OUTPATIENT SERVICES CONTRACT
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.
PSYCHOLOGICAL SERVICES
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.

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.

MEETINGS
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.

PROFESSIONAL FEES
SERVICES                                                                                   FEES QUOTED PER SESSION
CONSULTATION\EVALUATION                                                                       $175.00
INDIVIDUAL                                                                                                         $145.00
FAMILY THERAPY   OR COUPLE 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.

PAYMENT OF FEES
 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.
INSURANCE
 A monthly statement will contain all the information necessary for your insurance company. Attach your insurance claim form to the statement and submit it.
CONFIDENTIALITY
 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. There are times when a release of information will be requested so I can coordinate care with your psychiatrist or primary care physician.
DELINQUENT ACCOUNTS
 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.
 If any of the foregoing provisions are unsatisfactory please make alternative stipulations prior or during your fist appointment. Signing below indicates that you have read and understood these conditions.
__________________________________    _____________
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, it is not uncommon for people to require services beyond insurance benefits. 

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.

I have withdrawn from many insurance panels as a result of the intrusion and limitations imposed upon the provider of care that interferes with treatment in addition to the fee structure that was in place 30 years ago.

CONTACTING ME
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.
however, remember that the internet is not a confidential means of communicating.
PROFESSIONAL RECORDS
The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of the records unless I believe that seeing them would be emotionally damaging, in which case I will be happy to send them to a mental health professional of your choice. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. I recommend that you review them in my presence so that we can discuss the contents. Patients will be charged an appropriate fee for any time spent in preparing information requests.
MINORS
If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from parents that they agree to give up access to your records. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. I will also provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss

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