Welcome to ICHANGE!
Before your first visit please read this document carefully, as it contains information about our professional services and business policies. Should you have any questions, please contact us via email at firstname.lastname@example.org.
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychotherapist and patient, and the particular problems you are experiencing. There are various methods your psychotherapist may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for active involvement on your part. In order for the therapy to be most successful, you will have to work on things you talk about with your psychotherapist, both during your sessions and at home. Psychotherapy can have risks and benefits. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, anxiety and helplessness. Your problems may temporarily worsen after the beginning of therapy. For instance, individuals seeking treatment for anxiety often notice an increase in symptom severity during the first several weeks of therapy as they learn new ways of managing their anxiety. Finally, even with best efforts, there is a risk that therapy may not bring you your desired outcomes. On the other hand, psychotherapy is well-documented to have many benefits. It 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.
The first few sessions will involve an evaluation of your goals and needs. By the end of the evaluation, your psychotherapist will be able to offer you some first impressions of what your work together 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 your psychotherapist. Therapy involves a large commitment of time, money and energy, so please be careful about the psychotherapist you select. If you have questions about your psychotherapist’s procedures, you and your psychotherapist should discuss them whenever they arise. You may, at any time, refuse treatment, request a change in treatment approach, or ask for a referral elsewhere. There are circumstances in which your psychotherapist may not be the most appropriate provider for your psychological services. This may occur if your concerns are outside the scope of your psychotherapist’s training or expertise, if your working together would create a conflict of interest, or if your psychotherapist’s approach to therapy appears not to be working after a reasonable amount of time and effort.
Your therapist will normally conduct a diagnostic evaluation that will last around 90 minutes. He or she may choose to complete this is in one to three sessions. During that time, you can both decide if your therapist is the best person to provide the services you need in order to meet your treatment goals. Meaning, if he or she is a good fit to address your particular needs. Once psychotherapy has begun, your therapist will usually schedule one 45-60 minute session per week at a time you both agree on. However, you and your therapist may decide to meet for a different length of time, and/or more or less frequently.
Sessions are billed at $80 to $225 depending upon the complexity and length of the visit. If you have insurance benefits, session fees will be billed to your insurance and reduced to the rates we have agreed to as a contracted provider to your insurance company. If you have questions about your coverage, you should contact your insurance company. Other services such as written reports, travel time, review of records, communication with other professionals, and services provided by telephone may be charged at an hourly rate as determined by your psychotherapist. If you become involved in legal proceedings that require your therapist’s participation, you will be expected to pay for all of their professional time, including preparation and transportation costs, even if they are called to testify by another party. Legal involvement may be charged at an hourly rate as determined by your therapist. If you have special financial needs, please discuss these with your therapist.
When you call the office number (517) 879-0543, or email email@example.com, you will reach our founder who will direct or address your issue or concern. Due to your therapist’s work schedule, they are often not immediately available by telephone. Generally, they will not answer the phone when they are in session. When unavailable, most therapists route their calls to a personal voicemail that they monitor and your therapist 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 unable to reach your therapist and your situation is a non-emergency, you may contact the office by telephone or email. If you are unable to reach your therapist and feel that your situation is life threatening, contact your family physician or the nearest emergency room. If your therapist will be unavailable for an extended time, they should provide you with the name of a colleague to contact, if necessary.
The law protects the privacy of all communications between a patient and a therapist. In most situations, we can only release information about your treatment to others if you sign an Authorization form that meets certain legal requirements imposed by state law and/or HIPAA. However, your signature on this Agreement provides consent that we may disclose information in the following situations:
We may communicate with another health care provider within the organization in order to coordinate continuity of care if necessary. This includes sharing clinical information with a therapist who may be providing temporary coverage while your usual therapist is out of the office.
We may occasionally consult with other health or behavioral health professionals about a case. Should yourtherapist seek such consultation, they will make every effort to avoid revealing your identity. These other professionals are also legally bound to keep any information confidential. Unless you object, they will not tell you about these consultations unless they feel that it is important to your work together.
We may access your Clinical Record for administrative purposes, including but not limited to billing insurance, conducting peer review or quality assurance activity, supervision, or for a purpose expressly authorized by the patient. Staff is trained to protect your privacy and will not release any information without permission.
We are allowed to disclose information to your health insurance company to bill your sessions or to collect past due fees.
There are some situations where we are permitted or legally required to disclose information without either your consent or Authorization:
If you are involved in a court proceeding and a request is made for information about the professional services we provided you and the records thereof, such information is usually protected by the therapist-patient privilege law. Whether we provide any information depends on:
1) your written authorization;
2) you informing us that you are seeking a protective order against our compliance with a subpoena that has been properly served on your therapist and of which you have been notified in a timely manner; or
3) a court order requiring the disclosure. If you are involved in or contemplating litigation, you should consult with your attorney about likely required court disclosures.
If a government agency is requesting the information for health oversight activities, we may be required to provide it to them.
If you file a complaint or lawsuit against us, we may disclose information as relevant for our defense.
If you file a worker’s compensation or automobile insurance claim, and your treatment is relevant to the injury involved in your claim, we must, upon appropriate request, provide information necessary for utilization review purposes.
