CONSENT FOR TREATMENT AND HEALTH CARE OPERATIONS

Transcription

1 CONSENT FOR TREATMENT AND HEALTH CARE OPERATIONS I,, hereby authorize, Nancy Skelton, LCSW, (Name of client/guardian) And his/her business associates to provide treatment and carry out healthcare operation including billing. The specific operations are: a. Billing 3 rd party insurances b. Sending self pay bills to your home c. Utilizing administrative staff to carry out operations that are necessary to maintain schedules and charts d. Verifying insurance eligibility e. Contacting insurance companies for authorization to begin and to extend number of sessions f. Contacting insurance companies and primary care physicians to obtain referrals g. Allow your insurance company to review your file, including chart notes h. Other: (specify) This consent form will be in effect for a period of no more than 3 years or when all communications with third parties for payment is completed, whichever occurs first. I understand that my records are protected under the Health Insurance Portability and Accountability Act (HIPAA) and cannot be disclosed without my written consent. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it and that in any event this consent expires automatically as described above or on following date.. Signature of Client: Date: Signature of Guardian: Date:

2 AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION I,, hereby authorize, Nancy Skelton, LCSW, (Name of client/guardian) to release to and to receive from: the following information about: 1. Copies of chart notes. INFORMATION TO BE RELEASED 2. Copies of entire record, i.e., chart notes, billing information, reports prepared by therapist, etc. (not necessarily including therapist s personal notes). 3. Summary of impressions, diagnosis, treatment, response to treatment, history, recommendations, psychological test results. (may include copies of reports prepared by therapist). 4. Copies of computer-generated test reports. 5. Other (specify) PURPOSE OF DISCLOSURE This authorization allows your mental health provider to send/receive the above information to/from the above-named parties. (In addition, a thank you letter to the referring agency or individual is sometimes sent.) The specific purpose(s) of this disclosure (is/are): 1. To coordinate with other health/mental health providers 2. To obtain insurance or employment or government benefits. 3. To coordinate with attorneys, judges, probation officers, etc. 5. To coordinate with school officials/teachers, etc. 6. To obtain/provide history. 7. Other I understand that my records are protected under the Health Insurance Portability and Accountability Act (HIPAA) and cannot be disclosed without my written consent. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it and that in any event this consent expires automatically as described below. EXPIRATION DATE: Signature of Client or Parent/Guardian Date: (indicate relationship to client) Signature of Witness: Date:

3 PLEASE COMPLETE It is our hope to provide the highest quality of service. Below you will find a patient information sheet which provides our office with useful information that is helpful to our staff in contacting you, processing your billing and notifying you in case of an office closing, etc. PATIENT INFORMATION SHEET Patient Name Maiden Name Marital Status: Date of Birth SS# Parent/Guardian Complete Address City State Zip Code Length of time there Home phone # Cell Phone# Employer Work Phone# Extension Closest Relative (Not Spouse) Relationship Telephone Name of Church/Affiliation Referral Source Spouse/Legal Guardian Name Address (if different from above) Date of Birth SS# Telephone Employer Job Title Work Telephone Extension Length of time there MEDICAL INFORMATION Primary Care Physician Name Physician s Address Insurance Carrier ID# Group Policy Holder Name Policy Holder s Date of Birth: Address (if different from above) *A 24-hour cancellation notification is required. There will be a late cancellation fee charged for appointments cancelled without at least a 24 business hour notice. This fee is NOT billable to any insurance carrier. **PLEASE NOTE: You will be held liable for any collection costs and/or attorney fees in the event those services are needed to collect this debt. ***By signing this form, you are indicating that you have read and understand the accompanying office policies. Signature Date

4 Child s Name: Western New York Psychotherapy Services Child Intake Questionnaire Parent/Guardian to fill out pertaining to children 17 years and younger or if the patient still lives at home. Please complete this questionnaire about your son or daughter as accurately and completely as possible GENERAL INFORMATION Date of Birth: / / Age: Gender: Your Name: Relationship to the Child: Address City State Zip Code Phone Number (Day): Phone Number (Evening): Primary Care Physician: Phone Number: Address: FAMILY INFORMATION Please list all of the significant parental figures in the child s life Name Age Gender Relationship to the Child Highest Level of Education Occupation Contact Phone # Marital Status of the child s biological parents: Single Married Separated Divorced Remarried Living together Other: If married, date of marriage: *If divorced, date of divorce: *If divorced or separated a copy of the custody agreement must be provided If biological parents are divorced, who has legal custody of the child? Please describe the custody arrangements: Number of previous marriages & length of, mother: Number of previous marriages & length of, father: Did you adopt this child? Yes No If Yes, how old was the child when adopted?

