OFFICE POLICIES & GENERAL INFORMATION
AGREEMENT FOR PSYCHOTHERAPY SERVICES
Sarah Turner, Ph.D.
California License PSY17347
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your patient(s) written permission, except where disclosure is required by law.
When Disclosure Is Required By Law: Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent or elder abuse or neglect; where a patient presents a danger to self, to others, to property, or is gravely disabled.
When Disclosure May Be Required: Disclosure may be required pursuant to a legal proceeding. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by Dr. Turner. In couple and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. Dr. Turner will use her clinical judgment when revealing such information. Dr. Turner will not release records to any outside party unless she is authorized to do so by all adult family members who were part of the treatment.
Emergencies: If there is an emergency during our work together where Dr. Turner becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, she will do whatever she can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, she may also contact the person whose name you have provided as an Emergency Contact on the biographical sheet.
Health Insurance & Confidentiality of Records: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/EAP in order to process the claims. Please refer to the Federal Health Insurance Portability and Accountability Act (HIPAA) form on my website with regard to the use and disclosure of your Protected Health Information (PHI). Only the minimum necessary information will be communicated to the carrier. By signing this contract, you are consenting to a release of information about your case to your health plan for claims, certification and case management for the purposes of treatment and payment. Dr. Turner has no control or knowledge over what insurance companies do with the information she submits or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy or to future capacity to obtain health or life insurance.
I have reviewed and understand Dr. Turner’s HIPAA policies ________________________
Informed Consent for Telephone, Electronic, and Mail Contact: Ordinary privacy precautions such as voice scramblers, pin codes, voice mail boxes, and locked fax, mail, and computer rooms are by no means foolproof, so that your confidentiality is always compromised when communicating by electronic devices or mail. Nor is deletion or shredding of private material a totally safe means of disposal, so that you are always at risk of breaches in confidentiality when electronic or mail communication of any type is used for private information. Your use of such means of communication with Dr. Turner constitutes implied consent for reciprocal use of electronic and mail communication as well. By signing this contract, you agree to and understand the following:
1. Many people feel comfortable communicating via email, because they have installed programs designed to detect spyware, viruses, or other dangerous software. However, there is no guarantee that such programs will work 100%.
2. Sent and received emails are stored on both Dr. Turner’s and your computer until deleted. Dr. Turner may or may not delete such emails. Any saved emails will be kept in a password-protected account that only Dr. Turner has access to.
3. In addition, whenever you send an email, it is stored in cyberspace. It is possible for authorities to locate and read such emails under various circumstances. This is not a policy of Dr. Turner, but is due to the nature in which email is transmitted using the internet and other services or networks. For more information on this, please contact your Internet Service Provider or email service.
4. By singing below, I agree that I understand the disclosures listed above regarding communicating with Dr. Turner using email. I also agree that if I send an email to her and request a response via email, that I am willing to accept the above-stated risks. I also agree that I will not use email for emergencies.
Permission for Dr. Turner to initiate emails to you:
Sign below if you give your permission for Dr. Turner to initiate sending emails to you.
Print your email clearly:_____________________________________________________________
Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to, divorce and custody disputes, injuries, lawsuits, etc...), neither you (patient’s) nor your attorney’s, nor anyone else acting on your behalf will call on Dr. Turner to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.
Consultation: Dr. Turner consults regularly with other professionals regarding her patients; however, patient’s name or other identifying information is never mentioned. The patient’s identity remains completely anonymous, and confidentiality is fully maintained.
TELEPHONE & EMERGENCY PROCEDURES: If you need to contact Dr. Turner between sessions, you may contact her at 760-929-2737. If she is unavailable, your call will be returned as soon as possible. Dr. Turner checks her messages a few times a day, unless she is out of town. If an emergency situation arises, please indicate it clearly in your message. If you need to talk to someone immediately, you can call the crisis access line at 800-479-3339 or the Police (911).
