Marni Millet, LCSW, Master CASAC

6834 East Genesee Street, Understanding Bldg., Upstairs

Fayetteville, New York 13066

marnimillet@marnimillet.com

Psychotherapy Agreement

Welcome to my practice-I am happy you made this huge decision for yourself! Please read the following, as this will be our agreement throughout our time together, which begins today.

Psychotherapy is a very engaged activity and not a passive stance by the therapist. I will be engaged and collaborate with you, working through a holistic perspective. This therapy can be transformational, if you let it. I am versed in many theories, and use an eclectic approach to being. This is a collaborative partnership, so please ask questions, as this is a courageous step you are taking with me. Please know that our first session 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 and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, we will discuss if we believe this is a good fit to continuing our work together. Sometimes its just not a good fit for either how we work together, or my skill level for your problem, or scheduling conflicts could be a problem. If you find that I am just not the right therapist for you, I will give you referrals to other practitioners whom may be better suited to help you.

Confidentiality

In general, the privacy of all communications between a patient and a psychotherapist is protected by law, and I can only release information about our work to others with your written permission. But 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 legal proceedings, a judge may order my testimony if he/she determines that the issues demand it, and I must comply with that court order.

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 patient’s treatment. For example, if I believe that a child [elderly person or disabled person] is being abused or has been abused, I must [may be required to] make a report to the appropriate state agency.

If I believe that a patient is threatening serious bodily harm to another, I am [may be] required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If the patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. If a similar situation occurs in the course of our work together, I will attempt to fully discuss it with you before taking any action.

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 patient. The consultant is also legally bound to keep the information confidential. Ordinarily, I will not tell you about these consultations unless I believe that it is important to our work together. These practitioners are often licensed in New York and sometimes other states or countries, and are experts in clinical training. We will discuss if you are requesting video-recordings and you will consent before showing these recordings. Most sessions will not be video-recorded, and ISTDP is the sessions In offer for it.

Sessions

Practice hours are by appointment only. I ask that once attending the initial assessment, you make a commitment to meet for the next six sessions, if we agree to move forward with our partnership after the first visit. This gives us an opportunity to build our collaborative alliance, as our work together in therapy is important to reach your goals.

Payments

Standard Psychotherapy

$225 Assessment 60 minutes

$175 Individual Session 45 minutes

$225 per 60 minute session if you requested

Specialized, video-recorded therapy below pertains only if requested and agreed upon.

ISTDP Psychotherapy Assessment:

$475 (2.5 hours) Inquiry Session

$275 (60 Minutes) Individual Session

ISTDP Video-recorded treatment including block therapy option.

Block treatment(also known as Intensives) is prorated by length of session and consecutive days. Please be in New York State or Florida for this and we can schedule accordingly, as I am licensed in New York and also registered in Florida.

Payments are made at least three days before the appointment. I will email you an invoice through SQUARE INVOICE through email, and you can use any credit card including HSA/Flex payment. Please know that missed appointments not cancelled within 48 hours are charged in full for your set therapy fee.

Appointments scheduled, if on a Monday, will need to be cancelled by you no later than 12pm on the Friday prior to your Monday appointment. Otherwise, you will be charged the late cancel fee with weekend or Monday cancellations. I appreciate the early notification in order to keep my small practice operating successfully. Since we are not billing your insurance directly and you would like to submit a claim to your insurance company for reimbursement of costs associated with my services, I will supply you with a Superbill with all required information. In order for you to get reimbursement from your insurance company, I have to supply a clinical diagnosis to your insurance company that justifies the service as medically necessary. This is for your possible out of network (OON) benefit. The only way to keep this secure from an insurance company possibly auditing your record or you obtaining a diagnosis is for you to self-pay without insurance reimbursement. This is between you and your insurance carrier to discuss, as often rules/laws/protocols change with different plans. If we are using insurance as an in-network provider, please visit Obrien’s billing.com and complete the insurance verification. The Good Faith Estimate is explained on my webpage and you will pay before session, therefore, not accruing a balance. If there is a problem with insurance not paying for your services, you would ultimately owe the fees. O'Brien's Billing is a courtesy to you, please know your benefits, as well.

