Contract for Psychotherapy Services – Child

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Contract For Psychotherapy Services Child
Welcome to The Southfield Center for Development. Please take a moment to familiarize yourself with the office policies and procedures that are outlined in this contract. If there are any items that are unclear to you, please do not hesitate to ask for clarification. Also attached is a notice that explains in detail your privacy rights as mandated by state and federal guidelines, under the Health Insurance Portability and Accountability Act (HIPAA). HIPAA requires that the Center provides you with a copy of this notice and that we obtain your signature acknowledging that we have provided you with this information. When you sign this document, it also will represent an agreement between you and the Center. You may revoke this agreement in writing at any time.

Your Child’s Therapy Services:

At the start of the therapeutic process, your child and his/her therapist will typically spend a couple of sessions reviewing his/her history and evaluating his/her needs. Your child’s therapist also will spend some time discussing his or her approach to therapy and answering any questions your child may have about this process. You should evaluate this information along with your own opinions of whether you feel comfortable working with your therapist. Therapy involves a commitment of time, money, and energy, so you should be very careful about the therapist you select for your child. If you have questions about the therapist’s procedures, you should discuss them with the therapist whenever they arise. If your doubts persist, we will be happy to help you set up a meeting with another mental health professional for a second opinion.

Therapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of one’s life, your child may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, therapy also has been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But, there are no guarantees of what your child will experience. Further, there are often alternative treatments that may address some of your child’s issues, such as medication. Whenever your child’s therapist feels that an alternative treatment may be helpful, he or she will discuss this with you.

Therapy sessions are typically 50-minutes in length (one appointment hour of 60 minute duration, to allow for ten minutes of file documentation at the end of each session) and occur weekly. You and your child’s therapist will determine together a schedule of sessions that will meet your child’s needs. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation. In the case of sudden illness or other emergency, we are certainly willing to be more flexible.

Professional Fees:

Our hourly fee for psychotherapy is $220, which should be paid at the time of service. In addition to weekly appointments, the Center charges this amount for other professional services you may need. We will prorate the hourly cost if your child’s therapist works for periods of less than or more than one hour. Other services include report writing, telephone conversations lasting longer than 10 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of your child’s therapist. If you become involved in legal proceedings that require the participation of your child’s therapist, you will be expected to pay for all of his or her professional time.

If you are not directly escorting your child to the Center for his or her appointments, we require that you keep a credit card on file. Your card will be charged at time of service, and your card must be on file in advance of your child’s first session.

Contacting Your Child’s Therapist:

Our clinical staff can be reached at the Center at 203-202-7654 during business hours. Due to our type of work, we are often not immediately available by telephone when we are with patients. When we are unavailable, our telephone is answered by a voice mail that is monitored frequently. We 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 difficult to reach, please inform us of some times when you will be available. If you experience an emergency while the Center is closed, please visit your nearest emergency room. The Center does not provide 24-hour emergency support.

Illness Policy:

For the well-being and protection of all children being served at the Southfield Center, please reschedule your child’s session if he or she has had a fever or other contagious illness such as strep throat or stomach flu within 24 hours of scheduled session. If your child is taking penicillin or antibiotics please make sure they have been on them for at least 24 hours before coming in for therapy. A Few Words about Confidentiality and Privacy: The law protects the privacy of all communications between a patient and a psychotherapist. In most situations, the Center can only release information about your child’s treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this agreement provides consent for those activities. Attached to this form is a comprehensive notice of your rights regarding privacy. Please review this notice closely and discuss with us any questions you may have.

Professional Records:

Pursuant to federal guidelines, the Southfield Center keeps Protected Health Information about your child in two sets of professional records. One set constitutes your child’s clinical record. It includes information about your reasons for seeking therapy for your child, a description of the ways in which your child’s problem impacts his/her life, your child’s diagnosis, the goals that we set for treatment, your child’s progress towards those goals, your child’s medical and social history, your child’s treatment history, any past treatment records that we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and others, you may examine and/or receive a copy of your child’s clinical record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them in the presence of your child’s therapist, or have them forwarded to another mental health professional so you can discuss the contents.

Minors and Parents:

Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records unless your child’s therapist decides that such access is likely to injure the child. Because privacy in therapy is often crucial to successful progress, particularly with teenagers, it is sometimes our policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, your child’s therapist will provide you only with general information about the progress of the child’s treatment and his/her attendance at scheduled sessions. Your child’s therapist also will provide you with a summary of your child’s treatment when it is complete. Any other communication will require your child’s consent, unless your child’s therapist feels the child is in danger or is a danger to someone else. In these cases, your child’s therapist will notify you of his or her concern. Before giving parents any information, your child’s therapist will discuss the matter with your child, if possible, and do his or her best to handle any objections he/she may have.

Insurance Reimbursement:

If you have a health insurance policy, it will usually provide some coverage for mental health treatment. We will fill out forms and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of our fees. It is very important that you find out exactly what mental health services your insurance policy covers.

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. Of course, we will provide you with whatever information we can based on our experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, we will be willing to call the company on your behalf.

You also should be aware that your contract with your health insurance company requires that the Center provide it with information relevant to the services that we provide to you or your child. Your therapist is required to provide a clinical diagnosis. Sometimes we are required to provide additional clinical information such as treatment plans or summaries, or copies of your child’s entire Clinical Record. In such situations, we will make every effort to release only the minimum information about the treatment that is necessary for the purpose requested. 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, we 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. We will provide you with a copy of any report we submit, if you request it. By signing this agreement, you agree that we can provide requested information to your carrier.

Permission to Release/Exchange Information Between Southfield Center Practitioners

The Southfield Center for Development is a multidisciplinary practice that provides diagnostic, therapeutic and educational services in a collaborative environment. Our clinical and administrative team is dedicated to helping our clients achieve their full potential. The exchange of information between Southfield Center providers, including but not limited to psychologists, psychiatrists, social workers, marriage and family therapists, speech pathologists, occupational therapists, learning specialists, education advocates, nutritionists, and executive functions coaches (collectively “Providers”), is part of what allows us to provide the highest level of service to the clients we serve.

By signing this contract, you authorize information release/exchange concerning your child among Southfield Center providers. You understand that this information may be used for the provision of services, exchange of treatment information, diagnosis, progress and historical data, and continuation of the provision of services. You also understand that it is your right to revoke consent at anytime, except to the extent information has been released, obtained, or exchanged as originally permitted.