PAYMENTS & INSURANCE REIMBURSEMENT: Patients are expected to pay the agreed upon fee of __________ at the beginning of each 45 minute session unless other arrangements have been made. Telephone conversations, report writing and reading, release of information, reading records, longer sessions, etc. will be charged at the same rate, unless indicated and agreed otherwise. If patients are utilizing insurance to pay for their treatment, they are responsible for any applicable deductibles and co-payments at the time of service. By signing this contract, you agree that if you have not obtained any necessary authorizations from your insurance, or are not eligible at the time services are rendered, you are responsible for payment even if the determination is made after the services are rendered. Patients who carry insurance should remember that professional services are rendered and charged to the patient and not to the insurance company. All payments are to be made in the form of cash, check or credit card (Note: a service fee will be added for credit card transactions) . If payment is not made, Dr. Turner reserves the right to utilize a collections agency for means of collecting the payment. If a payment by check results in insufficient funds a $50 fee will be assessed. Please notify Dr. Turner if any problem arises during the course of therapy regarding your ability to make timely payments.
MEDIATION & ARBITRATION: By signing this office policy contract, you are agreeing that all disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of Dr. Turner and patient(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in San Diego County, CA in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed. Lawsuits are something that no one anticipates and everyone hopes to avoid. The method of resolving disputes by arbitration is one of the fairest systems for both patients and psychotherapists. Arbitration agreements between health care providers and their patients have long been recognized and approved by the California courts. You may still call witnesses and present evidence. Each party selects an arbitrator (party arbitrators), who then select a third, neutral arbitrator. These three arbitrators hear the case. This agreement generally helps to limit the legal costs for both patients and psychotherapists. Further, both parties are spared some of the rigors of trial and the publicity that may accompany judicial proceedings. My goal, of course, is to provide medical care in such a way as to avoid any such dispute. I know that most problems begin with communication. Therefore, if you have any questions about your care, please ask. Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, Dr. Turner can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceeding shall be entitled to recover a reasonable sum as and for attorney’s. fees. In the case of arbitration, the arbitrator will determine that sum.
THE PROCESS OF THERAPY/EVALUATION: By signing this agreement you are authorizing and requesting that Dr. Turner carry out psychological examinations, treatment and/or diagnostic procedures that now or during the course of your care as a patient are advisable. Participation in therapy can result in a number of benefits, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. Dr. Turner will ask for your feedback and views on your therapy, its progress and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc... or experiencing anxiety, depression, insomnia, etc... Dr. Turner may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations which can cause you to feel very upset, angry, depressed, challenged or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, Dr. Turner is likely to draw on various psychological approaches according, in part, to the problem that is being treated and her assessment of what will best benefit you. These approaches include behavioral, cognitive-behavioral, psychodynamic, existential, system/family, developmental (adult, child, family), or psycho-educational.
Discussion of Treatment Plan: Within a reasonable period of time after the initiation of treatment, Dr. Turner will discuss with you (patient) her working understanding of the problem, treatment plan, therapeutic objectives and her view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, Dr. Turner.s expertise in employing them, or about the treatment plan, please ask and you with be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits. If you could benefit from any treatment that Dr. Turner does not provide, she has an ethical obligation to assist you in obtaining those treatments.
Termination: As set forth above, after the first couple of meetings, Dr. Turner will assess if she can be of benefit to you. Dr. Turner does not accept patients who, in her opinion, she cannot help. In such a case, she will give you a number of referrals that you can contact. If at any point during psychotherapy Dr. Turner assesses that she is not effective in helping you reach the therapeutic goals, she is obligated to discuss it with you and, if appropriate, to terminate treatment.
In such a case, she would give you a number of referrals that may be of help to you. If you request it and authorize it in writing, Dr. Turner will talk to the psychotherapist of your choice in order to help with the transition. If at any time you want another professional’s opinion or wish to consult with another therapist, Dr. Turner will assist you in finding someone qualified, and if she has your written consent, she will provide her or him with the essential information needed. You have the right to terminate therapy at any time. If you choose to do so, Dr. Turner will offer to provide you with names of other qualified professionals whose services you might prefer.
CANCELLATION POLICIES: Since scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours notice is required for rescheduling or canceling an appointment. You will be charged $100 for sessions missed without such notification. Most insurance companies do not reimburse for missed sessions.
I have read the above Agreement and Office Policies and General Information carefully; I understand them and agree to comply with them:
Signature of Patient/Legal Representative Print Name Date
Signature of Patient/Legal Representative Print Name Date
Please print out this form, fill it out and bring it to our first meeting. This will allow us more time to meet together, and it gives you more time to look over my policies and bring in any questions you might have regarding them. For your convenience, I have provided the form in both the PDF and MSWord format.