| Overview of Child and Adolescent Treatment Process |
Welcome to our practice. This document contains important information about my professional
services and business policies. It also contains summary information about the Health Insurance
Portability and Accountability Act (HIPAA), a new federal law that provides new privacy protections and
new patient rights with regard to the use and disclosure of your Protected Health Information (PHI)
used for the purpose of treatment, payment, and health care operations. HIPAA requires that I
provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment,
payment and health care operations. The Notice, which is attached to this Agreement, explains
HIPAA and its application to your personal health information in greater detail. The law requires that I
obtain your signature acknowledging that I have provided you with this information at the end of this
session. Although these documents are long and sometimes complex, it is very important that you
read them carefully before our next appointment. We can discuss any questions you have about the
procedures at that time. When you sign this document, it will also represent an agreement between
us. You may revoke this Agreement in writing at any time. That revocation will be binding on me
unless I have taken action in reliance on it; if there are obligations imposed on me by your health
insurer in order to process or substantiate claims made under your policy; or if you have not satisfied
any financial obligations you have incurred.
PSYCHOLOGICAL SERVICES
Child and adolescent therapy is not easily described in general statements. It varies depending on
the personalities of the psychologist and patient, and the particular problems the child is
experiencing. There are many different methods I may use to deal with the problems that you hope to
address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on
your part and your child’s part. In order for the therapy to be most successful, you and your child will
have to work on things we talk about both during our sessions and at home.
Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant
aspects of your life, you or your child may experience uncomfortable feelings like sadness, guilt,
anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been
shown to have many benefits. Therapy often leads to better relationships, solutions to specific
problems, and significant reductions in feelings of distress. But there are no guarantees of what you
will experience.
Our first few sessions will involve an evaluation of your child’s needs. By the end of the evaluation, I
will be able to offer you some first impressions of what our work will include and a treatment plan to
follow, if you decide to continue with therapy. You should evaluate this information along with your
own opinions of whether you feel comfortable working with me. Therapy involves a large
commitment of time, money, and energy, so you should be very careful about the therapist you
select. If you have questions about my procedures, we should discuss them whenever they arise. If
your doubts persist, I will be happy to help you set up a meeting with another mental health
professional for a second opinion.
MEETINGS
I normally conduct an evaluation that will last from 2 to 4 sessions. During this time, we can both
decide if I am the best person to provide the services you need in order to meet your treatment goals.
If psychotherapy is begun, I will usually schedule one 50-minute session (one appointment hour of
50 minutes duration) per week at a time we agree on, although some sessions may be longer or
more frequent. Once an appointment hour is scheduled, you will be expected to pay for it unless you
provide 24 hours [1 day] advance notice of cancellation [unless we both agree that you were unable
to attend due to circumstances beyond your control]. It is important to note that insurance companies
do not provide reimbursement for cancelled sessions. [If it is possible, I will try to find another time to
reschedule the appointment.]
PROFESSIONAL FEES
My hourly fee is $120. In addition to weekly appointments, I charge this amount for other professional
services you may need, though I will break down the hourly cost if I work for periods of less than one
hour. Other services include report writing, telephone conversations lasting longer than 10 minutes,
consulting with other professionals with your permission, preparation of records or treatment
summaries, and the time spent performing any other service you may request of me. If you become
involved in legal proceedings that require my participation, you will be expected to pay for all of my
professional time, including preparation and transportation costs, even if I am called to testify by
another party. [Because of the difficulty of legal involvement, I charge $150 per hour for preparation
and attendance at any legal proceeding.]
CONTACTING ME
Due to my work schedule, I am often not immediately available by telephone. While I am usually in
my office between 9 AM and 5 PM, I probably will not answer the phone when I am with a patient.
When I am unavailable, my telephone is answered by an answering service my voice mail or by my
secretary [that I monitor frequently, or who knows where to reach me]. I will make every effort to return
your call on the same day you make it, with the exception of weekends and holidays. If you are
difficult to reach, please inform me of some times when you will be available. [In emergencies, you
can try me at 402-7959.] If you are unable to reach me and feel that you can’t wait for me to return
your call, contact your family physician or the nearest emergency room and ask for the psychologist
[psychiatrist] on call. If I will be unavailable for an extended time, I will provide you with the name of a
colleague to contact, if necessary.
LIMITS ON CONFIDENTIALITY
The law protects the privacy of all communications between a patient and a psychologist. In most
situations, I can only release information about your treatment to others if you sign a written
Authorization form that meets certain legal requirements imposed by HIPAA and/or Indiana law.
