Agreement for Psychotherapy Services
Welcome to my practice! This agreement contains important information about my professional services and business policies. Please read it thoroughly and bring up any matter you would like to discuss further. When you sign this document, it will represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding, unless we have taken action in reliance on this agreement; if you have not satisfied any financial obligations you have incurred.
INITIAL CONSULTATION
I offer a low fee, no obligation consultation of $75.
I only accept cash, check and credit card at this time. All fees are due at the beginning of the session.
Office Hours
By appointment in office or for virtual sessipns.
Psychological Services
Initial appointments will involve an evaluation of needs. By the end of the evaluation, I will be able to offer you some initial impressions about what our work together may include and recommendations for getting help, including psychotherapy. If so, I may or may not be able to provide you with psychotherapy, depending on your overall needs. Wherever you choose to obtain treatment, you should evaluate the information from your initial assessment along with your own opinions of what sort of treatment you are willing to do and whether you feel comfortable working with the treating clinician. Therapy involves a large commitment of time, energy, and often money, so you should be selective about the psychotherapist you select.
Psychotherapy is not easily described and often varies depending on the particular problems you are experiencing, the therapeutic methods used by your psychotherapist, and the personalities of the psychotherapist and client. There are many different methods psychotherapists may use to deal with the problems that you hope to address and in order for the therapy to be most successful, you will have to work on things that are discussed both during your sessions and on your own.
Psychotherapy can have benefits and risks. Therapy often involves discussing unpleasant aspects of your life and you may experience uncomfortable feelings like sadness, guilt, anger, shame, frustration, loneliness, and helplessness. The changes you make in therapy may also affect your relationships in unexpected ways. Psychotherapy also 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.
Sessions and Fees
The fee for services are $180 per therapy hour. Psychotherapy sessions are usually scheduled once a week for 50 minutes. Longer or more frequent sessions can be arranged. Payment of fees is required at the time counseling is provided unless other arrangements have been made. You are expected to pay for appointments not canceled 1 (one) week in advance, as your appointment time is set aside specifically for you. There is a $15.00 service fee for any returned check.
Phone Services
I do provide phone counseling and collateral work when appropriate and necessary. Phones sessions are billed at the same hourly rate as a regular session. If a phone call is under 15 minutes, there is no charge. If a telephone call is over 15 minutes, it is will be billed “pro-rated”.
Insurance Reimbursement
I do not accept insurance for services. I can provide a "Superbill" which you submit to your insurance for a reimbursement. All fees are due at time of service.
You will be provided a copy of the Notice of Privacy Practices. (see below)
Confidentiality
In accordance with professional ethics and California law, the information revealed in psychotherapy is confidential and will not revealed to anyone without your written consent, except as required by law. There are some situations where a psychotherapist is permitted or required to disclose information without either your consent or authorization:
Minors and Parents
Privacy in psychotherapy is often crucial to successful progress, particularly with adolescents and teenagers. Nonetheless, I realize that parental involvement is an essential part of the process, as such I am open to listening to any concerns parents may have throughout the course of treatment.
Please note that the treatment of a minor without parental consent is allowed by law (Civil Code 25.9) if: The minor is 12 years of age or older, and the minor is mature enough to participate
intelligently in outpatient mental health treatment or counseling, and the minor is the alleged victim of incest or child abuse, or without such mental health treatment or counseling the minor would present a danger of serious physical or mental harm to himself/herself or others.
Emergencies
I provide clients with my confidential voice mail, where you may leave a message. I make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you need immediate assistance, dial 911, your psychiatrist (if you have one), your primary care physician, contact your local county mental health center, or go to the nearest emergency room.
Vacations
If I will be unavailable for any period of time, you will be given reasonable notice and provided with the name of a colleague to contact, should you feel the need to talk to someone in my absence. This information will also be available on my voicemail as well.
Discontinuation of Treatment
Either party may elect to discontinue treatment at any time. It is desirable to have a final closing session if a decision to discontinue is made. If that decision is made, I will be able to provide you with names of other referral sources if you so desire.
************************************************************************************
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I am required by law to maintain the privacy and security of your protected health information (“PHI”) and to provide you with this Notice of Privacy Practices (“Notice”). I must abide by
the terms of this Notice, and I must notify you if a breach of your unsecured PHI occurs. I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.
Except for the specific purposes set forth below, I will use and disclose your PHI only with your written authorization (“Authorization”). It is your right to revoke such Authorization at any time by giving me written notice of your revocation.
Uses (Inside Practice) and Disclosures (Outside Practice) Relating to Treatment, Payment, or Health Care Operations Do Not Require Your Written Consent. I can use and disclose your PHI without your Authorization for the following reasons:
1. For your treatment. I can use and disclose your PHI to treat you, which may include disclosing your PHI to another health care professional. For example, if you are being treated
by a physician or a psychiatrist, I can disclose your PHI to him or her to help coordinate your care, although my preference is for you to give me an Authorization to do so.
