Adrianna Wechsler Zimring, Ed.M., Ph.D. Licensed Clinical Psychologist Specializing in Evidence-Based Practices with Children and Adolescents

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1 Adrianna Wechsler Zimring, Ed.M., Ph.D. Licensed Clinical Psychologist Specializing in Evidence-Based Practices with Children and Adolescents PATIENT INFORMATION BROCHURE, CONTRACT & CONSENT FORM PSYCHOLOGICAL TREATMENT This document contains important information about my professional services and business policies. Please read these pages carefully so that you can make an informed decision about participating in psychological services. Please write down any questions you have so that we can discuss them at our next meeting. Your decision to participate, or to have your child participate, in psychological services is voluntary. When you sign this document, it will represent an agreement between us. PSYCHOLOGICAL TREATMENT (Psychotherapy) - A Partnership I believe that you are the expert on your life, your child's life, and the difficulties you or your child are experiencing. I am an expert on the numerous evidence-based methods, skills, and tools available to assist children, adolescents, parents and families with the difficulties they face. My goal is to partner with my patients and their families, to combine our expertise, and to bring about positive change. Psychotherapy calls for a very active effort on both our parts. In order for the therapy to be most successful, you (and your family) will have to work on the goals and skills we are targeting both during our sessions and at home. It is therefore important that you take care in selecting a therapist that fits your style and treatment goals. Our first few sessions will involve an evaluation of your needs and my recommendation for an approach to treatment. During this time, it is important that we both consider if I am the best provider for you and/or your family. I encourage you to carefully consider my recommendations along with your own comfort level working with me. Therapy involves a large commitment of time, money, and energy, so you should be very careful selecting a therapist. If, for any reason, you believe that I am not a good fit for you, I will be happy to provide referrals to other providers. I may also provide referrals to a more appropriate provider if it is therapeutically indicated (e.g., your needs are outside the scope of my clinical expertise). The goals of therapy will be determined by mutual collaboration between us. The goals we establish will be reviewed during the course of our work in order to assess and/or modify the focus of therapy according to your needs. If any questions or concerns about our work together arise at any point during treatment, please bring them to my attention. Patients usually see me once a week for a predetermined period of time, often 4 to 6 months. After that, we meet less frequently for a few months as patients and families become more comfortable and confident in using their new skills independently. Psychotherapy typically comes to an end within 6 to 9 months, although this varies with each patient. The process of ending psychotherapy, called termination, is a valuable part of our work. Ending psychotherapy should not be done casually, although either of us may end psychotherapy at any time if we believe it is in your or your child's best interest. If you wish to end psychotherapy for yourself or your child prior to our planned termination, I ask that you agree now to allow me to meet with you or your child for a final appointment so that we can review our work together and appropriately end the therapeutic relationship. We will review your initial and current goals, discuss the work we have done and progress made, identify any work that could be done in the future, and I will provide additional resources and recommendations if appropriate. Psychotherapy can have benefits and risks. While there are no guarantees of what you will experience, I only begin therapy with patients and families I think I can help. Therefore, I will begin our work together with hope and optimism about our ability to address your concerns and reach our agreed upon goals. Since therapy often involves discussing difficulties or challenges, you or your child may experience AWZphd.com AWZphd@gmail.com Nevada License: PY 0720 office: (702) fax: (702) California License: PSY Page 1 of 13