However, in the following situations, no authorization is required:
• I may occasionally find it helpful to consult other health and mental health professionals about
a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The
other professionals are also legally bound to keep the information confidential. If you don’t object, I
will not tell you about these consultations unless I feel that it is important to our work together. I will
note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s
Policies and Practices to Protect the Privacy of Your Health Information).
• You should be aware that I practice with other mental health professionals and that I employ
administrative staff. In most cases, I need to share protected information with these individuals for
both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of
the mental health professionals are bound by the same rules of confidentiality. All staff members
have been given training about protecting your privacy and have agreed not to release any
information outside of the practice without the permission of a professional staff member.
• Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in
this Agreement.
• If you are involved in a court proceeding and a request is made for information concerning the
professional services I provided to you, such information is protected by the psychologist-patient
privilege law. I cannot provide any information without your (or your legal representative’s) written
authorization, or a court order. If you are involved in or contemplating litigation, you should consult
with your attorney to determine whether a court would be likely to order me to disclose information.
• If a government agency is requesting the information for health oversight activities, I may be
required to provide it for them.
• To a coroner or medical examiner, in the performance of that individual’s duties.
• If a patient files a complaint or lawsuit against me, I may disclose relevant information
regarding that patient in order to defend myself.
There are some situations in which I am legally obligated to take actions, which I believe are
necessary to attempt to protect others from harm and I may have to reveal some information about a
patient’s treatment. These situations are unusual in my practice.
If I have reason to believe that a child is a victim of child abuse or neglect, the law requires that
I file a report with the appropriate government agency, usually the local child protection service. Once
such a report is filed, I may be required to provide additional information.
If I have reason to believe that someone is an endangered adult, the law requires that I file a
report with the appropriate government agency, usually the adult protective services unit. Once such
a report is filed, I may be required to provide additional information.
If a patient communicates an actual threat of physical violence against an identifiable victim, or
evidences conduct or makes statements indicating imminent danger that the patient will use
physical violence or other means to cause serious personal injury to others, I may be required to
disclose information in order to take protective actions. These actions may include notifying the
potential victim, contacting the police, or seeking hospitalization for the patient.
If a patient communicates an imminent threat of serious physical harm to him/herself, I may be
required to disclose information in order to take protective actions. These actions may include
initiating hospitalization or contacting family members or others who can assist in providing
protection.
If such a situation arises, I will make every effort to fully discuss it with you before taking any action
and I will limit my disclosure to what is necessary.
While this written summary of exceptions to confidentiality should prove helpful in informing you
about potential problems, it is important that we discuss any questions or concerns that you may
have now or in the future. The laws governing confidentiality can be quite complex, and I am not an
attorney. In situations where specific advice is required, formal legal advice may be needed.
PROFESSIONAL RECORDS
The laws and standards of my profession require that I keep Protected Health Information about you
in your Clinical Record. Except in unusual circumstances that that disclosure would physically
endanger you and/or others, you may examine and/or receive a copy of your Clinical Record, if you
request it in writing. Because these are professional records, they can be misinterpreted and/or
upsetting to untrained readers. For this reason, I recommend that you initially review them in my
presence, or have them forwarded to another mental health professional so you can discuss the
contents. [I am sometimes willing to conduct this review meeting without charge.] In most
circumstances, I am allowed to charge a copying fee of $.15 per page (and for certain other
expenses). If I refuse your request for access to your records, you have a right of review, which I will
discuss with you upon request.
You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two
sets of professional records. One set constitutes your Clinical Record. It includes information about
your reasons for seeking therapy, a description of the ways in which your problem impacts on your
life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your
medical and social history, your treatment history, any past treatment records that I receive from other
providers, reports of any professional consultations, your billing records, and any reports that have
been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances
that involve danger to yourself and others, you may examine and/or receive a copy of your Clinical
Record, if you request it in writing. Because these are professional records, they can be
misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially
review them in my presence, or have them forwarded to another mental health professional so you
can discuss the contents. [I am sometimes willing to conduct this review meeting without charge.] In
most circumstances, I am allowed to charge a copying fee of $.15 per page (and for certain other
expenses). If I refuse your request for access to your Clinical Records, you have a right of review,
which I will discuss with you upon request.
In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are
designed to assist me in providing you with the best treatment. While the contents of Psychotherapy
Notes vary from client to client, they can include the contents of our conversations, my analysis of
those conversations, and how they impact on your therapy. They also contain particularly sensitive
information that you may reveal to me that is not required to be included in your Clinical Record.
