) I will charge you for this time at the rate of $25. I agree Needs discussion 6. Late Cancel/No Show Policy - I prefer one-week notice to cancel a session, but require a 24-hour notification to cancel a session for any reason. If you provide this advance notification, there will be no charge. If you do not provide me with a 24-hour notification, or you do not come to your session, there will be a $50 missed session fee. If I can fill your slot at the last minute, or move your session to another time open in that day, there will be no fee. I agree Needs discussion 7. Phone Consultations - In certain cases, you may need to call me if a problem develops between sessions. I encourage you to make a note of the details of the problem to discuss at our next scheduled session. If a phone consultation is needed, I would appreciate that it is kept to 10 minutes, longer calls will be charged to you at the amount of $25/quarter hour. Although my phone is turned on 24/7, I do not provide emergency services. If you believe you are having a life-threatening emergency and I am not available by phone, you should go to the nearest emergency room or call 911. I agree Needs discussion 8. HIPPA Notification - The Health Insurance Portability and Accountability Act (HIPPA), which was estabiished to protect your privacy, now requires that I provide you with the following information and obtain your signature confirming that you have read and understand: 1. The nature of the records I keep. 2. The manner in which those records are stored to protect your privacy. 3. The circumstances under which anyone other than my self would have access to any of the information contained in these records. "RECORDS": "Records" refers to records that include your name, address, telephone numbers, fee, dates of serssions and cancellations, charges, payments and balances, and other documentation of sessions. If an insurance companty is involved, these records will include required diagnostic and procedure codes. Before I provide any information to a third party I will discuss the request with you to be sure you wish me to honor it. Records are securely stored in a HIPPA compliant record under lock and key in my office or home office. Your privacy with regard to these records is protected by law, although records can be subpoenaed by a court of law, and I could be required to provide the records or information in them. "PSYCHOTHERAPY NOTES": "Psychotherapy Notes" are my private notes taken abut the sessions. Such notes are now far more protected by law from any third party intrusion than are the "Records" listed above. They are considered "privileged", meaning that I can legally refuse to turn them over to anyone, including you or a court of law, except under a few specified and extreme circumstances. I store my "Psychotherapy Notes" in a separate section of the chart from the "Records", and they have no identifying data on the except your initials. Periodically, when therapists meet with supervisors or trusted colleagues to further understanding of their work, portions of these notes may be discussed, taking care to protect your privacy by excluding any identifying information and disguising your identy. I agree Needs discussion Please sign and date - Your typed name/signature indicates your understanding and agreement to the HIPPA Notification Submit Δ Like this:Like Loading...
Susan R. Hansen 