2 uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. Therapy also includes developing skills and changing patterns of behavior, both of which can be challenging and even frustrating at times. Sometimes a patient's problems may temporarily worsen after the beginning of treatment. For instance, individuals seeking treatment for anxiety often notice an increase in anxiety symptoms during the first several weeks of treatment as they learn new ways of confronting and managing their anxiety. However, psychotherapy, and Evidence-Based Practices in particular, have been shown to have significant benefits in hundreds of well-designed research studies. Therapy often leads to solutions to specific problems, increased coping skills, improved mood, reduced anxiety, improved relationships, and significant reductions in feelings of distress. APPOINTMENTS AND OFFICE POLICIES Initial Appointment - Psychiatric Diagnostic Evaluation During our initial appointment we will discuss your reasons for seeking evaluation, consultation, or treatment. I will ask you and/or your child questions regarding symptom history and any previous services. I also will provide you with more information regarding the types of services I provide, future appointments, and what to expect if we agree to work together. I typically schedule 1-2 hours for this first meeting, as we will cover a lot of information. Psychological Treatment (Psychotherapy) Appointments Treatment sessions are typically scheduled for once each week. Depending on the treatment approach, session length will be either 1 clinical hour (50 minutes of therapy) or 1.5 clinical hours (75 minutes of therapy). Missed Appointments, Canceled Appointments, or Arriving Late to Appointments I expect you to attend the appointments for which you are scheduled. If you need to cancel an appointment for any reason (including illness, childcare issues, traffic, et cetera) you must provide me with at least 24 hours advance notice of the cancelation. If you cancel an appointment within less than 24 hours of your appointment time, you will incur a $25 fee. You will be charged your full regular fee for any appointments that you do not attend and do not call to cancel. Please note that insurance companies generally will not reimburse clients for missed appointments or appointments canceled with inadequate notice. Please also note that I do not provide refunds. If you have paid in advance for an appointment that you cancel or reschedule, your previously paid fees will be applied to the next appointment (minus $25 for a cancelation with less than 24 hours notice). If you do not attend and do not call to cancel your appointment, the previously paid fee will be applied to the missed appointment. If you are late to an appointment, it is unlikely that we will be able to meet for the full time, as I will generally have another appointment after yours. If I am ever unable to start on time, I ask your understanding and assure you that you will receive the full time that we have scheduled. Office Policies My office is a safe and welcoming place for all individuals and families seeking psychological services. The following policies have been established in order to protect all individuals, family members, staff, and providers. If you are unable to comply with these policies, I retain the right to terminate your services. All adults, including parents, caregivers, spouses, and any other adult family members will behave appropriately towards Dr. Zimring, her colleagues and staff, and any other individuals in the office. All individuals, including patients and their family members, are expected to respect the privacy of all other patients and family members who come to this office. I ask that you not disclose the name or identity of other individuals you may see in my office. Page 2 of 13

3 Notice of Student Participation In my capacity as an Adjunct Assistant Professor at University of Nevada, Las Vegas and an Adjunct Clinical Instructor in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine, I mentor, teach, and supervise graduate-level practicum students, interns, residents, fellows, and postdoctoral scholars. These students may join me during interview, testing, and feedback sessions for observation and training purposes. Students may also participate directly in your care or your child's care. All students are closely supervised and are bound to the same professional standards and rules of confidentiality as I am. PROFESSIONAL FEES, PAYMENT, AND INSURANCE REIMBURSEMENT Fees and Payment Fees will be discussed and agreed upon prior to our first appointment. My fee schedule is detailed under the "Fee Agreement Form" section of this document. Your signature on this form and the "Fee Agreement Form" constitutes your agreement to pay the indicated fees. All fees may be paid by cash or check. Checks should be made out to Dr. Zimring. All payments are due at the beginning of each appointment. If you accrue 2 unpaid appointments, no further appointments will be scheduled until your balance is paid in full. If your account is delinquent for more than 60 days and arrangements for payment have not been agreed upon, I reserve the right to use a collection agency or other legal means to secure payment. In most collection situations, the only information I release regarding a patient s treatment is his or her name, the nature of services provided, and the amount due. Insurance Reimbursement I am not contracted with any private insurance companies, and am thus considered an "out-of-network" provider for many of my patients. For these patients, I am unable to bill the private insurance provider directly. However, I routinely provide patients with a "Record of Services Provided & Fees Collected" (invoice). Patients may then submit this statement to their insurance company for reimbursement (if the patient is entitled to out-of-network benefits). My patients generally report that this arrangement works well for them. Please note that not all psychological services are covered by all insurance plans. Your insurance provider may only cover a portion of my fees. I strongly encourage you to review your health insurance policy prior to meeting with me in order to determine your mental health benefits. It is your responsibility to verify the specifics of your coverage and to file all claims on your own behalf. Depending on your financial circumstances and total medical costs for any year, psychological services and the cost of transportation to and from appointments may be tax-deductible expenses. I encourage you to discuss this with a tax advisor. I am a contracted provider with the Nevada Medicaid Fee-For-Service program. For NV Medicaid patients, billing and reimbursement are handled directly through my office. However, if a patient's eligibility or coverage under Medicaid ends, the patient becomes responsible for all fees. Medicare: I am required to inform you that currently I do not provide services through Medicare, regardless of your eligibility for these benefits. You are still able to use my services, but you are responsible for all charges. CONFIDENTIALITY The information you share with me is private and will be treated with utmost care. I am legally required to keep the information you share with me confidential. Broadly speaking, the privacy of all communications Page 3 of 13