[They also include information from others provided to me confidentially.] These Psychotherapy
Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to
you and cannot be sent to anyone else, including insurance companies without your written, signed
Authorization. Insurance companies cannot require your authorization as a condition of coverage nor
penalize you in any way for your refusal to provide it.
PATIENT RIGHTS
HIPAA provides you with several new or expanded rights with regard to your Clinical Records and
disclosures of protected health information. These rights include requesting that I amend your
record; requesting restrictions on what information from your Clinical Records is disclosed to others;
requesting an accounting of most disclosures of protected health information that you have neither
consented to nor authorized; determining the location to which protected information disclosures are
sent; having any complaints you make about my policies and procedures recorded in your records;
and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and
procedures. I am happy to discuss any of these rights with you.
MINORS & PARENTS
Patients under 18 years of age who are not emancipated and their parents should be aware that the
law may allow parents to examine their child’s treatment records. Because privacy in psychotherapy
is often crucial to successful progress, particularly with teenagers, it is sometimes my policy to
request an agreement from parents that they consent to give up their access to their child’s records.
If they agree, during treatment, I will provide them only with general information about the progress of
the child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with
a summary of their child’s treatment when it is complete. Any other communication will require the
child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which
case, I will notify the parents of my concern. Before giving parents any information, I will discuss the
matter with the child, if possible, and do my best to handle any objections he/she may have.
BILLING AND PAYMENTS
You will be expected to pay for each session at the time it is held, unless we agree. Payment
schedules for other professional services will be agreed to when they are requested. [In
circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or
payment installment plan.]
If your account has not been paid for more than 60 days and arrangements for payment have not
been agreed upon, I have the option of using legal means to secure the payment. This may involve
hiring a collection agency or going through small claims court which will require me to disclose
otherwise confidential information. In most collection situations, the only information I release
regarding a patient’s treatment is his/her name, the nature of services provided, and the amount
due. [If such legal action is necessary, its costs will be included in the claim.]
INSURANCE REIMBURSEMENT
Our office does not accept reimbursement through insurance companies. Payment is expected by
the client at the time of services. If you need information to submit your own claim, please let us
know and we will give you what ever information we can. Then you can submit that information to
your insurance carrier yourself. Our office has no control over what your insurance company may do
with that information of if they will pay your claim
services and business policies. It also contains summary information about the Health Insurance
Portability and Accountability Act (HIPAA), a new federal law that provides new privacy protections and
new patient rights with regard to the use and disclosure of your Protected Health Information (PHI)
used for the purpose of treatment, payment, and health care operations. HIPAA requires that I
provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment,
payment and health care operations. The Notice, which is attached to this Agreement, explains
HIPAA and its application to your personal health information in greater detail. The law requires that I
obtain your signature acknowledging that I have provided you with this information at the end of this
session. Although these documents are long and sometimes complex, it is very important that you
read them carefully before our next appointment. We can discuss any questions you have about the
procedures at that time. When you sign this document, it will also represent an agreement between
us. You may revoke this Agreement in writing at any time. That revocation will be binding on me
unless I have taken action in reliance on it; if there are obligations imposed on me by your health
insurer in order to process or substantiate claims made under your policy; or if you have not satisfied
any financial obligations you have incurred.
PSYCHOLOGICAL SERVICES
Child and adolescent therapy is not easily described in general statements. It varies depending on
the personalities of the psychologist and patient, and the particular problems the child is
experiencing. There are many different methods I may use to deal with the problems that you hope to
address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on
your part and your child’s part. In order for the therapy to be most successful, you and your child will
have to work on things we talk about both during our sessions and at home.
Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant
aspects of your life, you or your child may experience uncomfortable feelings like sadness, guilt,
anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been
shown to have many benefits. Therapy often leads to better relationships, solutions to specific
problems, and significant reductions in feelings of distress. But there are no guarantees of what you
will experience.
Our first few sessions will involve an evaluation of your child’s needs. By the end of the evaluation, I
will be able to offer you some first impressions of what our work will include and a treatment plan to
follow, if you decide to continue with therapy. You should evaluate this information along with your
own opinions of whether you feel comfortable working with me. Therapy involves a large
commitment of time, money, and energy, so you should be very careful about the therapist you
select. If you have questions about my procedures, we should discuss them whenever they arise. If
your doubts persist, I will be happy to help you set up a meeting with another mental health
professional for a second opinion.
MEETINGS
I normally conduct an evaluation that will last from 2 to 4 sessions. During this time, we can both
decide if I am the best person to provide the services you need in order to meet your treatment goals.
