OFFICE INFORMATION AND
OFFICE POLICIES
I am honored that you have selected me for
professional services. I will do my best to assist you in making this
experience meaningful and fruitful.
This information is intended to inform you about
office practices and policies. Because your relationship with your
psychotherapist is based on confidence and trust, it is important to be fully
informed about some key elements of that relationship. Please be assured that I
will be happy to discuss these issues with you in detail so that you may feel
comfortable with them. This form also serves to document that these issues have
been discussed. I will provide a copy for you if you would like. Please ask if
you need clarification on any information in these intake forms.
Psychological Services:
I provide a range of psychotherapy and
consulting services, including individual, couple, and family therapy. I am
also an Employee Assistance Professional. I am a Licensed Marriage and Family
Therapist, Licensed Chemical Dependency Counselor, Licensed Professional
Counselor and a Clinical Member of the American Association for Marriage and
Family Therapy.
Psychotherapy is not easily described in general
terms. It varies depending on the personalities of the therapist and client(s),
and the particular problems you are experiencing. There are many different
methods I can 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.
We will take time periodically to discuss your
goals in this process. Therapy is a joint effort between psychotherapist and
client, the results of which cannot be guaranteed. Progress depends on many
factors, including motivation, timing and other life circumstances such as
interaction with family, friends and associates.
Psychotherapy can have benefits and risks. Since
therapy sometimes 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 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 you will experience. It is important that we discuss any questions, discomfort,
or concerns you have regarding the psychotherapy process and what I have said. I will
adapt the psychotherapy process to better meet your unique needs.
Medicines may sometimes have side effects. In a
similar manner, there are risks associated with seeking psychotherapy. For
example, you may feel more anxious in the beginning of the process. You may
feel reluctant to talk about personal problems with someone you have just
met. These feelings tend to decrease as you become familiar with your
therapist. Although most people report benefits from psychotherapy, a minority
indicate that they felt worse as a result of treatment.
Length of Therapy:
Length of time you spend in therapy, as well as
the frequency of your sessions, will be determined by joint discussion. You may withdraw
from therapy at any time. Should you wish to stop before you have completed
your process, I will provide you with a list of practitioners with whom you may
want to continue working.
Payment for Services:
I request that clients pay fees or co-payments
at each session unless other arrangements have been made in advance. If you
have a health insurance policy, it will usually provide some coverage for mental
health treatment. I will provide certain forms and provide whatever assistance
we can in helping you utilize your benefits. However, you (not your insurance company) are
responsible for full payment of fees. It is very important that you Find out exactly what mental
health services your insurance policy covers.
If payment for services is not made within 30
days, I may inform you in writing that future services will not he provided and
will refer you to other practitioners or community agencies. Bills that are 60
days past due may be turned over to a collection agency.
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. I will attempt to
provide you with whatever information I can based on
my experience and will try to help you understand the information.
Managed Health Care plans such as HMOs , PPOs and Employee
Assistance Programs (E.A.P.’s) often require
authorization before they provide reimbursement for mental health services. Under
these plans, it may be necessary to seek approval for more sessions
periodically. You should also be aware that contracts with health insurance
companies and E.A.P.’s generally require that I
provide them with information relevant to the services you are being provided.
I am usually required to provide a clinical diagnosis. Sometimes, additional
clinical information such as treatment plans or summaries is also required. In
such situations, I make every effort to release only the minimum information about
you that is necessary for the purpose requested by telephone, in a written
letter or a fax.
In couples therapy I take a neutral stance by
supporting both partners equally. If either of you tells me a
secret that your partner does not know, I may have to reveal it to your spouse. (i.e. you are HIV positive; you are having an affair;). My
preference is that you tell your spouse about your secret in a joint session
with me.
In family therapy I often work with parents,
children and adolescents. I make every effort to maintain confidentiality and
your trust. The law requires me to inform parents who are the guardians of
children about information involving the therapy process with their child (ren) and/or adolescent(s). Please note I can only treat child(ren) and adolescent(s) when
I obtain written permission from the legal guardian(s). When the courts have
given legal guardians the right to provide medical care, I will ask you to
provide me with these documents to include in my file.
If parents are going through a divorce and I am
asked to go to court to testify and/or provide records, you will he charged $120 an
hour for my time including time for transportation to the court and back to my
office.
A little of the time medical records are
requested. If the court asks, I have a choice to ask the judge to suppress
all or part of your records; however, the judge can refuse this. If you, the client, ask, I
will have to have you sign a release of information in my office. if you ask me for your
or another’s records, and I believe that therapeutically it would hinder your
healing, then by law, I have a choice not to turn them over to you.