5 Please list all of the child s siblings Name Age Gender Relationship to the Child (Biological, Step, Half, etc) Currently Living in your Home? Yes No Does this child have any behavioral or emotional challenges? (Describe) Yes Yes Yes Yes Yes Yes Yes No No No No No No No DEVELOPMENTAL HISTORY Please list any difficulties that occurred during pregnancy or delivery: Please describe any concerns related to your child s development: Briefly describe any aspects of your family or family history that you believe may have a bearing on present difficulties: HEALTH Please list all major illnesses, injuries, surgeries, accidents, or other medical conditions that your child has experienced: Dates Incident Treating Physician

6 Please list all mental health services that your child has received: Dates Reason Therapist/Psychologist Please list all psychological or psychiatric hospitalizations that your child received: Dates Reason Hospital Please list any prescription medications that your child is currently taking: Medication Dosage Reason Taken # of times of # of days a Prescribing Physician day taken week taken School Days 7 Days As Needed School Days 7 Days As Needed School Days 7 Days As Needed School Days 7 Days As Needed School Days 7 Days As Needed Please describe you child s medication compliance: Please describe any side effects from the medications: Date of last physical:

7 CURRENT REASONS for SEEKING TREATMENT: Please describe the reasons that you are seeking treatment for your child at this time: Please briefly describe the history of these concerns and list all factors that may trigger or intensify these concerns: Does your child have a history of being physically or verbally assaultive to others? Describe any concerns that you have about your child s use of alcohol, drugs and/or tobacco products: Please list the things you have tried/done to help your child: Please describe your child s strengths:

8 To your knowledge, has your child ever had any of the following? Diagnosis or Problem Yes No Person who told you this and their position (ex. 3 rd grade teach, physician, self). Do not include names. Aggression Alternating Mania and Depression (Bipolar) Anxiety Attention Deficit Hyperactivity Disorder Autism Behavior or Discipline Problems at School Conduct Disorder Depression Emotional Disturbance Hospitalized for Emotional Problems Jail or Probation Due to Problems w/ the Law Learning Disability or Dyslexia Learning Problems at School Mental Retardation Muscle Twitches or Motor Tics Nervous Breakdown Obsessive Thoughts or Compulsive Actions Oppositional Defiant Disorder Problems with Alcohol Use or Abuse Problems with Drug Use or Abuse Schizophrenia Suicide Tourette s Syndrome Trouble with the Law Other Psychological/ Behavioral Problems*

9 EDUCATION School Name: Your child s current grade in school: Typical Grades: Has your child ever been held back in school? If so, please describe the circumstances: Has your child ever been suspended or expelled? If so, please describe the circumstances: Has your child ever been tested for intellectual ability or had any other psychological testing? If so, what was the most recent date of testing? (Please provide copies of any previous testing) Please describe the results: Does your child have a 504 Plan? If so, please describe the nature of the accommodations: Does your child receive special education services? If so, please describe the nature of the services received: Does you child s teacher have concerns about your child? If so, please describe: Is your child currently participating in a school/classroom intervention? If so, please describe: Please list any concerns that you have for your child related to school:

