OUTPATIENT SERVICES CONTRACT
Welcome to my practice. I look forward to helping you reach your goals!  This document contains important information about my professional service and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us.

PSYCHOLOGICAL SERVICES
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and client and the particular problems you bring forward.  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. In order for the therapy to be most successful, you 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 may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. However, there are no guarantees of what you will experience.

Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include, 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 give you referrals for other mental health professionals for a second opinion.

MEETINGS
Our first appointment is an intake session where I gain a better understanding of your needs and goals. 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 53-minute session (one appointment hour of 53 minutes duration) per week at a time we agree on (or every other week if appropriate); although, some sessions may be longer or more frequent depending on what we are working on.

Once an appointment hour is scheduled, you will be expected to provide full-fee payment unless you provide 24 hours advance notice of cancellation (unless we both agree that you were unable to attend due to circumstances beyond your control). If it is possible, I will try to find another time to reschedule the appointment.  If you miss an appointment without any notice or communication, I will assume you are terminating therapy and I will not hold your subsequent appointment.  Effective therapy requires consistency in meeting.  If you are unable to maintain consistent sessions (frequency and number agreed upon by myself and you), we will need to talk about possibly ending our work together.  

PROFESSIONAL FEES
My fees are set unless we have come to an agreement indicating otherwise (any agreement will be re-evaluated after 6 months).  My intake fee is $200.00 which includes time outside of the session for treatment planning. My usual fee per 53 minute session is $150.00.  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 and we agree to periods of less than one hour.  Other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. For these services, I charge 27.50 per 15 minute block and round up to the next 15 minutes block if it goes over 15 minutes.

If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party.  Because of the difficulty of legal involvement, I charge $200.00 per hour for preparation and attendance at any legal proceeding.

BILLING AND PAYMENTS
You will be expected to pay for each session prior to the session beginning, unless we agree otherwise or unless you have insurance coverage which requires another arrangement. You may permit me to store your credit card information in my secure, electronic health care records system. In this case, I will charge your card after our appointment. 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 (if such legal action is necessary, its costs will be included in the claim).  In most collection situations, the only information I release regarding a client’s treatment is his/her name, the nature of services provided, and the amount due.

INSURANCE REIMBURSEMENT
In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers.

You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf.  Due to the rising costs of health care, insurance benefits have increasingly become more complex.  It is sometimes difficult to determine exactly how much mental health coverage is available.
 
“Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some clients feel that they need more services after insurance benefits end.  Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy.

You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information such as treatment plans, summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer.  Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information data bank. I will provide you with a copy of any report I submit, if you request it.

Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above (unless prohibited by contract).

CONTACTING ME/COMMUNICATION BETWEEN SESSIONS
It is my goal to provide good communication with my clients.  I have some boundaries around email and telephone communication.  You may use email, but it is not guaranteed to be confidential.  It can be used with your consent and our mutual agreement.  I will read and return emails during my office hours (Wednesday-Friday).  I will use discretion in determining whether or not to respond to emails or wait until our session to discuss what was written.  I will not check emails or my phone when I am on vacation.  I will not answer the phone when I am with a client or out of the office. When I am unavailable, my telephone is answered by a confidential voice mail.  I will make every effort to return your call during my office hours.  In an emergency, in addition to calling me, please, call the crisis hotline mentioned on my voice mail and or 911.  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 or 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.

PROFESSIONAL RECORDS
The laws and standards of my profession require that I keep treatment records. You are entitled to review your records unless I believe that seeing them would be emotionally damaging, in which case I will be happy to send them to a mental health professional of your choice. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers, so you may review them in my presence so that we can discuss the contents.  Clients will be charged an appropriate fee for any time spent in preparing information requests.

As you know, I work with a group of independent mental health professionals.  This group is an association of independently practicing professionals that share certain expenses and administrative functions.  While the members share a name and office space, I want you to know that I am independent, operating under Sarah F. Collins, MA, LP, Inc, in providing you with clinical services, and I am responsible for those services.  My professional records are separately maintained and no member of the group can have access to them without your specific, written permission.  Appropriate people in the clinic as well as those associated with Empathic (online electronic health records and billing program) will have limited access to your personal information for the purpose of billing and coordination of care. For those clients using Health Partners or Aetna insurance, billing and record keeping is run through The Counseling Shop. This is the clinic name of a colleague through whom I am contracted with these insurance companies. This colleague will not have access to your session information.

MINORS
If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from parents that they agree to give up access to your records. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss.  Minors will be informed of all communication between parent/guardian and me.  

CONFIDENTIALITY
In general, the privacy of all communications between a client and a psychologist is protected by law, and I can only release information about our work to others with your written permission.  There are a few exceptions.

In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it.

If you are called as a witness in criminal proceedings, opposing counsel may have some limited access to your treatment records.  Testimony may also be ordered in the following situations:
 
1. Legal proceedings relating to psychiatric hospitalization
2. In malpractice and disciplinary proceeding brought against a provider
3. Court-ordered psychological evaluations
4. Certain legal cases where the client has died

There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a client’s treatment without his or her permission.
5. If there is reason to suspect the neglect or abuse of a minor or a vulnerable adult, I must file a report with the appropriate state agency.
6. I am required to take protective action if, in my professional judgment, I believe that a client is threatening serious bodily harm to another or to himself/herself. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client.

If something occurs where I feel it may become necessary for me to break confidentiality, I will make every effort to fully discuss it with you before taking any action but this may not always be possible.

There are several other matters concerning confidentiality:

7. I may occasionally find it helpful to consult other professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The consultant is also legally bound to keep the information confidential.
8. If I feel that it would be helpful to refer you to another professional for consultation, then with your authorization, I will discuss your case with him/her.
9. In the case of referral, records will be made available to the appropriate professional or designee.  Clients will be charged an appropriate fee for preparation of materials or reports.
10. If you decide to use your insurance (third-party reimbursement) to pay for therapy, I am required to provide the insurer with a clinical diagnosis and sometimes a treatment plan or summary.  There is a form you will be given to fill out and sign that provides written permission for me to disclose information necessary to process your claim.  If you request it, I will provide you with a copy of any bill or report I submit.
11. In family therapy, marital therapy, or in a group situation, for information to be released, all participants have to consent.  One marital partner may not wave privilege for another.  Therefore, in cases of marital therapy, the record may be released only if both parties wave privilege or if the release is court ordered.

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 at our next meeting. I will be happy to discuss these issues with you if you need clarification, but formal legal advice may be needed because the laws governing confidentiality are quite complex, and I am not an attorney.