Alison J. Bomba, Psy.D.

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1 Alison J. Bomba, Psy.D. Licensed Psychologist OUTPATIENT SERVICES CONTRACT Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and note any questions you might have so that we can discuss them at the time of our initial meeting. When you sign this document, it will represent an agreement between us. PSYCHOLOGICAL SERVICES Psychotherapy is not easily described in general terms. It varies depending on the personalities of the psychologist and patient and the specific presenting concerns. There are various methods I may use to address the concerns for which you are seeking treatment. Psychotherapy sessions are unlike medical doctor visits. Instead, it requires active patient/parent participation. In order for psychotherapy to be most effective, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may at times experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people who actively participate. Therapy often leads to improved relationships, solutions to specific problems, and significant reductions in feelings of distress; however, there are no guarantees regarding what you will experience. Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, I will provide you with my initial clinical impressions and treatment recommendations. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you schedule a meeting with another mental health professional for a second opinion. APPOINTMENTS The initial diagnostic evaluation typically requires two sessions. During this time, we can both decide if I am the best professional to provide the services you need in order to meet your treatment goals. If psychotherapy is initiated, I will usually recommend one 60- minute session per week until progress is made toward treatment goals, although some treatment plans will require more frequent visits. Follow up appointments may be scheduled online via the SCHEDULE link on my website, Once an appointment is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation by leaving a voic message at The only exceptions to this rule involve the cancelling of sessions due to emergency or inclement weather Buckeystown Pike, Suite 308, Frederick, MD * Phone: * Fax: *

2 PROFESSIONAL FEES My fee for initial diagnostic evaluation sessions is $185 per 60-minute therapy hour. My fee for subsequent sessions is $160 per 60-minute therapy hour. In addition to scheduled appointments, I charge this amount for other professional services you may need, though the fee will be prorated if I work for more or less than one hour. Other services include telephone conversations lasting longer than 10 minutes, letter writing, record reviews, attendance at meetings with other professionals you have authorized, preparation of treatment summaries, and time spent performing any other service you may request of me. 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 $225 per hour for preparation and attendance at any legal proceeding. Psychological Services Diagnostic Evaluation (typically the first 2 sessions) $185/60 min. therapy hour Psychotherapy $160/60 min. therapy hour Family Psychotherapy $160/60 min. therapy hour Group Psychotherapy $80/75 min. session Environmental Observation (including travel time) Attendance at Meeting (including travel time) Review of Records Explanation and Advice to Others Preparation of Report/Letter Writing Phone Consultation Other Services Copies $0.76 per page Preparation Fee $22 BILLING AND PAYMENTS Payment is due in full at the time services are rendered. You will be expected to pay for each session at the time it is held. Payment can be provided by cash, check, or credit card. Visa, MasterCard, Discover, and American Express are accepted. Health Savings Accounts (HSA s) and Flexible Spending Accounts (FSA s) can also be used to provide payment. A fee of $25 will be applied for each returned check. Additionally, it is required that a valid credit card be placed on file to be used to provide payments for missed appointments, cancellations without 24 hours prior notice, appointments in which no other form of payment is readily available, and other services rendered (e.g., phone conversations lasting longer than 10 minutes, letter writing, record reviews, attendance at meetings with other professionals, court appearances, etc.). You will be notified of any charges being made to the credit card on file. I have the option of using legal means to secure payments for outstanding balances. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, all costs, including attorney s fees, will be included in the claim. In most collection situations, the only information I release regarding a patient s treatment is his/her name, the nature of services provided, and the amount due. 2

3 INSURANCE REIMBURSEMENT I am an out of network, fee-for-service provider; therefore, you are responsible for payment of my fees. Many health insurance plans offer out of network benefits for psychological services, which entitle patients to obtain reimbursement for a percentage of amounts paid. Once payment is received, I will provide you with a detailed receipt, to include billing and diagnostic codes, which you may submit to your insurance company when seeking reimbursement. I am happy to help you receive the benefits to which you are entitled by completing treatment plans upon request. A prorated fee of is charged for time spent preparing treatment plans. 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. It is very important that you find out exactly what mental health services your health insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. You will be responsible for submitting and processing insurance claims, keeping track of authorizations and expirations if you are approved for a limited number of sessions, and requesting new authorization before the number of visits expires. You are encouraged to call your medical insurance provider to determine which company manages your mental health benefits, whether or not you have out of network benefits as a part of your plan, whether or not preauthorization is required, and how Health Savings Accounts and Flexible Spending Accounts can be used. If you plan to seek insurance reimbursement for services rendered, you should be aware that most insurance companies require that you authorize me to provide them with a clinical diagnosis. Sometimes additional clinical information such as treatment plans, summaries, or copies of the entire record is also requested. This information will become part of the insurance company s files and will likely be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with the information once it is in their possession. In some cases, they may share the information with a national medical information databank. Per your request, I will provide you with a copy of any report I submit. CONTACTING ME I am often not immediately available by telephone. I do not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by voic that I monitor Monday through Friday during normal business hours (9:00AM 5:00PM). I will make every effort to return your call by the end of the next business day. I am generally not available after regular business hours. If you are unable to reach me in an emergency, call 911 or proceed to the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended period of time, I will provide you with the name of a colleague to contact, if necessary. Your signature below authorizes me, or my designated colleague in an emergency, to leave messages on your voic at home, your cell phone voic , and/or to contact you via . Please be advised that information transmitted on a cell phone may be at risk for interception by a third party. Please do not me content related to your therapy sessions, as is not completely secure unless proper encryption is used. 3

