Informed Consent for Participation in Psychological Services
Hello, and welcome to my practice. Please read this document carefully because it contains important information about my business, office policies, and psychological practices. If you have questions, please write them down and ask me at your first meeting. When you sign this form, it represents a contract between us.
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SECTION 1: Types of Services Provided
Types of Services Provided: At your initial visit/intake session, you/your child will be interviewed and may be asked to fill out some questionnaires to assist Dr. Spader-Cloud in understanding how to best help you. Dr. Spader-Cloud will gather information on your/your child’s life history, your/your child’s current situation, and what brings you to therapy/assessment. Diagnostic Intake visits typically last 60-75 minutes. Dr. Spader-Cloud may decide the best way to help you is through psychological assessment/testing and/or psychological treatment. *
Types of Services continued: Psychological Testing
Psychological testing involves exploration of diagnostic possibilities. Particular diagnostic outcomes of the assessment cannot be guaranteed and do not always match the initial concerns discussed so please remain open to various possibilities. Appointments can last anywhere from one to several hours depending on the age of the patient, presenting concerns, attention, and behavior during testing. Dr. Spader-Cloud will attempt to complete all testing in one session, whenever possible. During testing, you/your child will complete a variety of activities. Rating forms are also given to parents, teachers, and significant others when needed. A feedback session, typically lasting 50-60 minutes, will be scheduled to review results and recommendations of testing in detail. A Psychological Assessment Results report will be provided to you at the conclusion of testing. *
Types of Services continued: Treatment/Intervention
Treatment/intervention sessions typically last 50-60 minutes, and parental involvement for children/adolescents will be required. Treatment will often involve work/tasks/activities for you/your child to complete prior to the next session. The number of treatment sessions needed is different for everyone and can be difficult to estimate. Throughout treatment we will assess progress towards your goals and revise goals as needed. If you are dissatisfied with testing or treatment at any time, please discuss this with Dr. Spader-Cloud so that we can try to address your concerns. Dr. Spader-Cloud will make a referral to another therapist if necessary and/or at your request, but she is not responsible for care received from professionals to whom you are referred. It is your right to discontinue treatment at any time. Dr. Spader-Cloud will ask you to generate goals for your/your child’s therapy because this will make your/your child’s therapy more effective. Sometimes, when beginning or throughout treatment, people experience a temporary increase in their distress because the process of addressing and clarifying personal issues can be difficult or painful. On the other hand, treatment has been shown to be beneficial for those who participate, although there can be no guarantee as to your response to treatment. *
SECTION 2: Billing and Insurance
Billing and Insurance: You have the right to use insurance benefits to cover your services with Dr. Spader-Cloud if you have an insurance carrier that she accepts (i.e., for which she is an In Network provider) and your insurance plan provides benefits that cover her services for you and/or your child. As a courtesy service to you, Dr. Spader-Cloud or her billing service will file your claims to your insurance company, but it is your responsibility to make sure that your bill is paid in full. If you have any questions about your bill, please contact Dr. Spader-Cloud. Services may not be covered if you are not eligible for benefits with the insurance plan, you have exhausted all benefits for the service(s), services requested are not covered under the plan, and/or services requested do not/no longer meet medical necessity as determined by the plan. Some insurance plans do not cover particular diagnoses such as learning disabilities and/or autism spectrum disorder. Insurance plans do not cover testing specifically for giftedness. Additionally, some insurance plans 'carve out' their Behavioral Health services to other plans, and you are advised to find this out prior to seeing Dr. Spader-Cloud.   *
Billing and Insurance continued: Payment considerations Part 1
Insurance may cover all, some, or none of the costs associated with the psychological services that you may receive. Should your insurance company refuse payment for the services, you will be held responsible for paying the amount in full or as allowable by the contract Dr. Spader-Cloud has with your insurance company. If you prefer to not use insurance benefits, payment of fees will be due at the time of service (see Fees below). If your insurance refuses to pay for services, payment of fees will be due at the time in which Dr. Spader-Cloud receives the Explanation of Benefits from your insurance company. You may also use Out of Network benefits if your plan covers this, and Dr. Spader-Cloud can give you an invoice/"superbill" so that you can seek reimbursement from your insurance; the full session fee will be due at the time of service. *