2. To obtain payment for your treatment. I can use and disclose your PHI to bill and collect payment for the treatment and services provided by me to you. For example, I might send your PHI to your insurance company to get paid for the health care services that I have provided to you, although my preference is for you to give me an Authorization to do so.
3. For health care operations. I can use and disclose your PHI for purposes of conducting health care operations pertaining to my practice, including contacting you when necessary. For example, I may need to disclose your PHI to my attorney to obtain advice about complying with applicable laws.
Certain Uses and Disclosures Require Your Authorization.
1. Psychotherapy Notes. I do not keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501; rather, I keep a record of your treatment and you may request a copy of such record at any time, or you may request that I prepare a summary of your treatment. There may be a reasonable, cost-based fees involved with copying the record or preparing the summary.
2. Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
3. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business. Certain Uses and Disclosures Do Not Require Your Authorization. Subject to certain limitations mandated by law, I can use and disclose your PHI without your Authorization for the following reasons:
1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
3. For health oversight activities, including audits and investigations.
4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
5. For law enforcement purposes, including reporting crimes occurring on my premises.
6. To coroners or medical examiners, when such individuals are performing duties authorized by law.
7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
9. For workers' compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers' compensation laws.
10.Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose
your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.
Certain Uses and Disclosures Require You to Have the Opportunity to Object.
1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend,
or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
YOUR RIGHTS YOUR REGARDING YOUR PHI
You have the following rights with respect to your PHI:
1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.
2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
3. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I
will agree to all reasonable requests.
4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.
5. The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health
care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.
6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.
7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have
agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.
HOW TO COMPLAIN ABOUT MY PRIVACY PRACTICES
If you think I may have violated your privacy rights, you may file a complaint with me, as the Privacy Officer for my practice, and my address and telephone number are:
3820 Del Amo Bl #207 Torrance, CA 90503
(310) 774-7224
You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by:
1. Sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201;
2. Calling 1-877-696-6775; or,
3. Visiting www.hhs.gov/ocr/privacy/hipaa/complaints.
I will not retaliate against you if you file a complaint about my privacy practices.
EFFECTIVE DATE OF THIS NOTICE This notice went into effect on September 20, 2013.
This form was obtained from the California Association of Marriage and Family
Therapist website 3/2014.
Welcome to my practice! This agreement contains important information about my professional services and business policies. Please read it thoroughly and bring up any matter you would like to discuss further. When you sign this document, it will represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding, unless we have taken action in reliance on this agreement; if you have not satisfied any financial obligations you have incurred.
INITIAL CONSULTATION
I offer a low fee, no obligation consultation of $75.
I only accept cash, check and credit card at this time. All fees are due at the beginning of the session.
Office Hours
By appointment in office or for virtual sessipns.
Psychological Services
Initial appointments will involve an evaluation of needs. By the end of the evaluation, I will be able to offer you some initial impressions about what our work together may include and recommendations for getting help, including psychotherapy. If so, I may or may not be able to provide you with psychotherapy, depending on your overall needs. Wherever you choose to obtain treatment, you should evaluate the information from your initial assessment along with your own opinions of what sort of treatment you are willing to do and whether you feel comfortable working with the treating clinician. Therapy involves a large commitment of time, energy, and often money, so you should be selective about the psychotherapist you select.
Psychotherapy is not easily described and often varies depending on the particular problems you are experiencing, the therapeutic methods used by your psychotherapist, and the personalities of the psychotherapist and client. There are many different methods psychotherapists may use to deal with the problems that you hope to address and in order for the therapy to be most successful, you will have to work on things that are discussed both during your sessions and on your own.
Psychotherapy can have benefits and risks. Therapy often involves discussing unpleasant aspects of your life and you may experience uncomfortable feelings like sadness, guilt, anger, shame, frustration, loneliness, and helplessness. The changes you make in therapy may also affect your relationships in unexpected ways. Psychotherapy also 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.
Sessions and Fees
The fee for services are $180 per therapy hour. Psychotherapy sessions are usually scheduled once a week for 50 minutes. Longer or more frequent sessions can be arranged. Payment of fees is required at the time counseling is provided unless other arrangements have been made. You are expected to pay for appointments not canceled 1 (one) week in advance, as your appointment time is set aside specifically for you. There is a $15.00 service fee for any returned check.
Phone Services
I do provide phone counseling and collateral work when appropriate and necessary. Phones sessions are billed at the same hourly rate as a regular session. If a phone call is under 15 minutes, there is no charge. If a telephone call is over 15 minutes, it is will be billed “pro-rated”.
Insurance Reimbursement
I do not accept insurance for services. I can provide a "Superbill" which you submit to your insurance for a reimbursement. All fees are due at time of service.
You will be provided a copy of the Notice of Privacy Practices. (see below)
Confidentiality
In accordance with professional ethics and California law, the information revealed in psychotherapy is confidential and will not revealed to anyone without your written consent, except as required by law. There are some situations where a psychotherapist is permitted or required to disclose information without either your consent or authorization:
- In cases of suspected child, dependent adult or elder abuse or neglect, I am required by law to report to the appropriative investigative agency.
