This Client Service Agreement contains important information about my services and business policies. When you sign this form, it will represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have to take action outlined in the limits of confidentiality or you have not satisfied any financial obligations you have incurred.
In addition to this Client Service Agreement, you will be provided with another form. The Health Insurance Portability and Accountability Act or HIPAA is a federal law that provides privacy protections and rights with regard to the use and disclosure of your Protected Health Information (PHI). HIPAA requires that I provide you with a Notice of Privacy Practices that outline and explains HIPAA and its application to your personal health information.
PSYCHOLOGICAL SERVICES:
I view psychotherapy as a collaborative process between you, me and anyone else you determine to be appropriate. During your sessions you will be free to discuss whatever it is you wish. I assume at that you know what is best for you and through our collaboration we can clarify how best to achieve it.
My philosophy is to view you as a whole person whose mind, body, and social activities are interconnected. My view is to see emotional, social, and physical health challenges as normal human experiences, which are impacted by one’s way of living and coping. These challenges can be an opportunity to enhance your health as well as an opportunity for growth. To meet the unique needs of each client, I integrate current scientific findings with your own intuitive healing process. There are a variety of services and techniques that may be helpful to integrate into your sessions. You may want to explore what combination, if any, might work best for you.
I also respect that it is most important for you to feel comfortable with your therapist. Should you ever have questions or concerns about our work together, please feel free to talk to me about them. Sometimes the therapist you start with may not feel like the right fit for you. I want to encourage you to express that to me and if you request it, I can help facilitate you finding the right professional that best fits your needs and style.
Psychotherapy can have many benefits and some risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings at times. On the other hand, psychotherapy has also been shown to have many benefits. Obviously there are no guarantees what you will experience. I believe that you have the ability within you to maximize your own success.
SESSIONS
Sessions will normally be 50 minutes in duration. If they are shorter or longer for some reason, the fee will be adjusted according to the quarter hour. Many people meet weekly for the first few sessions then decide on what is the best frequency for them. The frequency can vary depending upon need, schedules and finances.
TELEPHONE or VIDEO CALLS
If you dial the main number listed above, your call will be answered by me or my voice mail. If I do not answer your call at that moment, please leave a message in my confidential voice mail box along with the best time to reach you, and I will call back as soon as possible. If you have an emergency situation and need immediate assistance and I do not answer your phone call immediately, consider going to your nearest emergency room.
Brief phone or video calls to change appointments or clarify information are welcomed and will not be charged. However, if phone calls are longer than 10 minutes, they may be charged according to the quarter hour. If I will be unavailable for an extended time period, I will indicate on my voice mail greeting the name of a colleague who is covering for me.
Audio and video teletherapy may not be completely confidential, and clients are advised the therapist is not liable for breaches of technology.
FEES
The full fee at Alice Berry Counseling for one 45-50-minute session of psychotherapy or consultation is $180.00. A sliding fee scale can be used to arrange a reduction in this full fee. The sliding scale is normally based on a family’s annual income. The suggested rates for this sliding fee scale are as follows:
Annual Income Level Amount Charged per Hour of Psychological Service
$0 – 12,000 per year $20
$12,001 – 20,000 per year $25
$20,001 – 30,000 per year $30
$30,001 – 40,000 per year $40
$40,001 – 50,000 per year $50
$50,001 – 60,000 per year $60
$60,001 – 70,000 per year $70
$70,001 – 90,000 per year $85
90,000 – 115,000 per year $125
115,000 – 130,000 per year $150
$130,000 and above $180 (the full fee)
For couples therapy, each member of the couple pays according to their income level.
The actual amount paid by the client may vary from the list above. The client and I will collaborate to determine a fair fee for service. Many other factors will be considered when determining an out-of-pocket fee for a client including access to additional sources of income, exorbitant medical expenses and other excessive financial expectations. All clients will be asked to pay something for the services provided as part of their acknowledgement of the importance of these services.
I also may charge for other services you could need, though I will break down the hourly cost if I work for periods of less than one hour. These other services may include telephone conversations lasting longer than 10 minutes, consulting with other professionals with your permission, preparing records or treatment summaries, and the time spent performing any other service you may request of me.