10 PARENT DBD RATING SCALE Check the column that best describes this child. Please write DK next to any items for which you don t know the answer. Not at All Just a Little Pretty Much Very Much 1. often intrudes on others (e.g. butts into conversations or games) 2. has run away from home overnight at least twice while living in parental or parental surrogate home ( or once without returning for a lengthy period) 3. often argues with adults 4. often lies to obtain goods or favors or to avoid obligations (i.e. cons others) 5. often initiates physical fights with other members of his or her household 6. has been physically cruel to people 7. often talks excessively 8. has stolen items of nontrivial value without confronting a victim (e.g. shoplifting, but without breaking and entering, forgery) 9. is often easily distracted by extraneous stimuli 10. often engages in physically dangerous activities without considering possible consequences (not for the purpose of thrill seeking), e.g. runs into the street without looking 11. often truant from school, beginning before age 13 years 12. often fidgets with hands or feet or squirms in seat 13. is often spiteful or vindictive 14. often swears or uses obscene language 15. often blames others for his or her mistakes or misbehavior 16. has deliberately destroyed others property (other than by fire setting) 17. often actively defies or refuses to comply with adults requests or rules 18. often does not seem to listen when spoken to directly 19. often blurts out answers before questions have been completed 20. often initiates physical fights with others who do not life in her or her household (e.g. peers at school or in the neighborhood) 21. often shifts from one uncompleted task to another 22. often has difficulty playing or engaging in leisure activity quietly 23. often fails to give close attention to details or makes careless mistakes in schoolwork, work or other activities 24. is often angry and resentful

11 PARENT DBD RATING SCALE (CONT D) Not at All Just a Little Pretty Much Very Much 25. often leaves seat in classroom or in other situations in which remaining seated is expected 26. is often touchy or easily annoyed by others 27. often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace ( not due to oppositional behavior or failure to understand instructions) 28. often loses temper 29. often has difficulty sustaining attention in tasks or play activities 30. often has difficulty awaiting turn 31. has forced someone into sexual activity 32. often bullies, threatens or intimidates others 33. is often on the go or often acts as if driven by a motor 34. often loses things necessary for tasks or activities (e.g. toys, school assignments, pencils, books or tools) 35. often runs about or climbs excessively in situations in which it is inappropriate ( in adolescents or adults, may be limited to subjective feelings of restlessness) 36. has been physically cruel to animals 37. often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) 38. often stays out at night despite parental prohibitions, beginning before age 13 years 39. often deliberately annoys people 40. has stolen while confronting a victim (e.g. mugging, purse snatching, extortion, armed robbery) 41. has deliberately engaged in fire setting with the intention of causing serious damage 42. often has difficulty organizing tasks and activities 43. has broken into someone else s house, building or car 44. is often forgetful in daily activities 45. has used a weapon that can cause serious physical harm to others (e.g. a bat, brick, broken bottle, knife, gun)

12 INSTRUCTIONS: In the spaces below complete the rating at the end of each by marking an X on the lines at the points that describe how much your child s current challenges affect each area and whether you need treatment or special services for the challenges. 1a. How your child s challenges affect his/her relationship with friends No Problem Extreme Problem Definitely does not treatment or services Definitely needs need treatment or special special services 1b.. How your child s challenges affect his/her relationship with brothers or sisters (if no siblings, check here and skip to #2) No Problem Extreme Problem Definitely does not treatment or services Definitely needs need treatment or special special services 2.. How your child s challenges affect their relationship with you. No Problem Extreme Problem Definitely does not treatment or services Definitely needs need treatment or special special services 3. How your child s challenges affect their academic progress at school. No Problem Extreme Problem Definitely does not treatment or services Definitely needs need treatment or special special services 4. How your child s challenges affect their self-esteem. No Problem Extreme Problem Definitely does not treatment or services Definitely needs need treatment or special special services 5. How your child s challenges affect your family in general No Problem Extreme Problem Definitely does not treatment or services Definitely needs need treatment or special special services 6. Overall severity of your child s challenges in functioning and overall need for treatment No Problem Extreme Problem Definitely does not treatment or services Definitely needs need treatment or special special services

