Service Agreement and Consent to Treatment

This document contains important information about my professional services, your legal rights to privacy and confidentiality, and my business practices. Please read it carefully. When you sign this document, it will represent an agreement between us. 

PSYCHOTHERAPY

Psychotherapy is not easily described in general statements. It varies depending on the personalities of the therapist and client and the particular issues you bring forward. Psychotherapy is not like a medical 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 and in between our sessions. 

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 participate in it. It often lead to better relationships, solutions to specific problems, and significant reductions in feelings of distress, but 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 commitment of time, money, and energy so you should be careful about the therapist you select.

I conduct my practice in strict accordance with the Code of Ethics of the National Association of Social Workers, of which I am a member in good standing. I strongly suggest you become familiar with this Code, as it governs my professional conduct as a Licensed Clinical Social Worker and it will govern our professional relationship. It can be found here: 

http://www.socialworkers.org/p...

APPOINTMENTS and CANCELLATIONS

I normally conduct an evaluation that will last from 2 to 4 sessions. 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 60-minute session (one appointment of 60 minutes duration) per week at a time we agree on, although some sessions may be longer or may be held more frequently. 

Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 48 hours advance notice of cancellation. 

I require a valid credit card on file in order to assure that I am paid for any sessions cancelled without an agreed upon reason or without required notice. 

PROFESSIONAL FEES

My fee is $125 per 60-minute session.

In addition to weekly appointments, 

I charge $125. - $175. per hour, or fraction thereof, for other professional services you may need. Other services include report writing, telephone conversations lasting longer than 5 minutes, attendance at meetings with other professionals you have requested or authorized, preparation and/or transcription of 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 will be expected to pay for my professional time even if I am called to testify by another party in a legal proceeding in which you are involved. I charge $200. per hour for preparation and attendance at any legal proceeding. 

BILLING AND PAYMENTS

You will be expected to pay for each session at the time the session is conducted. Payment schedules for other professional services will be agreed upon when the services are requested. I have the option of using legal means to secure the payment[s] due This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs, calculated at my hourly fee for involvement in legal matters, 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

I accept a limited group of health insurances as a form of payment for my services. I will provide you with a detailed receipt for services that includes all relevant diagnostic codes, service codes, and licensed provider identification, that you will be able to present to your insurance carrier for reimbursement. 

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. 

It is sometimes difficult to determine exactly how much mental health coverage may be available to you.

Information submitted to insurance companies will become part of the insurance company’s files and will probably be stored electronically. I have no control over what insurance companies do with your information once it is in their hands. In some cases, they may share the information with a national medical information database, and in others with your employer or with the sponsors of your HMO or health plan.

CONTACTING ME

I am often not immediately available by telephone. While I am usually available between 9 AM and 6 PM on weekdays, I will not answer the phone when I am in session with a client. I do not have call-in hours and I do not conduct sessions by telephone or Internet. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are unable to reach me and feel that you cannot wait for me to return your call, contact the nearest hospital emergency room and ask for the psychiatric crisis worker on call. 

PROFESSIONAL RECORDS

The laws and standards of my profession require that I keep treatment records. If you request, you are entitled to receive a copy of your records. They can be subject to subpoena by a court of law. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, I recommend that you review them with me so that we can discuss the contents. You will be charged a fee, at my regular hourly rate, for any professional time spent in responding to information requests. I also keep session notes. These are legally confidential, and are not available to anyone else. They remain my personal property and are protected information. 

MINORS (under age 18)

I do not provide direct services to minors, and I am also unable to meet with minors in the company of their parents or legal guardians.

CONFIDENTIALITY

In general, the privacy of all communication between a client and a Licensed Clinical Social Worker is protected by law and I can only release information about our work to others with your written permission.  There are a few important 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 case under consideration demands it. 

There are some situations in which I am legally obligated to take action to protect a client or others from harm, even if I have to reveal some information about a client’s treatment. For example, if I believe that a child or other vulnerable person is being abused I must notify the police and file a report with the appropriate state agency. 

If I reasonably believe that a client is threatening serious bodily harm to her/himself or to any other(s), I am required to take protective actions. These actions will include notifying the potential victim, contacting the police, or seeking involuntary hospitalization for the client. If the client threatens to harm her- or himself, I may be obligated to seek hospitalization for her/him or to contact family members or others who can help provide protection. 

These situations have rarely occurred in my practice. If a similar situation occurs, I will make every effort 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 client. The consultant is also legally bound to keep this information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important for our work together. 

A complete description of your privacy rights and protections under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) can be found here: 

http://www.hhs.gov/ocr/privacy... 

and on the US Department of Health and Human Services HIPAA website homepage. 

I will be happy to answer any questions about your privacy rights that you may have. While this written summary of my policies concerning confidentiality should be helpful in informing you about your obligations in a treatment relationship with me, your legal protections, and potential problems that may arise, 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 topics with you at any time, at your request. 

Your signature below indicates that you have read the information in this document and that we both agree to abide by its terms during our professional relationship. 

AGREEMENT and INFORMED CONSENT TO TREATMENT

Your signature signifies your consent to receive mental health treatment provided by me under the terms of this agreement and under any terms and conditions that may also be agreed upon by you and me prior to the date of your signature. If any terms or conditions are established between us that are not contained in this document, they will be noted below.

This agreement will remain in force during our working relationship. Our working relationship will continue as long as you feel it is helpful to you and as long as I feel I can be of help to you. It will terminate when either of us decides it is not in your benefit or best interest to continue treatment with me. 

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Robert Barth, LCSW                                                                       Date