4 between a patient and a psychologist is protected by law. A psychologist can release information only with the patient's (or parent/legal guardian's) written permission. In short, I cannot disclose any of the information you share with me, or even the fact that you are a patient, unless you provide me with written consent to share specific information. My commitment to your confidentiality and privacy extends to community settings as well. In an effort to protect and respect your privacy, I may not initiate or pursue a conversation with you if we happen to meet in the community. Additionally, I do not accept friend or networking requests from clients through social media networks or online forums. There are some important exceptions to your privacy and our confidentiality agreement. In some cases I may be legally and/or ethically required to break our confidentiality agreement. These exceptions may include the following: Your Consent: I am legally permitted to disclose information if the patient or patient's representative provides me with written consent. Third Parties: If you or your child has been sent to me for evaluation or treatment by a court, school or school district, employer or other third party, that third party will expect a report from me. If this is your situation, please discuss this with me before you tell me anything you do not want the third party to know. You have a right to tell me only what you are comfortable telling. Treatment Emergencies: I may disclose information if a patient is experiencing a treatment emergency and information must be shared with other health care providers to ensure safety and protect the patient from immediate harm. Safety Emergencies: I may disclose information if a patient becomes unable to care for herself/himself, threatens to do serious physical damage to herself/himself, or threatens to do serious physical damage to another person. Under such circumstances, I will take actions within the limits of the law to prevent the patient from injuring anybody and to ensure that the patient receives proper medical care. Mandatory Reporting: I am a mandated reporter. If I have reasonable cause to believe that a minor, elderly adult, or disabled person of any age has been or will be the victim of physical abuse, sexual abuse, neglect, abandonment, exploitation, or other forms of maltreatment, I am legally required to notify appropriate authorities. Legal Issues: In general, if you become involved in a court case or proceeding, you can prevent me from testifying in court about what you have told me. This is called privilege, and it is your choice either to prevent me from testifying or to allow me to testify. However, there are some situations where a judge or court may require me to provide confidential information via court order. Court order for confidential information might include subpoena for records, subpoena for psychologist testimony under oath, or a search warrant. Additionally, if you waive privilege by filing legal or ethical charges against my practice, or me, I maintain the right to provide information that may be necessary for my defense. Continuity of Care: Patient information can be disclosed between qualified professionals. However, to share identifiable confidential information, professionals must be employed in same facility or be responsible for the same patient's care. Quality of Care: Research consistently shows that case consultation is critical to providing high quality treatment. For this reason, I consult regularly with a team of highly trained and qualified colleagues to discuss my cases. During consultation I share the minimum amount of information necessary for colleagues to understand the situation. If the individual with whom I consult is not a member of your treatment team, or someone else from whom you are receiving treatment, I will not share your name or identifying information. My colleagues are also legally and ethically required to maintain your confidentiality. Additionally, please note that in accordance with the California Civil Code, confidential information may be disclosed for quality of care reviews. Page 4 of 13

