Client Information and Office Policy Statement
I.
New Client: Welcome!
Thank you for choosing to enter treatment. This is an opportunity to acquaint you with information relevant to treatment, confidentiality and office policies. Your therapist will answer any questions you have regarding any of these policies.
II. Aims and Goals:
The major goal is to help you to identify and cope more effectively with problems in daily living and to deal with inner conflicts that may disrupt your ability to function effectively. This purpose is accomplished by:
1. Increasing personal awareness.
2. Increasing personal responsibility and acceptance to make changes necessary to attain your goals.
3. Identifying personal treatment goals.
You are responsible for providing necessary information to facilitate effective treatment. You are expected to play an active role in your treatment, including working with your therapist to outline your treatment goals and assess your progress. There may also be negative consequences if you do not follow through with recommended treatment(s).
You may be asked to complete questionnaires or to do homework assignments. Your progress in therapy often depends much more on what you do between sessions, than on what happens in the session.
III. Appointments:
Appointments are usually scheduled for 45-50 minutes. Patients are generally seen weekly or more/less frequently, as acuity dictates and you and your therapist agree. You may discontinue treatment at any time, but please discuss any decisions with your therapist. In the event of an emergency your therapist may be reached after 5:00 p.m. and on weekends at 243-2169. If you are unable to reach your therapist, contact your primary care physician or go to the local hospital emergency room. For urgent calls, our on-call therapist will assist you
IV. Confidentiality:
Issues discussed in therapy are important and are generally legally protected as both confidential and “privileged.” However, there are limits to the privilege of confidentiality. These situations include: 1) suspected abuse or neglect of a child, elderly person or a disabled person, 2) when your psychiatrist or therapist believes you are in danger of harming yourself or another person, or you are unable to care for yourself, 3) if you report that you intend to physically injure someone the law requires your therapist to inform that person as well as the legal authorities, 4) if your psychiatrist or therapist is ordered by a court to release information as part of a legal involvement in company litigation, etc., 5) when your insurance company is involved, e.g. in filing a claim, insurance audits, case review or appeals, etc., 6) in natural disasters whereby protected records may become exposed or, 7) when otherwise required by law. You may be asked to sign a Release of Information so that your therapist may speak with other mental health professionals or to family members.
Client Information and Office Policy Statement
Informed Consent
If you are concerned
about some of your information, you have a right to ask KPA, to not use or
share some of your information for treatment, payment or administrative
purposes. Such request must be made in
writing. Although KPA will try to respect your wishes,
KPA is not required to agree to your requested limitations. However, if KPA does agree, KPA is committed
to do as you ask. Your insurance company
may refuse to pay if consent is restricted and the patient or guardian
will be responsible in that case. Ask
your therapist for the form to restrict disclosure.
After you have signed this Consent Form, you have the right to revoke it at any time, by writing a letter to the KPA Privacy Officer, informing KPA that you no longer consent to the use and disclosure of your Personal Health Information. On receipt of your letter, KPA will comply with your wishes about using or sharing your information from that time on; your revocation of consent has no effect on information used or shared prior to its receipt by KPA.
V.
Complaints:
You have a right to have your complaints heard and resolved in a timely manner. If you have a complaint
about your treatment, your physician, therapist, or any office policy, please inform us immediately to
discuss the situation.
VI. Record Keeping:
A clinical chart is maintained describing your condition and your treatment and progress in treatment, dates of and fees for sessions and notes describing each therapy session. Your records will not be released without your written consent, unless in those situations as outlined in the Confidentiality section above.
VII. Payments:
Fees are due at the time of visit. Contact the office to make payment arrangements. Your therapist will file your insurance claim, but you are responsible for deductibles, co-insurance, and co-payments. It is your responsibility to familiarize yourself with your insurance benefit.
VIII. Cancellations and Missed Appointments:
You will be billed for all sessions that you cancel with less than 24 hours notice. You may leave messages
24 hours per day. You will be billed $ , not just a co-payment.
Insurance companies do not
reimburse for missed appointments. Your therapist is only compensated for time spent with patients.
Patient Financial
Responsibility
I understand that I am responsible for all balances
due to Karner Psychological Associates. I give permission for my insurance carrier to
be billed on my behalf, if applicable. I
agree to the following terms:
1. All payments and/or co-payments are due at the time
of the visit.
2. If payment cannot be made I will make arrangements
with the billing office. I understand
that there is a $15 surcharge.
3. If I receive payment from the carrier in error I
will
immediately turn it over
the KPA.
I would like KPA to keep my credit card on file:
Cardholder’s Name:
__________________________________________________
Patient’s Name:
__________________________________________________
MasterCard _______ Visa
_________ Other (specify) _________________________
Card Number: _____________________________________
Expiration Date: _____________________ Security Number: _____________
Informed Consent for Treatment
I am aware that the practice of psychotherapy is not an exact science and that results cannot be guaranteed. No promises have been made to me about the results of treatment.
The risks, benefits side effects and alternatives of treatment as well as the consequences of non-compliance with treatment have been discussed with me and I have had the opportunity to ask questions.
I understand that I need to provide accurate information about myself to my clinician so that I will receive effective treatment. I also agree to play an active role in my treatment process.
I understand that I may terminate treatment at any time.
My signature below shows that I understand and agree with all of the above statements and give consent for evaluation and treatment. I have had the opportunity to ask questions about the treatment process. If the client is a minor or has a legal guardian appointed by the court, the client’s parent or legal guardian must sign this consent.
If you do not sign this Consent form agreeing to the provisions of the KPA Notice of Privacy Practices and Policies and Procedures, KPA cannot treat you. Thank you for your cooperation and welcome to our practice!
______________________________________ _______________________
Signature of Patient or Parent/Guardian Date
______________________________________
Printed Name
______________________________________
Relationship to Patient (if applicable)
______________________________________ ________________________Witness
Signature Date