If you become involved in legal proceedings that require my participation, you may be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Because of the significant time and energy associated with legal involvement, I charge no less than $450 per hour for preparation and attendance at any legal proceeding. Please be aware that I am not practicing as a professional counselor, but as a counselor in collaboration with artists.
I request that you pay the whole fee at the end of each session, unless we have a written agreement otherwise. I am not accepting insurance payments at this time. Also, a fee of $35.00 will be added to your balance due for each check returned from the bank for insufficient funds. If you have a balance and do not have an appointment scheduled, you will receive a statement around the 15th of each month for services. Unless there is a financial hardship we have discussed and have developed an alternative arrangement, payment is requested upon receipt of the statement. Thank you in advance for your consideration.
COLLECTIONS
In the unlikely event that you do not reduce your balance in a 60-day period, 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 which will require me to disclose otherwise confidential information. 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. If such legal action is necessary, the costs will be included in the claim. Please note that the collection agency will report your delinquent account to the credit bureau and thus your credit rating may be affected.
CLIENTS UNDER THE INFLUENCE
I reserve the right to refuse or terminate a session if you or anyone in the session is suspected to be under the influence of a mood altering substance. If this occurs, you may still be responsible and charged for full payment of the normal fee.
CANCELLING APPOINTMENTS
Although it is usually best therapeutically to keep regular appointments, there may be times when you cannot make it into the office. It is requested that you call my number below at least 24 hours in advance to cancel the appointment. If you do not cancel more than 24 hours in advance, you may be charged the full normal fee for that session unless we have a written agreement otherwise. The exceptions to this policy are major illnesses, accidents you may be in, and weather which results in transportation difficulties. If I have an opening and can reschedule you during that week, you are not charged.
STOPPING OR PAUSING THERAPY
You have the right to stop therapy at any time. It might be helpful to you if we discuss when you are ready to stop and plan for it accordingly. It may be helpful to discuss any feelings you have as well as talk about strategies to maintain your progress. Some people take periodic breaks, others use the therapist as one resource in their life and may come in a couple of times a year as a way to maintain their gains. Feel free to discuss all of these options with me when and if you are ready.
CONFIDENTIALITY
There are laws that clarify the privacy of all communications between you and me. In most situations, I can only release information about you if you sign a written authorization form. There are some situations where I am required by law to break confidentiality. The law indicates four such situations and they are:
1. if you report child abuse.
2. if you report elder abuse.
3. if you are in immediate danger of harming yourself.
4. if you are in immediate danger of harming someone else.
Any other situation requires me to have a written, advance consent form signed by you before any confidential information can be released. Your signature on this Agreement indicates your understanding of confidentiality and the legal limits of confidentiality.
PROFESSIONAL RECORDS
You should be aware that, pursuant to HIPAA, I separate Protected Health Information about you from Psychotherapy Notes I may write about our session. The Protected Health Information is contained in your record. It may include information about your reasons for seeking therapy, a description of the ways in which your life is impacted, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, testing materials, your billing records, and any reports that have been sent to anyone.
Except in unusual circumstances that involve danger to yourself and others, you may examine and/or receive a copy of your record if you request it in writing and the request is signed by you and dated not more than 60 days from the date it is submitted. Because these records can sometimes be misinterpreted and/or upsetting to untrained readers, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, I am allowed to charge a copying fee of $1 per page for the first ten pages, 50 cents per page for pages 11 through 50, and 20 cents per page for pages in excess of fifty, plus $15 fee for records search, plus postage.
If your session includes other people, I cannot release the record or allow you to review it unless all parties present have signed an authorized release. The only exception to this policy is if a judge orders the record to be released.
In addition, I may keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your record. These Psychotherapy Notes are kept separate from your record. You may examine and/or receive a copy of your Psychotherapy Notes at your request. Please note that these records can be subpoenaed.
CLIENT RIGHTS
HIPAA provides you with several new or expanded rights with regard to your record and disclosures of Protected Health Information. These rights include requesting that I amend your record; requesting restrictions on what information from your record is disclosed to others; requesting an accounting of most disclosures of Protected Health Information that you have neither consented to nor authorized and that are not involved in treatment, payment or health care operations; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement and my privacy policies and procedures. I am happy to discuss any of these rights with you.