5 Criminal Activity: If psychological services were obtained in an effort to aid in the commission of a crime or to escape detection or apprehension related to a crime, privilege does not exist and our confidentiality agreement will be broken. Default on Payment: If you are behind on your bill or default on payments, I may refer your account to a collection agency. Under these circumstances, information will be released in accordance with ethical and legal requirements. Psychologist Personal Safety: I take any acts or threats of violence directed towards me or my associates very seriously. I reserve the right to communicate with the appropriate authorities should such a situation arise. These exceptions to confidentiality occur rarely. If it is ever necessary for me to break our confidentiality agreement, I will make every effort to fully discuss it with you before taking any action. I welcome any questions or concerns you may have about your privacy now or in the future. At your request I can provide you with relevant portions or summaries of the state laws regarding these issues. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep a record of our appointments and the services you receive from me. You are entitled to receive a copy of your records upon written request. Alternatively, I can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents. You may request that I correct the record if you believe an error has been made. Patients will be charged an appropriate fee for any professional time spent in responding to information requests. It is my policy to destroy patients records 7 years after the end of psychological services. If the patient is a minor at the time of psychological services, records will be destroyed 7 years after the patient reaches age 18 years (i.e., when the patient reaches age 25 years). Until then, I will keep your records in a secure place. If I must discontinue our relationship because of illness, disability, or other unforeseen circumstances, I ask you to agree to my transferring your records to another psychologist or licensed mental health professional who will assure their confidentiality, preservation, and appropriate access. CONTACTING ME OUTSIDE OF SCHEDULED APPOINTMENTS Administrative Tasks and General Communication You may call me at (702) I am rarely immediately available by telephone. While I am generally in my office between 9AM and 5PM Monday through Thursday, I do not answer the telephone when I am with a patient. Please leave me a voic and I will make every effort to return your call within 2 business days. Please provide me with times when you will be available. If you so choose, you may me for the purposes of scheduling appointments. I am unable to provide clinical services via unless this has been previously discussed, agreed upon, and incorporated into your treatment plan. Please note that electronic messages ( ) are not a secure medium for transmitting confidential information and I cannot guarantee that information transmitted will remain confidential. If you are unable to reach me and feel that you cannot wait for me to return your call, please contact your family physician, go to the nearest emergency room and ask for the psychologist or psychiatrist on call, or call 911. Clinical Services via Telephone or We will discuss the use of telephone and/or consultation during your initial appointments. If we decide to incorporate phone or consultation into our treatment plan, you will be charged based on the fees outlined in the "Fee Agreement." These fees only apply to clinical services provided via phone or Page 5 of 13

6 . Scheduling or rescheduling appointments, coordinating referrals, and other administrative communications are not considered clinical services and you will not be charged for such communications. WHAT TO EXPECT FROM OUR RELATIONSHIP As a professional, I will use my best knowledge and skills to help you. This includes following the standards of the American Psychological Association (APA). In the interests of the patient, the APA has placed the following limitations on the relationship between a psychologist and a patient. I will abide by these limitations. I am licensed and trained to practice psychology. I am not licensed or trained to practice law, medicine, finance, or any other profession. I am not able to advise you in these areas. State laws and the rules of the APA require me to keep what you tell me confidential. Please see the "Confidentiality" section of this document for more information. In your best interest, and following the APA s standards, I can only be your or your child's psychologist. I cannot have any other role in your life or your child's life. I cannot, now or ever, be a personal friend to or socialize with any of my patients or their family members. I cannot be a psychologist to someone who is already a friend. I can never have a sexual or romantic relationship with any patient (or close relation of a patient) during, or after, the course of evaluation or psychotherapy. I cannot have a business relationship with any patient (or close relation of a patient), other than the psychological services relationship. In keeping with the standards of the APA, even though you might invite me, I may not attend your family gatherings, such as parties or weddings. If you ever become involved in a divorce or custody dispute, I will not provide evaluations or expert testimony in court. You should hire a different mental health professional for any evaluations or testimony you require. This policy is based on the following: (1) My statements will be seen as biased in your favor because we have a therapy relationship; and (2) the testimony might affect our therapy relationship, and I must put this relationship first. By signing this form, you indicate that you understand and agree that I will not provide evaluations or expert testimony in court. STATEMENT OF PSYCHOLOGIST COMMITMENT It is my intention to abide by all the rules of the American Psychological Association (APA) and by the laws of my state license. As in any other relationship, problems can arise in our therapeutic relationship. If you are dissatisfied with any area of our relationship, please address your concerns to me as soon as possible. I am committed to hearing your concerns and working with you to seek solutions. If you feel that I (or any psychologist) have treated you unfairly or have broken a professional rule, please tell me. For patients who reside in Nevada: The State of Nevada Board of Psychological Examiners protects consumers of psychological services by regulating the practice of psychology. You may contact the Board of Psychological Examiners online at psyexam.nv.gov, by ing nbop@govmail.state.nv.us, by calling (775) , or writing to the following address: Board of Psychological Examiners 4600 Kietzke Lane, Bldg B-116 Reno, NV For patients who reside in California: The Department of Consumer Affairs Board of Psychology receives and responds to questions and complaints regarding the practice of psychology. You may contact the Board of Psychology online at by ing bopmail@da.ca.gov, by calling (866) , or writing to the following address: Page 6 of 13