4 Please do not contact me via in an emergency, as s are not reviewed 24 hours per day. If you choose to communicate with me via , be aware that all s are retained in the logs of your Internet service provider. While it is unlikely that someone will view these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider. You should also know that any s I receive from you and any responses that I send to you become a part of your legal patient record. Home Phone Cell Phone Other (SIGNATURE OF PATIENT OR PARENT/GUARDIAN) (DATE) SOCIAL MEDIA Interacting: Please do not use SMS (mobile text messaging) or messaging on Social Networking sites such as Twitter, Facebook, or LinkedIn to contact me. These sites are not secure, and these messages may not be read in a timely fashion. Do not use Wall replies, or other means of engaging with me in public online if a patient/therapist relationship has already been established. Engaging with me this way could compromise your confidentiality. It may also create the possibility that these exchanges become a part of your medical record and will need to be documented and archived in your patient chart. If you need to contact me between sessions, the best way to do so is by phone. Friending: I do not accept friend or contact requests from current or former clients on any social networking sites (Facebook, LinkedIn, etc.). I believe that adding patients as friends or contacts on these sites can compromise your confidentiality and your privacy. It may also blur the boundaries of the therapeutic relationship. Following: I may post psychology news on my professional Facebook page or on Twitter. I have no expectation that you, as a patient, will desire to follow my posts/streams. However, if you visit these sites, use an easily recognizable name, and I notice that you ve liked, commented on, or followed my streams, the potential impact on your working relationship may be discussed at your next session and may result in some circumstances in a termination of therapy with me. My primary concern is your privacy. If you share this concern, there are more private ways to follow Twitter (such as using an RSS feed or a locked Twitter list), which would eliminate you having a public link to my content. You are welcome to use your own discretion in choosing whether to follow me. Note that I will not follow you in return. I only follow other health professionals on social media websites and do not follow current or former patients on blogs, Twitter, etc. My reasoning is that I believe casual viewing of patients online content can create confusion regarding whether the viewing is being done as a part of your treatment or to satisfy personal curiosity. In addition, viewing your online activities without your consent and without our explicit arrangement toward a specific purpose could potentially have a negative influence on your working relationship with me. If there are things from your online life that you wish to share with me, please 4

5 bring them into your sessions where we can view and explore them together during the therapy hour. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of the records unless I believe that seeing them would be emotionally harmful, in which case I will be happy to send them to a mental health professional of your choice. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. I recommend that you review them in my presence so that we can discuss the contents. MINORS If you are under eighteen years of age, please be aware that the law may provide your parents or guardians the right to examine your treatment records. It is my policy to request an agreement from parents/guardians when treatment begins that their access to your records are waived. If they agree, I will provide them only with general information about our work together that I determine is appropriate or necessary. I will also notify them of my concern if there is a high risk that you will seriously harm yourself or someone else. I will provide your parents/guardians with a verbal summary of your treatment upon termination of services. Before providing them with any information, I may discuss the matter with you, if possible, and do my best to handle any objections you may have with the information I plan to discuss. However, I will make the final decision as to what information I will share with your parents/guardians. CONFIDENTIALITY In general, the privacy of all communications between a patient and a psychologist is protected by law, and I can only release information about our work to others with your written permission. In the case of family, group, or couples counseling, ALL participants must provide written consent in order for any information to be released. One family member, marital partner, or group member may not waive privilege for any other. There are, however, a few exceptions. In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some proceedings, such as those involving child custody and/or those in which your emotional condition is of concern, a judge may order my testimony. There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a patient s treatment. For example, if I believe that a child, elderly person, or disabled person is being or has been abused or neglected, I must file a report with the appropriate state agency. If I believe that a patient is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, and/or seeking hospitalization for the patient. If the patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. 5

6 I may occasionally find it helpful to consult with other professionals about a case. During a consultation, I make every effort to avoid revealing the identity of the patient discussed. The consultant is also legally bound to keep the information confidential. If you do not object, I will not tell you about these consultations unless I feel that it is important to our work together. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have at our initial meeting. I will be happy to discuss these issues with you if you need general advice, but formal legal advice may be needed because the laws governing confidentiality are quite complex. Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. (PATIENT NAME) (DATE OF BIRTH) (SIGNATURE OF PATIENT OR PARENT/GUARDIAN) (DATE) ALISON J. BOMBA, PSY.D. (DATE) 6

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