Informed Consent
Thank you again for considering my practice on your personal journey of growth and healing. This document contains important information about my professional services and business policies. You have also been provided with a document entitled Notice of Privacy Practices, which outlines information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights related to the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will represent an agreement between us. We can discuss any questions you have in advance of signing or at any time in the future.
Therapeutic Process
You have taken an important step by deciding to seek therapy, which involves both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, or frustration, because the process of therapy often involves discussing challenging aspects of life. However, extensive research shows that therapy has benefits for individuals who engage in it. Therapy provides a safe and accepting environment that often helps lead to a significant reduction in distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing emotions, and resolutions to specific problems. There are no guarantees about the outcomes of our work together. Therapy requires consistent and active effort on your part. Your action on your own needs and goals in between our sessions is the strongest determinant of success. I cannot promise that your circumstances, thoughts, emotions, or behavior will change; however, I can promise to do my very best to understand and support you, as well as to help you clarify what it is that you want for yourself.
Session Structure
Our first session will involve conversation about your concerns, needs, goals, and expectations for the therapeutic process. These are important pieces of our work together that we will continue to explore over time. Additionally, I will be able to offer you some initial impressions of what our work might include. As we begin working together, you should assess whether you feel comfortable working with me. You have the right to ask questions about any aspects of therapy, my approach, and my specific training and experience whenever they arise.
Appointments will be 45 minutes in duration at a routine time we agree on, although some sessions may be longer or more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. You are responsible for coming to your session on time; if you are late, your appointment will still need to end on time. Arrival after 20 minutes into your scheduled session will be considered a "no show”. In the event you need to cancel a session, more than one day of advance notice by phone is required. Cancellation of a session on the calendar day prior to the session will result in a fee of $50.00. Missing a session or cancellation of a session on the calendar day of the session will result in a fee of $100.00. Exceptions may be made at the therapist's discretion and only in the event of an emergency. If possible, we will try to find another time to reschedule the appointment.
When visiting the office for in-person therapy sessions, it is kindly requested you not enter the building if you are experiencing a viral or bacterial illness, including a common cold, are not feel well physically, or have recently been in close contact with an individual experiencing these symptoms. This is important in maintaining a safe and healthy environment for those who are more vulnerable to illness or immunocompromised. In this case, we will work together to meet over telehealth or reschedule our session. You will not be charged a late cancellation fee associated with switching formats to a telehealth session or rescheduling your session due to illness.
If you are unhappy with what is happening in therapy, I hope you will talk with me so I can hear and respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist and are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination based on race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment.
Payment for Services
I am glad to be a participating in-network provider with a variety of health insurance carriers. These include most plans offered by Aetna, All Savers (UHC), Allied Benefit Systems, Christian Brothers Services, GEHA - United Healthcare Shared Services, Harvard Pilgrim, Health Plans Inc., Health Scope, Medica, Meritain, Nippon, Optum, Oscar, Oxford, Surest (formerly Bind), United Healthcare (as well as Exchange, Global, Shared Services, and Student Resources plans), Trustmark Health Benefits, Trustmark Small Business Benefits, and UMR. Please note that I am not a participating provider with Medicare or Medicaid in any format. I also welcome members of the Optum Employee Assistance Program (EAP). Your out-of-pocket cost per session is determined by your insurance carrier based on plan specifics, in-network deductible status, applicable co-insurance, and/or co-payment amount. Please note that I work with a provider network called Alma, which will correspond with you regarding insurance billing, eligibility, co-payments, and deductible payments. Information shared with Alma will be limited to that required in order to submit and process payments and insurance reimbursement.
In some cases, our work may not be eligible for insurance coverage. Examples include when you are available for or prefer telephone-only therapy sessions or when criteria for medical necessity are not met. In these circumstances, we will explore alternate coverage and/or payment options available to you as soon as possible.
The standard self-pay rate for each individual therapy session is $120.00 per 45 minute session or $160 per 60 minute session. You have the option to seek personal reimbursement through your health insurance plan's out-of-network benefits. I will gladly provide you with a detailed superbill following each session at your request to assist with this process. Please note that I am not able to provide superbills retroactively nor submit out-of-network claims on your behalf, and out-of-network coverage is not guaranteed.
There are a limited number of reserved spots available for individuals who are uninsured and experiencing unique levels of financial hardship who can contract with me through an affordable therapy collective called Open Path. Please feel free to discuss this option at the time of intake if it applies to you.
You are responsible for paying the set rate at the time of your session unless prior arrangements have been made. All major credit and debit cards, including Visa, MasterCard, American Express, and Discover, Health Savings Accounts (HSA), Flexible Spending Accounts (FSA), and some wellness cards are accepted as payment. A credit, debit, or HSA card must be kept on file in order to begin therapy. By keeping a credit card on file with my practice or with Alma, you agree for that credit card to be automatically charged for the cost of sessions attended, missed, and/or cancelled late at the rates outlined earlier in this agreement. Instances of insufficient funds are subject to an additional fee of $25.00. In addition to our sessions, it is my practice to charge a fee of $80.00 per hour on a prorated basis for other professional services such as report writing, telephone conversations or professional collaboration of more than 15 minutes per week, attendance at meetings or consultations you have requested, or the time required to perform any other additional service that you may request.
Confidentiality and Communication
My policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled Notice of Privacy Practices. You have been provided with a copy of that document and we can continue to discuss those issues at any time during our work together. If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to confidentiality is of great importance to me and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you and generally feel it is not appropriate to engage in lengthy discussions outside of the therapy office. In accordance with my personal and professional ethics, I will not pursue any form of personal relationship with you outside of our working professional relationship.
When communicating about personal matters, it is strongly recommended that you contact me by phone or secure message in the TheraNest client portal. While I do use encrypted e-mail, it is generally used for business matters and may pose added risk to confidentiality when discussing personal information. Please note that my phone line does not accept text messages. By signing this agreement, you consent to my reply to email sent by you, as well as the electronic transmission of any additional information upon your request. I am often not immediately available by telephone and do not answer my phone when I am in session or otherwise unavailable, and am not considered to be on-call. At these times, you are encouraged to leave a message on my confidential voicemail and your call will be returned as soon as possible. If you are unable to reach me and you feel unable to keep yourself safe or in the event of any other serious emergency, please go to your local hospital emergency room or call 911. Should you need immediate support and find that I am unavailable, please consider calling 988 for the Suicide & Crisis Lifeline (formerly the National Suicide Prevention Lifeline).
I look forward to our work together and welcome you to what I hope is a meaningful and rewarding process!
Informed Consent Effective March 17, 2018
Last Revised March 20, 2024