If psychotherapy is begun, I will usually schedule one 50-minute session (one appointment hour of
50 minutes duration) per week at a time we agree on, although some sessions may be longer or
more frequent. Once an appointment hour is scheduled, you will be expected to pay for it unless you
provide 24 hours [1 day] advance notice of cancellation [unless we both agree that you were unable
to attend due to circumstances beyond your control]. It is important to note that insurance companies
do not provide reimbursement for cancelled sessions. [If it is possible, I will try to find another time to
reschedule the appointment.]
PROFESSIONAL FEES
My hourly fee is $120. In addition to weekly appointments, I charge this amount for other professional
services you may need, though I will break down the hourly cost if I work for periods of less than one
hour. Other services include report writing, telephone conversations lasting longer than 10 minutes,
consulting with other professionals with your permission, preparation of records or treatment
summaries, and the time spent performing any other service you may request of me. If you become
involved in legal proceedings that require my participation, you will be expected to pay for all of my
professional time, including preparation and transportation costs, even if I am called to testify by
another party. [Because of the difficulty of legal involvement, I charge $150 per hour for preparation
and attendance at any legal proceeding.]
CONTACTING ME
Due to my work schedule, I am often not immediately available by telephone. While I am usually in
my office between 9 AM and 5 PM, I probably will not answer the phone when I am with a patient.
When I am unavailable, my telephone is answered by an answering service my voice mail or by my
secretary [that I monitor frequently, or who knows where to reach me]. I will make every effort to return
your call on the same day you make it, with the exception of weekends and holidays. If you are
difficult to reach, please inform me of some times when you will be available. [In emergencies, you
can try me at 402-7959.] If you are unable to reach me and feel that you can’t wait for me to return
your call, contact your family physician or the nearest emergency room and ask for the psychologist
[psychiatrist] on call. If I will be unavailable for an extended time, I will provide you with the name of a
colleague to contact, if necessary.
LIMITS ON CONFIDENTIALITY
The law protects the privacy of all communications between a patient and a psychologist. In most
situations, I can only release information about your treatment to others if you sign a written
Authorization form that meets certain legal requirements imposed by HIPAA and/or Indiana law.
However, in the following situations, no authorization is required:
• I may occasionally find it helpful to consult other health and mental health professionals about
a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The
other professionals are also legally bound to keep the information confidential. If you don’t object, I
will not tell you about these consultations unless I feel that it is important to our work together. I will
note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s
Policies and Practices to Protect the Privacy of Your Health Information).
• You should be aware that I practice with other mental health professionals and that I employ
administrative staff. In most cases, I need to share protected information with these individuals for
both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of
the mental health professionals are bound by the same rules of confidentiality. All staff members
have been given training about protecting your privacy and have agreed not to release any
information outside of the practice without the permission of a professional staff member.
• Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in
this Agreement.
• If you are involved in a court proceeding and a request is made for information concerning the
professional services I provided to you, such information is protected by the psychologist-patient
privilege law. I cannot provide any information without your (or your legal representative’s) written
authorization, or a court order. If you are involved in or contemplating litigation, you should consult
with your attorney to determine whether a court would be likely to order me to disclose information.
• If a government agency is requesting the information for health oversight activities, I may be
required to provide it for them.
• To a coroner or medical examiner, in the performance of that individual’s duties.
• If a patient files a complaint or lawsuit against me, I may disclose relevant information
regarding that patient in order to defend myself.
There are some situations in which I am legally obligated to take actions, which I believe are
necessary to attempt to protect others from harm and I may have to reveal some information about a
patient’s treatment. These situations are unusual in my practice.
If I have reason to believe that a child is a victim of child abuse or neglect, the law requires that
I file a report with the appropriate government agency, usually the local child protection service. Once
such a report is filed, I may be required to provide additional information.
If I have reason to believe that someone is an endangered adult, the law requires that I file a
report with the appropriate government agency, usually the adult protective services unit. Once such
a report is filed, I may be required to provide additional information.
If a patient communicates an actual threat of physical violence against an identifiable victim, or
evidences conduct or makes statements indicating imminent danger that the patient will use
physical violence or other means to cause serious personal injury to others, I may be required to
disclose information in order to take protective actions. These actions may include notifying the
potential victim, contacting the police, or seeking hospitalization for the patient.
If a patient communicates an imminent threat of serious physical harm to him/herself, I may be
required to disclose information in order to take protective actions. These actions may include
initiating hospitalization or contacting family members or others who can assist in providing
protection.
If such a situation arises, I will make every effort to fully discuss it with you before taking any action
and I will limit my disclosure to what is necessary.
