Getting Started with Treatment
To initiate treatment, it’s essential that you have a comprehensive understanding of the therapeutic process outlined in the documents provided below. Please review these forms prior to our initial session and print out the last page of the Client Information Brochure, Notice of Privacy Practices, and Permission to Use Telepsychology, and the Medicare Opt-Out Patient Contract if you are a Medicare Beneficiary. These forms require your signature. Please bring the signature pages with you for our initial meeting. I will guide you through each document, address any inquiries you may have, and clarify any concerns. You can sign the appropriate forms while in the office and I will make a copy for your records. Your cooperation in this process is greatly appreciated.Client Bill of Rights
This document outlines your entitlements while under treatment with me. Feel free to discuss any aspects of it directly with me. I eagerly anticipate collaborating with you!
Client Information Brochure — Informed Consent and Consent Form
Prior to commencing treatment, I will provide a detailed explanation of the treatment process, known as informed consent, as outlined in my client information brochure. This includes information about my qualifications, the potential benefits and risks of treatment, treatment methods employed, confidentiality rights (as well as its limitations), anticipated duration of therapy, my approach to working with children, adolescents, and families, financial policies, service fees, and other pertinent therapy-related details. Your signature on the consent form is necessary to commence treatment. For minors, parental consent is required.
Intake Evaluation
The Initial Intake Evaluation serves as a pivotal step for diagnosis and treatment planning. I will inquire about various aspects of your life, including psychological, social, academic, career, and medical history. By the conclusion of this evaluation, together we will establish a provisional diagnosis, formulate your treatment plan, and discuss the various therapeutic methods and strategies I will employ in your treatment.
Medicare Opt-out Contract
Notice of Privacy Practices (NPP) and Consent Form
In compliance with HIPAA regulations, I am obligated to inform you about the protection of your protected health information (PHI) from unauthorized disclosure, and how it is utilized within my practice and disclosed to other covered entities (CEs) for treatment, payment, and healthcare operations (TPO). Your signature on the consent form is required to commence treatment. For minors, parental consent is necessary.
Permission for Telepsychology Visits
Request/Authorization to Release Confidential Records and Information
You have the option to authorize me to communicate with another healthcare provider regarding your care for collaborative purposes and treatment planning. The request/authorization to release confidential records and information must be signed to grant permission for this communication. For minors, parental consent is required. This authorization encompasses the release of records and provides detailed information regarding the handling of such information.