13 Nancy Skelton, LCSW Western New York Psychotherapy Services 3065 Southwestern Blvd, Suite Alberta Drive, Suite 211 Orchard Park, New York Amherst, New York Telephone: (716) Telephone: (716) Fax: (716) Fax: (716) Missed Appointment Fee and Late Cancellation Fee Policy I,, have read the policies given to me, which not only explain the services available to me, but also explain my responsibilities and obligations which include payment for services rendered and appropriate notice for sessions to be cancelled. I understand that a 24 hour notice is required to avoid a missed appointment or late cancellation fee. The fee will only be waived if the appointment cancelled with less than 24 hours notice 1. is filled with another client 2. or the roads are closed due to a weather emergency. We would like to emphasize that there are generally no exceptions to the above policy. In other words, the policy applies even if there is a good reason, such as an emergency that requires you to cancel your appointment. It is the practice of this office to offer courtesy calls. These are done on a daily basis. However, there are times when, due to circumstances beyond our control, we do not have that opportunity. You are responsible for keeping your appointments. Please note that any messages left with the answering service are viewed as less than 24 hours notice. Also, when canceling a Monday appointment you must phone by the appropriate time on Friday. I also understand that I am responsible for this $50.00 fee and it is not billable to my insurance. I have discussed these fees with my therapist and fully understand them. Signature: Date:

14 Western New York Psychotherapy Services COURTESY CALLS It is the preference of most clinicians at Western New York Psychotherapy Services to have the secretarial staff make courtesy calls to most of our patients one or two days before their appointment. This is to serve as a reminder but is not always possible, due to secretarial workload. Also, there are times when we make an effort to contact our patients but do not succeed, due to incorrect numbers, no answering machines, changed numbers or other reasons that may prevent us from successfully contacting you. There have also been, on extreme occasions, times when we were unable to make the calls, due to weather, illness, or other unforeseen circumstances. We wish to make it clear that although we try to call on a regular basis, you are solely responsible for the making, keeping, and/or canceling appointments in a timely fashion. Release of Liability: We would like to know if you would like to be on our courtesy call list. Please place your name, number to call, as well as whether or not we can leave messages with anyone who may pick up the phone, or disclose your appointment to the answering machine or voic , if no one answers. The only information disclosed will be the clinician s name, the date and time of the appointment. Please fill out the following below: (Print) **Name: ** (If Patient is under 18, please write both the name of Patient and your name as the Legal Parent/Guardian) Would you like to receive a courtesy call prior to your appointment: Yes No Number: ( ) - Home Cell Work Please state if we are able to verify your appointment: With family members: Yes* No *If Yes, specify: Name: Relationship: Name: Relationship: On the answering machine/voic Yes No Be aware that by signing this form you are releasing us from any liability associated with leaving information regarding your or your child s appointment. Signature: Date:

15 Western New York Psychotherapy Services 3065 Southwestern Blvd, Suite Alberta Drive, Suite 211 Orchard Park, New York Amherst, New York Telephone: (716) Telephone: (716) Fax: (716) Fax: (716) Billing Policy Please be aware that co-payments, co-insurances, etcetera are due at the time of service. A $5 (five dollar) billing fee will be added to your account if the time of service requirement is not met. If your insurance policy includes a deductible, you must pay the entire allowable fee at the time of service as well. The above billing fee applies if this requirement is not met. If your insurance company notifies us that your deductible has been met, your account will be credited the appropriate amount. If we are certain that your deductible has been met at the time of service, the appropriate co-payment or co-insurance applies. All co-payments for services provided to a child are the responsibility of the person bringing the child to the visit, even if you have a separation or divorce agreement that states otherwise. It is up to you to work out financial responsibility with the other parent. Please note that an additional fee will be added each month that the balance remains outstanding. For example, after two months the billing fee will be $10.00 (ten dollars). Also, if co-pays and/or deductibles are not made at the time of service, additional visits may not be scheduled and/or future appointments may be office cancelled. Please be aware that if, at any time, there is a change of insurance, our billing office must be notified of the new insurance information at least 3 days prior to your next scheduled appointment. If new insurance information is received at the time of your appointment, the appointment will be considered self-pay until the insurance is verified by our billing office. Not all therapists participate with every insurance plan and some plans require pre-authorization in order for the insurance company to reimburse for services provided. If you have any further questions, please feel free to contact our billing office at (716) , option 4, Monday through Friday from 9am to 4pm. (Patient/Parent Signature) (Date) (Print name)