While this written summary of exceptions to confidentiality should prove helpful in informing you
about potential problems, it is important that we discuss any questions or concerns that you may
have now or in the future. The laws governing confidentiality can be quite complex, and I am not an
attorney. In situations where specific advice is required, formal legal advice may be needed.
PROFESSIONAL RECORDS
The laws and standards of my profession require that I keep Protected Health Information about you
in your Clinical Record. Except in unusual circumstances that that disclosure would physically
endanger you and/or others, you may examine and/or receive a copy of your Clinical Record, if you
request it in writing. Because these are professional records, they can be misinterpreted and/or
upsetting to untrained readers. For this reason, I recommend that you initially review them in my
presence, or have them forwarded to another mental health professional so you can discuss the
contents. [I am sometimes willing to conduct this review meeting without charge.] In most
circumstances, I am allowed to charge a copying fee of $.15 per page (and for certain other
expenses). If I refuse your request for access to your records, you have a right of review, which I will
discuss with you upon request.
You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two
sets of professional records. One set constitutes your Clinical Record. It includes information about
your reasons for seeking therapy, a description of the ways in which your problem impacts on your
life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your
medical and social history, your treatment history, any past treatment records that I receive from other
providers, reports of any professional consultations, your billing records, and any reports that have
been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances
that involve danger to yourself and others, you may examine and/or receive a copy of your Clinical
Record, if you request it in writing. Because these are professional records, they can be
misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially
review them in my presence, or have them forwarded to another mental health professional so you
can discuss the contents. [I am sometimes willing to conduct this review meeting without charge.] In
most circumstances, I am allowed to charge a copying fee of $.15 per page (and for certain other
expenses). If I refuse your request for access to your Clinical Records, you have a right of review,
which I will discuss with you upon request.
In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are
designed to assist me in providing you with the best treatment. While the contents of Psychotherapy
Notes vary from client to client, they can include the contents of our conversations, my analysis of
those conversations, and how they impact on your therapy. They also contain particularly sensitive
information that you may reveal to me that is not required to be included in your Clinical Record.
[They also include information from others provided to me confidentially.] These Psychotherapy
Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to
you and cannot be sent to anyone else, including insurance companies without your written, signed
Authorization. Insurance companies cannot require your authorization as a condition of coverage nor
penalize you in any way for your refusal to provide it.
PATIENT RIGHTS
HIPAA provides you with several new or expanded rights with regard to your Clinical Records and
disclosures of protected health information. These rights include requesting that I amend your
record; requesting restrictions on what information from your Clinical Records is disclosed to others;
requesting an accounting of most disclosures of protected health information that you have neither
consented to nor authorized; determining the location to which protected information disclosures are
sent; having any complaints you make about my policies and procedures recorded in your records;
and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and
procedures. I am happy to discuss any of these rights with you.
MINORS & PARENTS
Patients under 18 years of age who are not emancipated and their parents should be aware that the
law may allow parents to examine their child’s treatment records. Because privacy in psychotherapy
is often crucial to successful progress, particularly with teenagers, it is sometimes my policy to
request an agreement from parents that they consent to give up their access to their child’s records.
If they agree, during treatment, I will provide them only with general information about the progress of
the child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with
a summary of their child’s treatment when it is complete. Any other communication will require the
child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which
case, I will notify the parents of my concern. Before giving parents any information, I will discuss the
matter with the child, if possible, and do my best to handle any objections he/she may have.
BILLING AND PAYMENTS
You will be expected to pay for each session at the time it is held, unless we agree. Payment
schedules for other professional services will be agreed to when they are requested. [In
circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or
payment installment plan.]
If your account has not been paid for more than 60 days and arrangements for payment have not
been agreed upon, I have the option of using legal means to secure the payment. This may involve
hiring a collection agency or going through small claims court which will require me to disclose
otherwise confidential information. In most collection situations, the only information I release
regarding a patient’s treatment is his/her name, the nature of services provided, and the amount
due. [If such legal action is necessary, its costs will be included in the claim.]
INSURANCE REIMBURSEMENT
Our office does not accept reimbursement through insurance companies. Payment is expected by
the client at the time of services. If you need information to submit your own claim, please let us
know and we will give you what ever information we can. Then you can submit that information to
your insurance carrier yourself. Our office has no control over what your insurance company may do
with that information of if they will pay your claim
Downloadable Forms
 |
| |
 |
| |
 |
| |
 |
| |
 |
Legalshrink.com
David Lombard, Ph.D
Licensed Clinical Psychologist
260-459-2900
Lombard@legalshrink.com
David Lombard, Ph.D
Licensed Clinical Psychologist
260-459-2900
Lombard@legalshrink.com