Billing and Insurance continued: Payment considerations Part 2
Payment: Payment for service fees or payment related to copayment/coinsurance and/or deductibles will be required at the time of service. If insurance payments are not received within 60 days of the claim (most often submitted on the date of service), you will be responsible for the bill. Please note that a collection agency may be used for bills over 90 days past due, and you will be charged for any collection fees Dr. Spader-Cloud may incur. A fee collection agency may release your personal information related to unpaid balances to third parties including attorneys and national credit reporting agencies.  There will be a $25 fee for any returned checks.   *
Billing and Insurance continued: Payment considerations Part 3
The parent/guardian bringing a child in for services is responsible for paying any fees associated with that day's appointment regardless of which parent/guardian the insurance policy is under. *
Billing and Insurance continued: Payment considerations part 4
If you are an adult (age 18 and over) but currently using your parent’s insurance, you will be responsible for making sure that money owed to Dr. Spader-Cloud will be paid. *
Billing and Insurance continued: Other considerations
It is important to understand that quotes obtained from insurance companies, either by yourself, Dr. Spader-Cloud, and/or Dr. Spader-Cloud's billing service, are not a guarantee of coverage/payment. It is strongly suggested that you contact your insurance company in order to fully understand your mental health benefits and coverage such as what services are covered, how many hours are covered, if an authorization/pre-authorization is needed, and if you have a copay/coinsurance/deductible. The Testing Authorization Checklist on Dr. Spader-Cloud's website can assist in your inquiry (www.spaderpsychology.com, see Forms page). When using insurance, please be aware that Dr. Spader-Cloud must make a formal diagnosis that will, to the best of her knowledge, be a part of you/your child’s permanent medical record. *
Fees for Services (if insurance does not cover your bill, if Dr. Spader-Cloud is out of network for your insurance, and/or if you are choosing to obtain services on a Private Pay basis).

The cost of testing is $180 per hour, and evaluations take 4-7 total hours, depending on the reason(s) for testing (an approximate amount of time will be provided per discussion of your testing needs). Testing services include time spent during the intake interview, administering the tests, and discussing the testing results as well as the additional time required for chart review, planning the testing session(s), scoring/analyzing/interpreting the results, and writing the Psychological Assessment Results Report.

Additional Services/Fees
$35 per 15 minutes (billed to you as insurance will not cover/pay)
-Phone calls lasting more than 10 minutes
-Written letters/reports requiring more than 10 minutes 
-Medical records preparation/sending to another treating provider requiring more than 10 minutes
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SECTION 3: Cancellation Policy
Cancellation Policy: Please know that Dr. Spader-Cloud takes great care to avoid being late for any patient. Consequently, if you arrive more than 15 minutes late for an appointment, she may not be able to see you on that day (although she will make every effort). If Dr. Spader-Cloud has to cancel an appointment due to illness or emergency, please know that she does so to protect you and your child from her illness, or she is experiencing a personal matter that requires immediate attention. You will be offered her next available appointment, and she will make every effort to accommodate your availability. *
Cancellation Policy continued: Cancellation Fee
You may cancel an appointment at any time by calling (614) 852-4152, emailing contact@spaderpsychology.com, or using therapyappointment.com. Please make every attempt to cancel Monday appointments by noon on Thursday. If you miss an appointment without canceling at least 48 hours in advance, unless it is agreed that you were unable to attend due to circumstances beyond your control, you will be charged $50 for a missed Treatment or Feedback appointment and $50 per hour that was scheduled for a Testing session (Testing incurs a greater charge as Dr. Spader-Cloud has set aside 2-3 hours of her schedule for your appointment). Insurance companies will not cover/pay this fee so you will be billed. If you are unable to give 48 hours’ notice, call as soon as you can because if your appointment time can be filled, you will not be charged the cancellation fee. *
SECTION 4: Contacting Dr. Spader-Cloud & Emergencies