- If I have reason to believe that you are danger to yourself, a danger to another person or property of another person, then disclosure must be made to an appropriate person or
agency that can address the threatened danger. - If ordered by the courts to testify or release records.
- If a client files a complaint or lawsuit against my practice, I may have to disclose relevant information regarding that client in order to testify regarding allegations.
Minors and Parents
Privacy in psychotherapy is often crucial to successful progress, particularly with adolescents and teenagers. Nonetheless, I realize that parental involvement is an essential part of the process, as such I am open to listening to any concerns parents may have throughout the course of treatment.
Please note that the treatment of a minor without parental consent is allowed by law (Civil Code 25.9) if: The minor is 12 years of age or older, and the minor is mature enough to participate
intelligently in outpatient mental health treatment or counseling, and the minor is the alleged victim of incest or child abuse, or without such mental health treatment or counseling the minor would present a danger of serious physical or mental harm to himself/herself or others.
Emergencies
I provide clients with my confidential voice mail, where you may leave a message. I make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you need immediate assistance, dial 911, your psychiatrist (if you have one), your primary care physician, contact your local county mental health center, or go to the nearest emergency room.
Vacations
If I will be unavailable for any period of time, you will be given reasonable notice and provided with the name of a colleague to contact, should you feel the need to talk to someone in my absence. This information will also be available on my voicemail as well.
Discontinuation of Treatment
Either party may elect to discontinue treatment at any time. It is desirable to have a final closing session if a decision to discontinue is made. If that decision is made, I will be able to provide you with names of other referral sources if you so desire.
************************************************************************************
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I am required by law to maintain the privacy and security of your protected health information (“PHI”) and to provide you with this Notice of Privacy Practices (“Notice”). I must abide by
the terms of this Notice, and I must notify you if a breach of your unsecured PHI occurs. I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.
Except for the specific purposes set forth below, I will use and disclose your PHI only with your written authorization (“Authorization”). It is your right to revoke such Authorization at any time by giving me written notice of your revocation.
Uses (Inside Practice) and Disclosures (Outside Practice) Relating to Treatment, Payment, or Health Care Operations Do Not Require Your Written Consent. I can use and disclose your PHI without your Authorization for the following reasons:
1. For your treatment. I can use and disclose your PHI to treat you, which may include disclosing your PHI to another health care professional. For example, if you are being treated
by a physician or a psychiatrist, I can disclose your PHI to him or her to help coordinate your care, although my preference is for you to give me an Authorization to do so.
2. To obtain payment for your treatment. I can use and disclose your PHI to bill and collect payment for the treatment and services provided by me to you. For example, I might send your PHI to your insurance company to get paid for the health care services that I have provided to you, although my preference is for you to give me an Authorization to do so.
3. For health care operations. I can use and disclose your PHI for purposes of conducting health care operations pertaining to my practice, including contacting you when necessary. For example, I may need to disclose your PHI to my attorney to obtain advice about complying with applicable laws.
Certain Uses and Disclosures Require Your Authorization.
1. Psychotherapy Notes. I do not keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501; rather, I keep a record of your treatment and you may request a copy of such record at any time, or you may request that I prepare a summary of your treatment. There may be a reasonable, cost-based fees involved with copying the record or preparing the summary.
2. Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
3. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business. Certain Uses and Disclosures Do Not Require Your Authorization. Subject to certain limitations mandated by law, I can use and disclose your PHI without your Authorization for the following reasons:
1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
3. For health oversight activities, including audits and investigations.
4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
5. For law enforcement purposes, including reporting crimes occurring on my premises.
6. To coroners or medical examiners, when such individuals are performing duties authorized by law.
7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
9. For workers' compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers' compensation laws.
10.Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose
your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.
Certain Uses and Disclosures Require You to Have the Opportunity to Object.
1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend,
or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.
YOUR RIGHTS YOUR REGARDING YOUR PHI
You have the following rights with respect to your PHI:
1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.
2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
3. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I
will agree to all reasonable requests.
4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.
5. The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health
care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.
6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.
7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have
agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.
HOW TO COMPLAIN ABOUT MY PRIVACY PRACTICES
If you think I may have violated your privacy rights, you may file a complaint with me, as the Privacy Officer for my practice, and my address and telephone number are:
3820 Del Amo Bl #207 Torrance, CA 90503
(310) 774-7224
You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by:
1. Sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201;
2. Calling 1-877-696-6775; or,
3. Visiting www.hhs.gov/ocr/privacy/hipaa/complaints.
I will not retaliate against you if you file a complaint about my privacy practices.
EFFECTIVE DATE OF THIS NOTICE This notice went into effect on September 20, 2013.
This form was obtained from the California Association of Marriage and Family
Therapist website 3/2014.
Melissa Garcia, MFT Therapy Services
1050 Duncan Avenue Suite J Manhattan Beach CA 90266
(310) 774-7224
Melissa@MelissaGarciaTherapy.com
Web Hosting by iPage
1050 Duncan Avenue Suite J Manhattan Beach CA 90266
(310) 774-7224
Melissa@MelissaGarciaTherapy.com
Web Hosting by iPage