7 Board of Psychology, 1625 North Market Blvd, Suite N-215 Sacramento, CA In my practice as a psychologist, I do not discriminate against patients based on any of the following: age, sex, marital/family status, race, color, religious beliefs, ethnic origin, place of residence, veteran status, physical disability, health status, sexual orientation, or criminal record unrelated to present dangerousness. This is a personal commitment, and it is also required by federal, state, and local laws and regulations. I will always take steps to advance and support the values of equal opportunity, human dignity, and racial/ethnic/cultural diversity. If you believe you have been discriminated against, please bring this matter to my attention immediately. Page 7 of 13

8 INFORMATION FOR MINORS & PARENTS OF MINORS INFORMATION FOR MINORS If you are under age 18 years, please be aware that your parents may have the legal right to examine your psychological treatment (psychotherapy) records. It is my policy to request a written waiver from your parents or guardians indicating that they agree to give up access to your complete psychotherapy records. If your parents/guardians agree to waive their right to access your records, I will provide them only with general information about our work together, such as our treatment goals, treatment status, and your attendance at appointments. However, if I ever become concerned that there is a high risk that you will seriously harm yourself or someone else, I may choose to share this information with your parents or guardians. In this case, I will discuss my concern and decision with you as soon as possible. At the end of your treatment, I will prepare a summary of our work together for you and your parents/guardians. We will have the opportunity to review and discuss the summary before I send it to your parents/guardians. INFORMATION FOR PARENTS OF MINORS: CONFIDENTIALITY AND YOUR MINOR CHILD When providing psychotherapy for children and adolescents, I often work closely with parents and other family members, guardians or caregivers. Indeed, a great deal of a family's therapeutic work may focus on building relationships between parents and children or working closely with parents to build and refine specific parenting or behavior management skills. However, even when parents, guardians, or other caregivers are actively involved in treatment, confidentiality between the identified patient and psychologist is essential. Confidentiality between your child and her/his psychologist is important aspect of the therapeutic relationship, as it allows for trust, honesty, and behavior change. For this reason, specific information that your child shares with me will be kept private unless your child opts to share that information. Generally, I will provide you with updates regarding treatment goals, treatment status, and attendance at scheduled appointments. Exceptions to confidentiality between myself and your child include, but are not limited to, situations in which I am concerned for your child's safety (e.g., I am concerned that she/he may hurt himself or somebody else; I am concerned that your child is being hurt or abused). By signing below you are waiving your right to access your child's complete psychological record. Parent/Guardian # 1 Signature Parent/Guardian #1 Name (Printed) Parent/Guardian #2 Signature Parent/Guardian #2 Name (Printed) Page 8 of 13