16 WNY Psychotherapy Services 3065 Southwestern Boulevard, Suite Alberta Drive, Suite 211 Orchard Park, New York Amherst, New York Telephone: (716) Telephone: (716) Fax: (716) Fax: (716) Western New York Psychotherapy Services was created to provide a broad range of psychotherapy services within the privacy of an independent practice setting. WNY Psychotherapy Services consists of psychologists, social workers, psychotherapists, counselors, and nurse practitioners. Each therapist at WNY Psychotherapy Services is an independent provider. Each clinician has been selected on the basis of their professional competence and their concern for others. While they are associated with the network known as WNY Psychotherapy Services, each therapist is entirely independent in providing clinical or medical services. WNY Psychotherapy Services (through Zannoni Enterprises) provides each therapist in the network with secretarial, billing and other administrative staff, office space, etc. Psychotherapy records are maintained separately from those of the other providers and no other network provider is allowed access to them without your written permission. Once you have completed treatment, your therapist is responsible for storing and maintaining your clinical records. These inactive records are not stored in our facilities. In addition, WNY Psychotherapy Services does not keep a copy of the clinical record. Questions about your clinical care should be addressed to your individual therapist, not to WNY Psychotherapy Services. Likewise, checks for services rendered are made out to your specific therapist, not WNY Psychotherapy Services. In the pages that follow, we have outlined information to the questions most commonly asked. Please feel free to ask your therapist and the staff for further explanation to anything covered in this brochure. It is our hope that all of these services are provided in a professional and reassuring manner. Sincerely, Joseph Zannoni, LCSW President

17 (1) SERVICES OFFERED AT WNY PSYCHOTHERAPY SERVICES: Individual, group and marital psychotherapy for adults Family psychotherapy Testing and assessment of children and adults with learning and/or emotional disorders Individual psychotherapy for children Child custody and visitation assessment Consultation and staff development to agencies, institutions and organizations Industrial liaison programs A speakers bureau FACILITIES: AMHERST OFFICE: For your assistance, there is an elevator at the back entrance of the building. Restrooms are available on the second floor down the hall from the office. A wheelchair accessible unisex restroom is located on the second floor near the elevator. Keys for all restrooms are on the receptionist s counter. ORCHARD PARK OFFICE: There is an elevator straight down the hall from the main entrance in the hallway on both floors. Please do not leave young children unsupervised in the waiting rooms. The receptionists are neither able nor responsible to supervise them; we cannot guarantee their safety. If there are special circumstances concerning children in the waiting room, please discuss them with your therapist. ASSIGNING A THERAPIST TO YOUR CARE: Following an initial request for an appointment, the Intake office staff contacts each new patient. In doing so, it is our goal to assign the therapist who best matches your stated, specific needs. Factors such as

18 (2) work schedule, insurances and the like are also taken into consideration. At Intake, we wish to familiarize you with our policies and assist in answering your questions. We make every effort to schedule your first appointment within one week of your request. FEE AND PAYMENT POLICIES: In our experience, a clear and detailed statement regarding fee and payment policies is helpful in preventing financial misunderstandings. Such misunderstandings can adversely affect your confidence in treatment. For this reason, we make every effort to make policies clear. We understand that evaluation and treatment can be expensive. We encourage you to discuss any aspects of our billing and payment procedures with your therapist or with the Billing Department (Monday through Friday between 9:00 AM and 3:30 PM). The clinical providers are professionals with differing experience and training. The therapists fees for service have been set at different rates. These differences in rates do not reflect the therapist s skill in the practice of psychotherapy, testing, etc, rather these rates reflect an attempt on our part to offer services to individuals having varying resources and needs. Fee schedules are reviewed annually. You will be notified in advance if your therapist is expecting an increase in fees. This should allow adequate opportunity to discuss the effect of any rate increase. The clinicians at WNY Psychotherapy Services participate in a wide variety of insurance plans. They comply with all rules and requirements set forth by these insurance companies. Most companies require some for of copayments. It is the responsibility of the patient to know the extent of his/her insurance coverage. Should your insurance claim be denied for any reason, you are responsible for direct payment of fees. All co-payments and noninsurance covered self-pay fees are due in full at the time of services. There are no exceptions to this policy. ****All co-payments for services provided to a child are the responsibility of the person bringing the child to the visit, even if you have a separation or divorce agreement that states otherwise. It is up to you to work out financial responsibility with the other parent. All patient s insurance plans that require pre-authorization or referrals are the patient s responsibility. If the patient does not obtain this, services will be billed on a self-pay basis until proper authorization is obtained.