MINORS & PARENTS
Clients under 14 years of age and their parents should be aware that the law allows parents to examine their child’s treatment records unless I decide that such access would injure the child or we agree otherwise. According to Illinois law, clients 14 years of age and over are able to keep all medical records private, including psychotherapy records, even from their parents. Confidentiality is strictly required except when a client reports child abuse or elder abuse or when a client is deemed to be in immediate danger of harming themselves or someone else. Outside of these exceptions, no information about these sessions may be disclosed to anyone including parents without the child’s written agreement.
While privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, parental involvement is also essential to successful treatment. For children 14 and over, it is generally my policy to request an agreement between my client and his/her parents allowing me to share general information about the progress of the child’s treatment and his/her attendance at scheduled sessions. Any other communication will require the child’s authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the appropriate people of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.
Your signature below indicates that you have read the information in this document and agree to its terms and also serves as an acknowledgement that you have received the HIPAA Notice Form described above.
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Client’s or Authorized Person’s Name (please print)
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Client’s or Authorized Person’s Signature Date
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Therapist’s Name (please print)
Therapist’s Contact Number __________________________________________________________
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Therapist’s Signature Date
HIPPA Fact Sheet
PROTECTING THE PRIVACY OF PATIENTS’ HEALTH INFORMATION
The first-ever federal privacy standards to protect patients’ medical records and other health information provided to health plans, doctors, hospitals and other health care providers took effect on April 14, 2003. Developed by the Department of Health and Human Services (HHS), these new standards provide patients with access to their medical records and more control over how their personal health information is used and disclosed. They represent a uniform, federal floor of privacy protections for consumers across the country. State laws providing additional protections to consumers are not affected by this new rule. Congress called on HHS to issue patient privacy protections as part of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA included provisions designed to encourage electronic transactions and also required new safeguards to protect the security and confidentiality of health information. These efforts include answers to hundreds of common questions about the rule, as well as explanations and descriptions about key elements of the rule. These materials are available at http://www.hhs.gov/ocr/hipaa.
The new privacy regulations ensure a national floor of privacy protections for patients by limiting the ways that health plans, pharmacies, hospitals and other covered entities can use patients’ personal medical information. The regulations protect medical records and other individually identifiable health information, whether it is on paper, in computers or communicated orally. Key provisions of these new standards include:
Access To Medical Records. Patients generally should be able to see and obtain copies of their medical records and request corrections if they identify errors and mistakes. Health plans, doctors, hospitals, clinics, nursing homes and other covered entities generally should provide access these records within 30 days and may charge patients for the cost of copying and sending the records.
Notice of Privacy Practices. Covered health plans, doctors and other health care providers must provide a notice to their patients how they may use personal medical information and their rights under the new privacy regulation. Doctors, hospitals and other direct-care providers generally will provide the notice on the patient’s first visit and upon request. Patients generally will be asked to sign, initial or otherwise acknowledge that they received this notice. Health plans generally must mail the notice to their enrollees and again if the notice changes significantly. Patients also may ask covered entities to restrict the use or disclosure of their information beyond the practices included in the notice, but the covered entities would not have to agree to the changes.
Limits on Use of Personal Medical Information. The privacy rule sets limits on how health plans and covered providers may use individually identifiable health information. To promote the best quality care for patients, the rule does not restrict the ability of doctors, nurses and other providers to share information needed to treat their patients. In other situations, though, personal health information generally may not be used for purposes not related to health care, and covered entities may use or share only the minimum amount of protected information needed for a particular purpose. In addition, patients would have to sign a specific authorization before a covered entity could release their medical information to a life insurer, a bank, a marketing firm or another outside business for purposes not related to their health care.
Prohibition on Marketing. The final privacy rule sets new restrictions and limits on the use of patient information for marketing purposes. Pharmacies, health plans and other covered entities must first obtain an individual’s specific authorization before disclosing their patient information for marketing. At the same time, the rule permits doctors and other covered entities to communicate freely with patients about treatment options and other health-related information, including disease-management programs.
Stronger State Laws. The federal privacy standards do not affect state laws that provide additional privacy protections for patients. The confidentiality protections are cumulative; the privacy rule will set a national “floor” of privacy standards that protect all Americans, and any state law providing additional protections would continue to apply. When a state law requires a certain disclosure — such as reporting an infectious disease outbreak to the public health authorities — the federal privacy regulations would not preempt the state law.
