Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us.OUTPATIENT SERVICES CONTRACT
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you bring forward. There are many different methods I may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor 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 our sessions and at home.PSYCHOLOGICAL SERVICES
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 go through it. Therapy often leads 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 and a treatment plan to follow, 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 large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion.
The initial session, and sometimes subsequent sessions will be devoted to evaluation. 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 50-minute session (one appointment hour of 50 minutes duration) per week at a time we agree on, although in some instances sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation.MEETINGS
PROFESSIONAL FEES
SERVICES
FEES QUOTED PER SESSION
CONSULTATION\EVALUATION
$175.00
INDIVIDUAL OR COUPLE
THERAPY
$145.00
FAMILY
THERAPY
$160.00
HOME SCHOOL OR HOSPITAL (TIME @
SITE+TRAVEL)
$160.00
PSYCHOLOGICAL TESTING (+SCORING+REPORT
WRITING)
$100.00
GROUP
THERAPY
$ 70.00
Consultations and psychotherapy sessions are scheduled for 50
minutes; group and family therapy sessions are scheduled for 90
minutes.
Sessions must be cancelled 24 hours in advance to avoid a charge being
made.
Full payment of fees is expected at the time services are rendered unless other arrangements have been made in advance. Even though insurance coverage may pay all or a portion of the charges, you are responsible for the entire bill-not the insurance company. A finance charge of one and one-half percent per month may by added to all outstanding accounts in excess of thirty days (18% annually). A $15.00 service charge will be assessed for any checks that are returned by your bank.PAYMENT OF FEES
A monthly statement will contain all the information necessary for your insurance company. Attach your insurance claim form to the statement. If you choose to have our office handle the billing a $10.00 service fee may be charged each time it is processed.INSURANCE
Written and spoken material from any and all sessions, including psychological testing, will be strictly confidential, unless you give written permission to release all or part of this information to a specified person or agency. Exceptions to this confidentiality involves situations where a licensed psychotherapist is mandated to report instances of child or elder abuse; imminent danger to you or others is present; or your mental health is used in your defense in litigation. In addition it should be understood that your therapist may consult with other professionals associated with Anaheim Hills Psych. Center, or your referring physician, to ensure the highest quality of service.CONFIDENTIALITY
If accounts become delinquent (past 30 days) our office may begin collection procedures. We will attempt to contact you directly, however if accounts remain delinquent (90 days) an outside collection agency or small claims court action may be pursued. In addition to a service charge, you are responsible for any legal fees, court costs and collection charges involved as a result of any collection activity. In such instances information of a nonconfidential nature regarding this account may be released.DELINQUENT ACCOUNTS
__________________________________ _____________
Signature of client or
guardian
date
You should 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. Due to the rising costs of
health
care, insurance benefits have increasingly become more complex. It is
sometimes
difficult to determine exactly how much mental health coverage is
available.
“Managed Health Care” plans such as HMOs and PPOs often require
authorization
before they provide reimbursement for mental health services. These
plans
are often limited to short-term treatment approaches designed to work
out
specific problems that interfere with a person’s usual level of
functioning.
It may be necessary to seek approval for more therapy after a certain
number
of sessions. While a lot can be accomplished in short-term therapy,
some
patients feel that they need more services after insurance benefits
end.
[Some managed-care plans will not allow me to provide services to you
once
your benefits end. If this is the case, I will do my best to find
another
provider who will help you continue your psychotherapy.]
You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it.
Once we have all of the information about your insurance coverage,
we
will discuss what we can expect to accomplish with the benefits that
are
available and what will happen if they run out before you feel ready to
end our sessions. It is important to remember that you always have the
right to pay for my services yourself to avoid the problems described
above
[unless prohibited by contract].
I am often not immediately available by telephone. Please appreciate that when I am with you I don’t take calls, so when I am with someone else the same holds true. When I am unavailable, my telephone is answered by voice mail [that can page me if needed]. I will make every effort to return your call on the same day you make it, though it may be at the conclusion of my day 9:00 pm. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist [psychiatrist] on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, when necessary. You may also communicate with me via email at drfoust@sbcglobal.net.CONTACTING ME
Your signature below indicates that you have read the information in
this document and agree to abide by its terms during our professional
relationship.
Your signature also signifies that you have been given copy of the form
describing confidentiality exceptions, fee schedule and patient rights
and responsibilities.
Signature
_________________________
date ________________________________
The California Board of Psychology directs psychologists to inform
patients that in the event we are unable to resolve any disputes, or if
you have concerns about the treatment provided you may contact the
Board
at:
1422 Howe Avenue, Suite 22
Sacramento, CA 95825-3200
800-6332322
bopmail@dca.ca.gov