9 LEGAL CUSTODY It is my policy that all parties with legal custody of a minor (e.g. custodial and non-custodial parents who have legal custody; other legal guardians) agree to the minor's participation in psychological services. By signing below you are acknowledging this policy and indicating that you are authorized by all parties to initiate psychological services for your child. If you share legal custody of your child with another guardian and you are not fully authorized to initiate psychological services for your child please notify me immediately and indicate the names of all legal guardians below. Parent/Guardian # 1 Signature Parent/Guardian #1 Name (Printed) Parent/Guardian #2 Signature Parent/Guardian #2 Name (Printed) Names of Any and All Legal Guardians Not Listed Above: COURT TESTIMONY AND YOUR MINOR CHILD In custody proceedings, a judge may order a psychologist's testimony if the judge determines that the issues demand it. As your child's psychologist, it is my duty to provide your child with the best care possible. If I am required to provide records or testimony to the court, this may contribute to a "dual-role relationship" between myself and your child. This means that I am serving in conflicting roles (e.g., parent's witness and child's psychologist). These roles can have a negative impact on the patient, your child, for multiple reasons including potential violations of therapeutic trust, disclosure of confidential information, and other therapeutic issues. Additionally, releasing certain psychological evaluation and treatment records to the court may pose legal and ethical issues. For these reasons, unless pre-arranged before you begin psychological services, I will not provide evaluation or treatment records to the court for litigation. If I am required to release records under court order, I reserve the right to terminate psychological services. Page 9 of 13

10 PATIENT INFORMATION BROCHURE, CONTRACT & CONSENT FORM PSYCHOLOGICAL TREATMENT & CONSULTATION SIGNATURE PAGE OUR AGREEMENT I, the patient (or parent/guardian), acknowledge that I have received a copy of the "Patient Information Brochure, Contract, and Consent." My signature below indicates that I have read and discussed this agreement with my psychologist, Dr. Adrianna Wechsler Zimring, and have had the opportunity to ask questions necessary for clarification. I understand that any of the points detailed in this document can be discussed at any time. Additionally, this document and agreement are subject to change. I understand that no specific promises have been made to me by this psychologist about the results of evaluation. My signature confirms that I will act in accordance with the terms detailed in this document and that I agree to participate in psychological services with this psychologist. Patient Signature Parent/Guardian # 1 Signature Parent/Guardian #1 Name (Printed) Parent/Guardian #2 Signature Parent/Guardian #2 Name (Printed) Page 10 of 13

11 FEE AGREEMENT PRIVATE PAY 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. I strongly encourage you to consider my fee schedule carefully prior to your initial appointment. I also encourage you to review your health insurance policy to determine your mental health benefits, any limitations on these benefits, if you are entitled to out-of-network benefits, and any reimbursement rates. My fee schedule is listed below. CPT Codes are included in order to assist in your communication with your insurance provider. Unless otherwise discussed and agreed upon in writing, you are solely responsible for payment of fees as listed. Payment is due at the beginning of each appointment and may be paid via check or cash. CPT Code Service Provided Time Fee Psychiatric Diagnostic Evaluation Initial Appointment minutes $ Psychiatric Diagnostic Evaluation Consultation Appointment minutes $ Individual Psychotherapy 60 minutes $ Individual Psychotherapy 90 minutes $ Family Psychotherapy without Patient Present 60 minutes $ Family Psychotherapy with Patient Present 90 minutes $ :GT Teletherapy Individual Psychotherapy 60 minutes $ , Evaluations for ages birth through 5 years* Varies* $ , , Evaluations for ages 6 through 25 years* Varies* $2500 /Phone and telephone consultation 10 minutes $25 Document Document review and consultation 10 minutes $25 Missed Appt Missed appointments Time as scheduled Full Fee Late Cancel Appointment Cancelled without 24 hour notice Time as scheduled $25 ISF Insufficient Funds (Returned Check) N/A $25 * Psychological, Neuropsychological, Psychoeducational, and Neurodevelopmental Evaluation is billed at a flat rate although time and CPT codes vary based on the referral question and the patient's developmental level. Please speak with me directly if you have any questions. Occasionally, patients request additional services such as supplemental reports, attendance at meetings, school visits or conferences, consultation with other providers, or other services not included in weekly psychotherapy or evaluation. My fee for such services is $175/hour. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $250/hour for preparation and attendance at any legal proceeding. If you have questions or concerns regarding fees, I encourage you to speak with me directly. I am committed to providing need-based financial assistance on a limited basis. If the financial commitment required for my services exceeds your resources, you may choose to contact your insurance provider for Page 11 of 13