19 (3) Some individuals have the type of insurance coverage which reimburses them directly for our services. As with all healthcare, the patient or the designated responsible party is expected to provide payment directly to us at the time of service with the insurance company providing reimbursement to the patient. A patient balance may not exceed one visit without prior discussion and approval from your therapist. In such instances, patients will be notified by mail that the account must be paid or services will be interrupted after the next scheduled appointment. While we do not reduce the fees charged by any therapist, most therapists are, under certain circumstances, willing to work out various payment plans. These plans are available only under special circumstances and require prior approval by your therapist. Consultation with parents regarding their children sometimes may not be covered by your insurance plan. Different insurance carriers have different policies regarding this service. We suggest that you review your plan or contact your insurance company representative. We also recommend that you get the name of the representative who advises you. The fee for these services is at the same hourly rate as is charged for family psychotherapy. Occasionally, a therapist is required to provide expert witness testimony on behalf of a patient in a legal proceeding. There will be a fee charged for these services based both on the actual time spent in Court and on the time necessary for preparation for testimony and travel. Advance payment is required. There is no insurance reimbursement for this service. Please discuss the fee with your individual therapist. You ay wish to have your therapist attend a meeting or conference on your or your child s behalf. This situation arises most frequently when a parent requests that a child s therapist attend a school conference or when a patient requests that their therapist meet with their family physician. These services are usually not billable under most insurance plans. If you think that you might require this service, we suggest that you contact your insurance company beforehand to determine if our policy provides such reimbursement. Should you request this service, your therapist will discuss charges with you. Accounts having uncollected fees due to non-payment will follow standard collection procedures. These procedures may involve the use of a collection service for non-payment accounts and/or prosecution in the

20 (4) case of checks being returned. In the event any unpaid debt is turned over to our collection agency, the patient will be held liable for any and all collection fees and/or attorney fees needed to collect the debt. We have offered a detailed and comprehensive explanation in order to anticipate questions and avoid misunderstandings. For that reason, we have attempted to outline the roles of the patient and this office regarding fees and payment. If you have any questions regarding payments, insurance coverage or any related policies, please speak to your therapist directly or to our Billing Department. We will gladly clarify any confusion. MISSED APPOINTMENT AND LATE CANCELLATION FEE POLICIES: Our office policy requires that we be notified 24 business hours in advance of a cancellation. Sessions missed without proper notice, regardless of the reason, will be billed as a missed appointment. Insurance does not cover this charge. The missed appointment fees range from $50.00 to $ No late cancellation fee will be charged if we are able to fill the appointment with another patient. All missed appointment and late cancellation fees must be paid in full on or before the date of your next scheduled appointment unless you have an arrangement with your therapist. Failure to do so may result in all future appointments being suspended until the fee is paid. Some therapists have their own policies regarding their fees and you should discuss this policy with your therapist. This office can take appointment/cancellations calls anytime we are open at (716) (Amherst) or (716) (Orchard Park). Y(u may also leave cancellation messages with the answering service. Time requirements apply to messages left with the service; Saturday, Sunday and Holidays do not count in the 24 hours. (For example, you must cancel an appointment scheduled for 10:00 am MONDAY by 10:00 am FRIDAY.) These fees are not intended as a punishment, but rather reflect our belief that the patient should share in the cost of the reserved therapist time that cannot otherwise be utilized by another patient. PHONE CALLS: WNY Psychotherapy Services maintains offices in two locations in Erie County. Between these offices, therapists are available six days and five evenings a week. In addition, we maintain a 24-hour emergency answering service. Each provider is available for emergency after hours