Notice of Policies and Practices to
Protect the Privacy of Your Health Information
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND
MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND H0W YOU CAN GET
ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
1. Uses and Disclosures for Treatment, Payment, and Health Care Operations
Barbara Abramowitz may use or disclose
your protected health information (PHI) for treatment, payment, and
health care operations purposes with your general consent. To help clarify these
terms, here are some definitions
“PHI” refers to information in your health
record that could identify you
“Treatment, Payment and Health Care
Operations”
Treatment is when I provide,
coordinate or manage your health care and other services related to your health
care. An example of treatment would be when I consult with another health care
provider, such as your family physician, a colleague. your
insurance carrier or your EAP.
Payment is when I obtain reimbursement for your
health care. Examples of payment are when we disclose your PHI to your health
insurer to obtain reimbursement for your health care or to determine
eligibility or coverage.
Health Care Operations are activities that
relate to the performance and operation of my practice. Examples of health care
operations are quality assessment and improvement activities, business-related
matters such as audits and administrative services and ease management and care
coordination.
‘‘Use’’ applies only to activities within
Barbara Abramowitz, such as utilizing information that identifies you.
“Disclosure” applies to activities outside
of Barbara Abramowitz, such as releasing, transferring, or providing access to
information about you to other parties.
II. Uses and Disclosures Reguirin2
Authorization
I may use or disclose PHI for purposes outside of treatment, payment and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when we are asked for information for purposes outside of treatment, payment and health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes I have made about our conversation regarding individual, group, joint, or family counseling sessions or during a private telephone call. These notes are given a greater degree of protection than PHI.
You may revoke all such authorizations (of PHI
or psychotherapy notes) at any time, provided each revocation is in writing.
You may not revoke an authorization to the extent that (1) I have relied on
that authorization; or (2) if the authorization was obtained as a condition of
obtaining insurance coverage, and the law provides the insurer the right to
contest the claim under the policy.
I may use or disclose PHI without your consent
or authorization in the following circumstances:
Child Abuse: If I have cause to
believe that a child has been, or may be, abused, neglected, or sexually abused
during his or her life at any time, I must make a report of such within 48
hours to the Texas Department of Protective and Regulatory Services, the Texas
Youth Commission, or to any local or state law enforcement agency.
Abuse of the Elderly and Disabled: If I have cause to
believe that an elderly or disabled person is in a state
of abuse, neglect, or exploitation, I must immediately report such to the
Department of Protective and Regulatory Services.
Regulatory Oversight: If a complaint is
filed against a therapist with a regulatory authority, they have the authority
to subpoena confidential mental health information relevant to that complaint.
If you are HIV positive, I may inform your spouse. If you are suicidal,
homicidal or both, I have to make some therapeutic decisions such as whether to
put you in a hospital, require that you stay with a family member, friend or
coworker for 48 hours, call the intended victim, police or your doctor.
Please feel free to ask any questions you might have about the limits of confidentiality.
At any time you may discuss any concerns, issues
and or access to the psychotherapy notes. If you request a copy of my notes, I
may only release what you have said.
Partners or spouses each need to sign a written
request for their records. You may only receive copies of records by the
signature of the one who has given written consent. charge
my hourly fee for the copy of all or some of your records
Clients seen by me from an Employee Assistance
Program or Health Insurance Carrier will have their highest degree of
confidentiality maintained. Information contained in my files will not be
released without my client’s written authorization except under a legally
authorized subpoena or court order compelling disclosure. The only other times
confidentiality may be broken is under the following circumstances under the
law: (I) There is a signed subpoena, strong indication of child or elderly or
handicapped abuse or neglect; (2) there is a strong indication of sexual abuse
(3) The client has given me written consent to disclose or (4) If a client sues
me; If you are HIV positive, I may inform your spouse.
All Insurance Carriers, hospitals, Employee
Assistance Programs, and other Mental Health Professionals are subject to the
H.I.P.P.A. Act too.
H.I.P.P.A. Act requires me to get your
permission on the way I disclose information. Please answer the following by
checking off your answers:
Please indicate below how I may contact you and whether I can leave a message:
Home Phone___________________ May we leave a message (Circle One)? Yes No
Work Phone____________________ May we leave a message (Circle One)? Yes No
Cell Phone _____________________ May we leave a message (Circle One)? Yes No
U.S. Regular Mail to home address__________________________________________________________________________________________________________________________________________
Unencrypted (normal) email (address): ________________________________________________________________________
Other (Specify) __________________________________________________________
You may change the above instructions at any time by requesting another one of these forms or otherwise instructing us in writing.
ACKNOWLEDGEMENT
I have been provided a copy of the Notice of Policies and Practices to Protect the Privacy of Your Health Information and the Office Information and Office Policies. I understand and accept those policies and practices. Barbara Abramowitz is hereby granted consent to contact me as specified above, and for the use of my health information as described in those policies for Treatment, Payment and Health Care Operations.
Client Signature _______________________________ Date________________
Client Signature _______________________________ Date________________
If the client is a minor, signature of parent or guardian
______________________________________ Date __________________
Refused to Sign_______
Unable to Sign (Specify Reason)________________________________________
___________________________________________________________________
Signature of Person Documenting Refusal or Inability to Sign
____________________________
Date