12 assistance locating an in-network mental health provider. I may be able to provide you with appropriate referrals as well. For Parents of Minors The parent who brings the child is responsible for payment in full at the time of service. If the child attends a session without the parent, payment will need to be sent with the child or provided in advance. In the case of separated or divorced parents, where one parent is court-ordered to pay for services, a copy the court-order in its entirety must be provided before this information can be used. Additionally, in the case of separated or divorced parents where both parents have legal custody, both parents are required to review and sign Fee Agreement and the complete Patient Information Brochure, Contract & Consent Form. Fee Agreement Summary I hereby acknowledge having received and reviewed the information contained in this document with Adrianna Wechsler Zimring, EdM, PhD. I have had the opportunity to ask questions for clarification. I understand that my agreed upon fee of is due at the beginning of the first psychological evaluation appointment, unless other arrangements have been made in advance and documented in writing. All fees may be paid by cash or check. Checks can be made out to Dr. Zimring. I understand that I am responsible for all fees, even if I expect these charges to be covered by my insurance company or any other third party payer. I understand that I am responsible for submitting all insurance claims on my own behalf. I understand that any insufficient funds (NSF) or returned checks may be subject to a $25 fee. I understand that I will be charged for missed appointments or appointments canceled with less than 24 hours notice. I understand that my insurance company will not reimburse me for missed appointments or appointments canceled with insufficient notice. Additionally, I understand that telehealth, phone and consultation, and document review are not typically covered by insurance, and that I may not be reimbursed for these charges. I understand that Dr. Zimring does not provide refunds. I understand that any and all unpaid balances may be turned over to a collection agency. Patient Signature Parent/Guardian # 1 Signature Parent/Guardian #1 Name (Printed) Parent/Guardian #2 Signature Parent/Guardian #2 Name (Printed) Page 12 of 13

13 PATIENT BILL OF RIGHTS Source: California Board of Psychology The following items are provided as informational guidance to consumers. This resource is provided as an educational tool to assist consumers to help themselves find quality professional mental health services when needed. This "Patient Bill of Rights" is not a mandate set forth in law and cannot be enforced by any licensing board or other authority. You have the right to: Request and receive information about the psychologist's professional capabilities, including licensure, education, training, experience, professional association membership, specialization, and limitations. Verify licensure of the psychologist and receive information about any license discipline. In California you can do this on the Board of Psychology website at by clicking on "License Verification." In Nevada you can do this on the Board of Psychological Examiners website at and clicking on "Licensing/Certification." Have written information about fees, methods of payment, insurance reimbursement, number of sessions, length of sessions, professional assistance when your psychologist is not available (in cases of vacation and emergencies), and cancellation policies before beginning therapy. This kind of information is referred to as informed consent. Know the limits of confidentiality and the circumstances in which a psychologist is legally required to disclose information to others. Receive a verbal or written treatment plan. Have a safe environment, free from sexual, physical or emotional abuse. Expect that your psychologist should not involve you in any social or business relationship that conflicts with your therapy relationship. Ask questions about your therapy or psychological assessment. Refuse to answer any question or disclose any information you choose not to reveal. Request that the psychologist inform you of your progress. Know if there are supervisors, consultants, students, registered psychological assistants or others with whom your psychologist will discuss your case. Refuse a particular type of treatment or end treatment at any time without obligation or harassment. Refuse or request electronic recording of your sessions. Request and (in most cases) receive a summary of your records, including the diagnosis, treatment plan, your progress, and type of treatment. Report unprofessional behavior by a psychologist. Receive a second opinion at any time about your therapy or about your psychologist's methods. Receive referral names, addresses and telephone numbers in the event that your therapy needs to be transferred to someone else and to request that a copy or a summary of your records be sent to any therapist or agency you choose. Page 13 of 13