Service Agreement

Welcome to My Practice!
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As a new client I am sure you will have many questions about who I am and how I work. I invite you to discuss any concerns you may have as it is my hope that we can establish an open communication. This agreement outlines important information that you need to have before you embark on this journey with me. Please read this carefully. Once you sign the last page, this document will represent an agreement between us.

Qualifications
I received my doctorate in Clinical Psychology from Columbia University, New York. I am a NY State Licensed Clinical Psychologist (license number: 018350). My training has been in both psychodynamic and cognitive-behavioral approaches. I have been practicing in the field of mental health for the past 15 years. My specialty is in the integration of Eastern mindfulness with Western psychology. I firmly believe in the power of now and using present-moment awareness to bring empowerment and balance into our lives. I lecture on mindful living and parenting around the world.

The Therapeutic Journey
I look at the process of therapy as a journey towards increased consciousness. The therapist, in her role as a witness ushers the client towards a state of inner integration and wholeness. During our first meetings, I will get to know you and begin to understand how it is I can help you achieve your goals. As treatment progresses, I will enlist your active participation to discover your own strength and healing potential. I firmly believe that each of us holds the key to our own healing, but have simply forgotten how to access this key. I will try my best to help you rediscover this and find a way to manifest your higher purpose. The therapeutic process can sometimes feel uncomfortable. At times, you may experience uncomfortable feelings such as sadness, guilt, anger, frustration, loneliness and helplessness. Yet, if we can learn to tolerate these emotions we have the opportunity to reach a more empowered place of living and relating to others.

Meetings
The first 2-4 sessions usually involve a history-taking as I need to learn about who you are and what your presenting issues are. I also encourage clients to use this time to decide if I am the best person to provide the services you need in order to meet your life goals. It is worth mentioning that treatment goals continually evolve as treatment continues. Once we agree on a schedule, I customarily hold individual sessions that last 50 minutes each, unless otherwise therapeutically indicated. Once the appointment time is scheduled, you will be expected to pay for it. The cancellation policy requires a 48-hour window. If you are unable to keep your appointment because of an emergency situation, I will try my best to reschedule the appointment. However, if you continually cancel appointments, without sufficient notice, we will have to reconsider our agreement and discuss the issues involved.

Contacting Me
Due to my work schedule, I am often not immediately available by telephone. I will make every effort to return your call on the same day you make it, with the exception of weekdays or holidays. If you are unable to reach me and feel that you cannot wait for me to return your call, please contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended period of time, I will provide you with the name of a colleague if necessary.

Confidentiality
The law protects the privacy of all communications between a client and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require that you provide written, advance consent. Your signature on this Agreement provides consent for these activities as follows:

  • I may occasionally find it helpful to consult other health and mental health professionals about your situation. During these consultations, I ensure that your identity is protected. The other professionals are also legally bound to keep the information confidential. If you do not object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your clinical record
  • If a client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection.

There are some situations where I am permitted or required to disclose information without either your consent or authorization:

  • If you are involved in a court proceeding and request is made for information concerning the professional services that I provide you, such information is protected by the psychologist-client privilege law. If I am ordered by the court to provide this, I may be required to follow the procedures involved therein.
  • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them
  • If a client files a complaint or lawsuit against me, I may need to disclose relevant information regarding the client in order to defend myself
  • If I am providing treatment for conditions directly related to worker’s compensation claims, I may have to submit such records, upon appropriate request, to the Chairman of the Worker’s Compensation Board on such forms and at such times as the Chairman may require.

There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice.

  • If I receive information in my professional capacity from a child or the parents or guardian or other custodian of a child that gives me reasonable cause to suspect that a child is an abused or neglected child, the law requires that I report this to the appropriate governmental agency, usually the statewide central register of child abuse or maltreatment, or the local child protective services office. Once such a report is filed, I may be required to provide additional information.
  • If a client communicates an immediate threat of serious physical harm to an identifiable victim, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client.

If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed.

Professional Records
The laws and standards of my profession require that I keep Protected Health Information (PHI) about you in your clinical record. In addition, I keep a clinical chart on each client that includes a description of your condition, your treatment goals, your treatment plan and progress in treatment, dates and fees for sessions and notes describing each therapy session. I also keep records of any consent, release, assessments, or other forms completed in the course of your therapy. Clinical records are kept in a locked file cabinet.

Minors and Parents
Clients 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. Even where parental consent is given, children over the age of 12 may have the right to control access to their treatment records. While privacy in psychotherapy is very important, particularly with teenagers, parental involvement is also essential to successful treatment, particularly with younger children. For children age 12 and over, I request an agreement between my client and his/her parents allowing me to share general information about the progress of the child’s treatment and his/her attendance at scheduled sessions. I will also provide parents with a summary recommendation either verbally or in writing when the therapy is complete. Any other communication will require the child’s authorization unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concerns, Before giving the parents any information, I will try and discuss the matter with the child, and do my best to handle any objections he/she may have.

Insurance Reimbursement
In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full and timely payment of my fees. (In other words, I bill you, you pay me, and your insurance company reimburses you.) It is therefore important that you find out exactly what mental health services your insurance policy covers.

 

Client Agreement Acknowledgement

 

 

Please provide name of Parent/Guardian if client is minor:

 

 

 

 

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