If your therapist has reasonable suspicion that a child has suffered abuse or neglect, the law requires that the therapist file a timely report with the appropriate government agency.
If your therapist has reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred, the law requires that the therapist file a report with the appropriate government agency.
If your therapist has reason to believe that you or someone else is in imminent danger, your therapist may be required by law to take protective actions, including notifying potential victims, contacting the police, seeking hospitalization for you, or contacting family members or others who can provide protection.
In any of the above situations, we will make an effort to discuss it with you before taking action and we will limit our disclosure to what is necessary.
In the event that support group sessions are provided, you are expected to keep materials shared in the group confidential. We cannot be held responsible for a breach of confidentiality on the part of group members.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential disclosures, it is important that you discuss any questions or concerns that you may have now or in the future with your therapist. The laws governing confidentiality can be quite complex. In situations where specific advice is required, formal legal advice may be needed.
The laws and standards of the psychotherapy profession require that we keep Protected Health Information (PHI) about you in your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that are set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that are received 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 the unusual circumstance that your therapist concludes that disclosure could reasonably be expected to cause danger to the life or safety of you or another, or that disclosure could reasonably be expected to lead to your identification of the person who provided information to your therapist in confidence under circumstances where confidentiality is appropriate, you may examine and/or receive a copy of your Clinical Record, and you must request this in writing. Because these are clinical 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 therapist, or have them forwarded to another mental health professional so you can discuss the contents.
HIPAA provides expanded rights regarding Protected Health Information (PHI). You can provide a written request to 1) amend your Clinical Record; 2) request restrictions on what information in your Clinical Record is disclosed to others; 3) request an accounting of most disclosures of PHI and where they were sent; 4) request that any complaints you make about our policies and procedures be recorded in your record, and 5) receive a printed copy of this Agreement and our privacy policies.
Minors & Parents
Michigan patients under 18 years of age who are not emancipated, Michigan patients under 17 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. They should also be aware that Michigan patients over 14 years of age can consent to (and control access to information about) their own treatment, although that treatment cannot extend beyond 12 sessions or 4 months. They should also be aware that Michigan patients over 12 years of age can consent to (and control access to information about) their own treatment, although that treatment cannot extend beyond 8 (90 minute) sessions. While privacy in psychotherapy is very important, particularly with adolescents, parental involvement is also essential to successful treatment. Therefore, it may be your therapist’s policy to request an agreement from any patient between 14 and 18 years of age and his/her parents allowing the therapist to share general information with parents about the progress of treatment and the child’s attendance at scheduled sessions.
In certain cases, the therapist’s responsibility to your child may require involvement in conflicts between parents. By signing the consent form, you agree that the therapist’s involvement will be strictly limited to that which will benefit your child. This means, among other things, that you will treat anything that is said in session with the therapist as confidential. Neither parent will attempt to gain advantage in any legal proceeding from treatment with your child. You agree that in any such proceedings, neither parent will ask the therapist to testify in court, whether in person or by affidavit. You also agree to instruct your attorneys not to subpoena the therapist or to refer in any court filing to anything that has been said in treatment. If the therapist is required to testify, the therapist is ethically bound not to give any opinion about either parents’ custody or visitation suitability. If the therapist is required to appear as a witness, the party responsible for the therapist’s participation agrees to reimburse at a rate to be determined with the therapist in advance for time spent traveling, preparing reports, testifying, being in attendance, and any other case-related costs.
Payment for Services
You will be expected to pay for each session at the time it is held, unless we agree otherwise or you have insurance coverage that requires another arrangement (ie. balance to be billed to you upon receipt of the insurance processing). You are responsible for payment for all services you receive, whether or not your insurance reimburses for a portion of the charges. “No show” or “late cancel” appointments may also be billed to you. If there have been no payments on your account for more than 60 days and arrangements for payment have not been agreed upon, we have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court, which will require us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a client’s treatment is his/her name, the nature of services provided, and the amount due.
We do not anticipate collections procedures, but have established this policy so that all clients are clear as to our office procedure. If you have questions about fees, payments or your balance, please speak directly with your therapist, contact us via email at firstname.lastname@example.org.
Many health insurance plans provide coverage for necessary mental health treatment when you see a licensed therapist. It is your responsibility to know the limitations and restrictions to your insurance benefits. Note that many policies may only cover a limited number of sessions each year, may have restrictions on the licensure of the therapist you see, and may or may not provide payment for a therapist considered to be out of network with your health insurance plan. We will complete 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 fees. It is important that you find out exactly what mental health services your insurance policy covers. Great Lakes Psychology Group does not provide services through Medicaid, regardless of whether you are eligible for said benefits.
Please check your coverage carefully prior to your first session. Of course, our staff 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. You can call the number on your insurance card and ask the following questions:
Do I have benefits for outpatient mental health services?
Do I have coverage when I see an Out of Network provider?
How much is my deductible and has it been met this year?
Is there a separate deductible for mental health services?
Once we have all the information about your insurance coverage, you may discuss with your therapist what you can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. You always have the right to pay for services yourself to avoid the problems described above (unless prohibited by contract), and we are also able to provide you with a statement which you can submit to your insurance company directly for reimbursement.