Other Fees

In addition to weekly appointments, I charge $225/hr 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 any type of documentation and report writing to other entities including telephone conversations lasting longer than 15 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 from me. 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 $500 per hour for preparation, travel, and attendance at any legal proceeding. If I am requested to travel farther than 20 miles from my address, I will estimate a travel bill and request payment before traveling to the destination. I will not travel longer than three hours or 180 miles from my address. Please know that once a session is paid for I do not refund the fee if you are having technological problems or other reasons you cannot attend the appointment. If it is for an assessment and you change your mind or cannot make the appointment, I will not refund the fee, as this appointment was saved just for you and I cannot recoup the expense of refunding your money. We will work closely together in order to prevent miscommunication.

Contacting me

I am not always immediately available by telephone. You may leave a message on my cell phone, better method is to email me (no clinical information, please).

If you are in a medical or psychiatric crisis (symptoms feeling out of control/ suicidal or homicidal), please call me at 315-480-7160 for immediate assistance. Call twice in a row to ensure my phone rings. If I do not answer, you should call 988 or proceed immediately to the ER or to your local Comprehensive Psychiatric Emergency Program (Syracuse-located at St. Joseph’s Hospital) for emergency evaluation/ intervention. We will make an immediate appointment to discuss your ongoing safety, after you have the facility contact me.

For non-emergent discussion, please do not contact me on weekends or Holidays, or outside the hours of 9am-8pm weekdays, unless it is an emergency. In doubt, call me. The therapy is psychodynamic so all discussions are left for the treatment room. Insurance, billing, scheduling, etc., may need an email or call and I welcome it.

Please DO NOT TEXT emergencies and DO NOT EMAIL emergencies. I may not see them and I cannot help you if I am unaware of them. For Emergencies: Please call two times in a row in order for my phone to go off sleep mode and ring.

Client consent to psychotherapy

I have read this statement, had sufficient time to be sure that I considered it carefully, asked any questions that I needed to, and understand it. I understand the limits to confidentiality required by law. I consent to the use of a diagnosis in billing, and to release that information and other information necessary to complete the billing process. I agree to pay the fees listed above. I understand my rights and responsibilities as a client, and my therapist's responsibilities to me. I agree to billing/clinical use through O'Brien's Billing, and HIPAA compliant Google Workspace, Square Invoicing, GoDaddy Contact forms, Insurance Carrier, and ZOOM Pro licensed platform. I agree to undertake therapy with Marni Millet, LCSW, Master CASAC. I know I can end therapy at any time I wish and that I can refuse any requests or suggestions made by Marni Millet. I am over the age of thirteen.

I have read the policies and understand and agree with them. I hereby agree to be treated by Marni Millet, LCSW, CASAC. I agree that I am personally responsible for ensuring that all charges for services rendered are paid by myself. I authorize Marni Millet to provide information concerning my treatment to any physician or therapist who referred me. Patients are under no obligation to continue services should they decide to terminate at anytime.

NOTICE OF PRIVACY PRACTICES and CONFIDENTIALITY AGREEMENT

I acknowledge that I have read, been offered and/or signed a copy, signed the Notice of Privacy Practices. I may be contacted through Text, Email, Phone, and message may be left on my Voicemail. I realize that PHI is not be identified through these communications, but for confirmation for scheduled appointments. Superbills are sent through Google Enterprise PLus Workspace with TSL and S/SME enablers with a password protected document and SMS verification before sending the superview to your requested email. The superbill may have PHI in it. PHI discussions are only through your request and agreement for supportive texts between sessions, after our discussing first. Please know that dual relationships, current, or after discharge, are unethical, and no social media will be shared (FB, Instagram, Twitter, LinkedIn, or other forms of social media)between therapist and client, out of respect for client confidentiality.

If you reach out with personal information via texting(which I highly advise you do not, as it could be breached d/t internet) you give permission for me to text personal information including information protected by Federal Regulations Article 42 CFR Part 2, when I respond to your texting for additional support between session. I highly advise against this and typically will not text through this method.

I, the undersigned, agree that I am financially responsible for all services provided by Marni Millet, LCSW, CASAC. I am aware that the office policy requires payment before the time of service. Marni Millet, LCSW, Master CASAC