21 (5) telephone calls, which can be made by dialing the Amherst office phone number (716) Should your therapist be unavailable, another therapist provides clinical coverage. We will always try to be available to you for after hour emergencies. If such an occasion arises, please advise our answering service that you are placing an emergency or urgent call. We will return your call as soon as possible. Should you require emergency service before your call is returned, you should obtain these services at the emergency room of your local hospital. Non-emergency calls will be returned the next business day by your therapist. CONFIDENTIALITY: Assuring your privacy is very important. If you are an adult, anything you say or do in the context of psychotherapy cannot be revealed to another person without your permission. For this reason, we do not have a sign-in sheet; please check in at each of your appointments. Historically, complete confidentiality has applied to communications between most types of psychotherapists and patients. However, recent legal developments have limited the scope of confidentiality as follows: If you behave in a manner that poses a threat of a physical nature to another person, your therapist will use his/her judgment in deciding whether to inform a responsible person. A therapist is to assess the degree of risk to a patient s life when suicidal feelings present themselves. If, in the therapist s opinion, there is a substantial risk of suicide, he/she will take steps to reduce the risk of suicide. If you disclose intent to commit a crime, privilege is waived. That is, psychotherapists may not tacitly aid or abet in the commission of crimes. The Law requires your therapist to report cases of potential, clear, or alleged child abuse. It is our experience that most adults having problems with child abuse want help. This if often a complex and frightening problem that seems to be best helped when a therapist can be involved in helping you while meeting the requirements of the law. In special circumstances, a judge may order that a patient s records be made available to the Court. Your therapist MUST comply with a judge s request. Your confidentiality cannot be absolutely assured in any therapy in which more than you and your therapist are present. WNY Psychotherapy Services clinicians will be extremely careful to respect your needs in that situation.

22 (6) Parents or guardians of minors (12 years old and younger) are entitled to information communicated by their children in psychotherapy. However, ethics require your child s therapist to communicate only in ways that will be helpful. For example, if your child s intellectual abilities are evaluated, they will provide you with as much helpful information as possible regarding strengths, weaknesses and potentials, but may refrain from indicating to you the IQ score itself. We require that the custodial parent be informed before a report may be released to a non-custodial parent. If a non-custodial parent wishes to have his/her child evaluated without the custodial parent s permission, please plan to discuss this problem with your therapist before scheduling an appointment for your child. Patients whose fees are covered by insurance should be aware that the insurance company might require a diagnosis and the information necessary to substantiate it. Occasionally, insurance companies review your therapist s chart records. He or she will be glad to discuss the diagnosis with you. It is assumed that when you give us an insurance form, it releases your therapist to fill out the diagnosis and other portions of that form. Your therapist is often asked to provide information or to request information from a third party. It is a common occurrence that referring physicians request an initial report and possibly a progress report from your therapist. Many insurance companies require your primary care physician to request such reports. Often by signing a contract with your insurance company, you have given written permission for your physician to receive such reports. For third party requests, you will be asked to sign a Release of Information form, without which your therapist cannot send records. It is your choice whether to sign the Release; please discuss this with your therapist. IN CONCLUSION: We make every effort to assure that your therapy will be productive. Research has shown that patient satisfaction and patient-therapist congruence correlate highly with a positive therapy outcome. Patient satisfaction is given a high priority. WNY Psychotherapy Services has conducted random patient satisfaction surveys. Ninety-three percent of the patients surveyed were highly satisfied with their treatment. (2% did not respond, 5% were dissatisfied). Patient-therapist congruence is

23 (7) another important factor in therapy outcome. Generally, patients who have similar attitudes, values and beliefs (about psychotherapy, how therapy works and what can be expected from therapy) to their therapists tend to be more successful in their therapy. Because each patient is an individual and because a variety of factors affect the outcome of treatment, it is not ethical to guarantee positive results. Occasionally, the treatment may have unexpected results. If you have any questions in this regard, please plan to discuss them with your therapist. We hope this information is helpful to you. Please keep this copy for future reference. We look forward to providing you with the highest quality standard of care in a professional, yet relaxed and comfortable atmosphere. If you have any further questions, please do not hesitate to direct them to your therapist. If they cannot answer your questions, they will direct you to the member of our staff that will be able to assist you. Thank you for choosing Western New York Psychotherapy Services.