Confidential communications. Under the privacy rule, patients can request that their doctors, health plans and other covered entities take reasonable steps to ensure that their communications with the patient are confidential. For example, a patient could ask a doctor to call his or her office rather than home, and the doctor’s office should comply with that request if it can be reasonably accommodated.
Complaints. Consumers may file a formal complaint regarding the privacy practices of a covered health plan or provider. Such complaints can be made directly to the covered provider or health plan or to HHS’ Office for Civil Rights (OCR), which is charged with investigating complaints and enforcing the privacy regulation. Information about filing complaints should be included in each covered entity’s notice of privacy practices. Consumers can find out more information about filing a complaint at http://www.hhs.gov/ocr/hipaa or by calling (866) 627-7748.
HEALTH PLANS AND PROVIDERS
The privacy rule requires health plans, pharmacies, doctors and other covered entities to establish policies and procedures to protect the confidentiality of protected health information about their patients. These requirements are flexible and scalable to allow different covered entities to implement them as appropriate for their businesses or practices. Covered entities must provide all the protections for patients cited above, such as providing a notice of their privacy practices and limiting the use and disclosure of information as required under the rule. In addition, covered entities must take some additional steps to protect patient privacy:
Written Privacy Procedures. The rule requires covered entities to have written privacy procedures, including a description of staff that has access to protected information, how it will be used and when it may be disclosed. Covered entities generally must take steps to ensure that any business associates who have access to protected information agree to the same limitations on the use and disclosure of that information.
Employee Training and Privacy Officer. Covered entities must train their employees in their privacy procedures and must designate an individual to be responsible for ensuring the procedures are followed. If covered entities learn an employee failed to follow these procedures, they must take appropriate disciplinary action.
Public Responsibilities. In limited circumstances, the final rule permits — but does not require — covered entities to continue certain existing disclosures of health information for specific public responsibilities. These permitted disclosures include: emergency circumstances; identification of the body of a deceased person, or the cause of death; public health needs; research that involves limited data or has been independently approved by an Institutional Review Board or privacy board; oversight of the health care system; judicial and administrative proceedings; limited law enforcement activities; and activities related to national defense and security. The privacy rule generally establishes new safeguards and limits on these disclosures. Where no other law requires disclosures in these situations, covered entities may continue to use their professional judgment to decide whether to make such disclosures based on their own policies and ethical principles.
Equivalent Requirements For Government. The provisions of the final rule generally apply equally to private sector and public sector covered entities. For example, private hospitals and government-run hospitals covered by the rule have to comply with the full range of requirements.
HHS’ Office for Civil Rights (OCR) oversees and enforces the new federal privacy regulations. Led by OCR, HHS has issued extensive guidance and technical assistance materials to make it as easy as possible for covered entities to comply with the new requirements. Key elements of OCR’s enforcement efforts include:
Information line. To help covered entities find out information about the privacy regulation and other administrative simplification provisions of the Health Insurance Portability and Accountability Act of 1996, OCR and HHS’ Centers for Medicare & Medicaid Services have established a toll-free information line. The number is (866) 627-7748.
Complaint investigations. Enforcement will be primarily complaint-driven. OCR will investigate complaints and work to make sure that consumers receive the privacy rights and protections required under the new regulations. When appropriate, OCR can impose civil monetary penalties for violations of the privacy rule provisions. Potential criminal violations of the law would be referred to the U.S. Department of Justice for further investigation and appropriate action.
Civil and Criminal Penalties. Congress provided civil and criminal penalties for covered entities that misuse personal health information. For civil violations of the standards, OCR may impose monetary penalties up to $100 per violation, up to $25,000 per year, for each requirement or prohibition violated. Criminal penalties apply for certain actions such as knowingly obtaining protected health information in violation of the law. Criminal penalties can range up to $50,000 and one year in prison for certain offenses; up to $100,000 and up to five years in prison if the offenses are committed under “false pretenses”; and up to $250,000 and up to 10 years in prison if the offenses are committed with the intent to sell, transfer or use protected health information for commercial advantage, personal gain or malicious harm.
____________________________ Client Printed Name
Copyright 2003 and used by permission of the U.S. Department of Health & Human Services · 200 Independence Ave. SW · Washington, D.C. 20201
