This will acquaint you with information relevant to your treatment, confidentiality and my office policies. I will answer any questions you have regarding any of these policies, and I will have a copy of this information for you.

Aims and Goals

The major goal is to help you identify and cope more efficiently with problems in daily living and to deal with inner conflicts which may disrupt your ability to function efficiently. This purpose is accomplished by:

• Increasing personal awareness
• Increasing personal responsibility and acceptance to make changes necessary to attain your goals.
• Identifying personal treatment goals.
• Promoting wholeness through psychiatric treatment and/or psychological and spiritual healing and growth.

You are responsible for providing necessary information to facilitate effective treatment. You are expected to play an active role in your treatment, including working with me to outline your treatment goals and assess your progress. There may also be negative consequences if you do not follow through with recommended treatment(s).

You may be asked to complete questionnaires or to do homework assignments. Your progress in therapy often depends much more on what you do between sessions that on what happens in the session.

Appointments

Appointments are usually scheduled for 45 minutes. Patients are generally seen weekly or more/less frequently as acuity dictates, and as you and I agree. You may discontinue treatment at any time, but please discuss any decisions with me first. In the event of an emergency, please contact me at my office number, 201-714-4948. If you are unable to reach me, you may call your primary care physician or the local emergency room, or a crisis hotline.

Confidentiality

Issues discussed in therapy are important, and are generally legally protected as both confidential and “privileged”. However, there are limits to the privilege of confidentiality.

These situations include:

1. Suspected abuse or neglect of a child, elderly person or a disabled person.

2. When your psychiatrist or therapist believes you are in danger of harming yourself or another person, or you are unable to care for yourself.

3. If you report that you intend to physically injure someone, the law requires your therapist to inform that person as well as the legal authorities.

4. If your psychiatrist or therapist is ordered by a court to release information as well as a part of a legal involvement in company litigation, etc.

5. When your insurance company is involved, e.g. in filing a claim, insurance audits, case review or appeals, etc.

6. In natural disasters whereby protected records may become exposed.

7. When otherwise required by law.

You  may be asked to sign a Release of Information so that your therapist may speak with other mental health professionals or to family members. Information disclosed will be the least amount necessary to achieve the desired purpose. Only information that is directly relevant to the purpose for which the disclosure is made will be revealed. I will have you fill out and sign a release for disclosures not falling into the mandatory situations above. The patient has the right to request a list of the disclosures of the patient’s/ client’s PHI (Private Health Information).

This excludes

1. Information prior to 4/14/03

2. To carry out our treatment, payment, or healthcare operations.

3. To individuals of their own PHI

4. Incident to a use or disclosure required by the privacy standard. Requests for an accounting of disclosure must be made in writing to your therapist.

1. Date

2. Name and address of person or entity that received disclosure

3. Brief description of information

4. Purpose.

Record Keeping

A clinical chart in maintained describing your condition and your treatment and progress in treatment, dates of and fees for sessions, and notes describing each therapy session. Your records will not be released without your written consent, unless in those situations as outlined in the Confidentiality section above. Medical records are locked and kept on site.

Fees

Fee for the initial visit are dependant upon your insurance carrier.

Payments

Payment is due at the time of the session unless other arrangements have been made. I will file your insurance claim, but you are responsible for deductibles, co-insurance, and co-payments. It is your responsibility to familiarize yourself with your insurance benefit.

Cancellations and Missed Appointments

You will be billed for a session that you cancel with less that 24 hours notice. You may leave messages 24 hours per day. You will be billed the full rate, not just a co-payment. Insurance companies generally do not reimburse for failed appointments.

Complaints

You have a right to have your complaints heard and resolved in a timely manner. If you have a complaint about your treatment, or any office policy, please inform me immediately and we will discuss the situation. If you do not feel the complaint has been resolved, you may also inform your insurance carrier and file a complaint if you so choose.