Contacting Dr. Spader-Cloud & Emergencies: Dr. Spader-Cloud is usually not immediately available. While she typically in her office Monday and Tuesday (except for holidays), she does not answer the phone while with a patient. Please leave a voicemail at (614) 852-4152 or email contact@spaderpsychology.com (both services are HIPAA-compliant although there is no guarantee regarding the security of the services), and Dr. Spader-Cloud will return your communication within 3-4 business days. Dr. Spader-Cloud able to respond most quickly to email communication, but email should never be used for emergency situations. There will be little to no discussion of treatment-related matters via phone/email; please schedule an appointment to discuss such matters. If you experience an emergency and cannot reach Dr. Spader-Cloud, please call your family doctor, 911, Columbus Springs, or go to the nearest emergency room. If Dr. Spader-Cloud will be unavailable for an extended period of time, coverage options will be discussed, and you will be given the name of another therapist to contact if you wish. With regard to social media, Dr. Spader-Cloud does not accept “friend” or contact requests from current or former patients on social networking sites (Facebook, LinkedIn, etc). *
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SECTION 5: Confidentiality and Disclosure
Your patient information is always held confidential in accordance with both legal and ethical standards. This information includes patient appointments, session notes, test results, written reports, demographic information, and financial information. Please review the Notice of Privacy Practices as it gives detailed information regarding the protection of your private healthcare information (PHI) and how it may be shared. Dr. Spader-Cloud may ask you to sign release of information forms for her to communicate with other professionals to coordinate you/your child’s care; you have the right to refuse to sign these forms if you so choose. Additionally, Dr. Spader-Cloud may seek consultation from colleagues regarding your care, but no identifying information will be shared. If Dr. Spader-Cloud sees you in public, she will not acknowledge your presence so as to not break your confidentiality but will respond if you greet her first. *
Confidentiality & Disclosure continued: Limits of Confidentiality
Please be aware that there are certain circumstances in which Dr. Spader-Cloud is required by law to breach patient confidentiality. These circumstances include: 1) If Dr. Spader-Cloud believes that a patient is a danger to him/herself or others, 2) If Dr. Spader-Cloud believes that an individual is the victim of child/elder/disabled adult abuse or neglect (She is a mandated reporter), 3)  Court mandated subpoenas, and 4) Your insurance carrier may require confidential patient information in order to authorize treatment or reimbursement. *
Confidentiality and Disclosure continued: Working with minors and parents/legal guardians
When working with a minor, the confidentiality of the minor is important in order to have an effective therapeutic relationship. Dr. Spader-Cloud will speak with parents to try and ensure that minors experience the same degree of confidentiality as adults. However, parents do have the legal right to examine a minor’s treatment records. Please note that any parent/legal guardian has rights to the information specifically pertaining to a child held within a child’s treatment records unless there is a court document stating otherwise. *
SECTION 6: Professional Records
Professional Records: The laws and standards of the psychological profession require that Dr. Spader-Cloud maintain treatment records. Information discussed during sessions/visits, on the phone, and via email all become part of your professional record. You are entitled to receive a copy of you/your child’s records, or Dr. Spader-Cloud can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or upsetting to read. If you wish to see your/your child’s records, Dr. Spader-Cloud recommends that you review them with her so that you can discuss the contents. *
SECTION 7: Release of Liability
Release of Liability: Dr. Spader-Cloud will be released from liability for your psychological care in the following circumstances: 1) If you/your child fails to show for an appointment and Dr. Spader-Cloud does not hear from you within one week of that missed appointment, 2) If you cancel an appointment without rescheduling (you are welcome to reschedule at any time, pending Dr. Spader-Cloud's availability, provided that any past balances (including missed appointment fees) are paid), 3) If you fail to show and/or fail to provide 48 hours’ cancellation notice 2 times in a row or 3 times within a 3 month period, which may result in termination of psychological services with Dr. Spader-Cloud, and 4) Any other justifiable reason for the termination by Dr. Spader-Cloud of your psychological services with her. If there are extenuating circumstances, such as family emergencies or sudden business trips, please contact Dr. Spader-Cloud as soon as possible to inform her. *
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