Informed Consent and Clinical Policies

THRIVE Center for ADHD and Comprehensive Mental Health Informed Consent and Clinical Policies Welcome to THRIVE. This document contains important information about our professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at your first meeting. When you sign this document, it will acknowledge your understanding of and agreement to THRIVE s policies. MENTAL HEALTH SERVICES Psychotherapy takes hard work and should follow a plan designed by client and therapist. Psychotherapy varies depending on the personal style of the clinician and client and the particular topics you bring forward. Unlike a visit to a medical doctor, psychotherapy, to be most successful, calls for a very active effort on your part by working on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Since therapy can involve discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has benefits: it often leads to better relationships, solutions to specific problems, and significant reductions in symptoms. But there are no guarantees of what you will experience as each situation is unique. Your first sessions, including the intake evaluation will involve an evaluation of your mental health needs and any relevant diagnoses. By the end of the initial evaluation (more information below), we will be able to offer you some first impressions of what our work will include and a treatment plan to follow. You should evaluate this information along with your own opinions of whether you feel comfortable working with us. Therapy involves a commitment of time, energy and financial resources, and you should be careful about the therapist you select. If you have questions about our procedures, please discuss them whenever they arise. If doubts persist, we will be happy to help you set up a meeting with another mental health professional at THRIVE or outside. 1

INTAKE EVALUATION The First Appointment The Intake Evaluation is the first step towards a treatment plan. The purpose of the intake evaluation is to get an overview of your history, prior treatment, current symptoms, and medical information. We can provide some initial impressions, a tentative diagnosis, recommendations for treatment, and suggest which clinician may be a good fit for you. We also review the concepts contained in this client services contract such as informed consent, confidentiality and, if you are being prescribed a medication, the separate Medical Consent Form. FOLLOW UP APPOINTMENTS Schedule recommended appointments. After the intake evaluation, you will be recommended to one of our professionals, who are Licensed Social Workers, Licensed Clinical Professional Counselors, Licensed Psychologists or Executive Function coaches. During the initial sessions you and your provider will work together to come up with a treatment plan that addresses the various issues you bring to Thrive and what you hope to accomplish. During this time, both you and the provider can decide if we are the best people to provide the services you need in order to meet your treatment goals. If treatment has begun, your provider will schedule you for one of two types of appointments, both of which may be submitted for reimbursement from insurance (more on insurance later): CPT Code 90834 CPT Code 90837 45 minute psychotherapy (38 to 52 minutes) 60 minute psychotherapy (53 to 67 minutes) Please note, Executive Function Coaching is not an insurance reimbursable service, as it is not conducted with a mental health professional. POLICY REGARDING APPOINTMENT CONSISTENCY Attend appointments consistently. In order to provide you with the highest level of care, we request you follow treatment recommendations, which includes appointment consistency. If there comes a period of time in which you have not seen your practitioner, we will call to check in on you and see if you would like to make an appointment. If you don t make an appointment, for any number of reasons, we need to send a letter stating your intention to discontinue services with us and we will supply you with three referrals should you wish to obtain services elsewhere. POLICY REGARDING CANCELLATIONS AND MISSED APPOINTMENTS Cancelling appointments requires two (2) business days notice. The time you reserve for an appointment is valuable. Just as you expect your practitioner to be present at all appointments, you are expected to attend all appointments. Once an appointment is scheduled, you will be expected to pay for it unless you provide two (2) business days (Monday through Friday) advance notice of cancellation. For example, if you have an appointment on Wednesday, you will need to call to cancel by the end of the 2

day on Monday (by 5 pm). For appointments scheduled on Monday, you will need to call before the end of the day (5 pm) on Thursday. Appointments may not be cancelled outside of business hours, or on weekends. Exceptions can be made if you and your practitioner both agree that you were unable to attend due to circumstances beyond your control. In our commitment to support your treatment, we will make every effort to contact each person the day before about their upcoming appointment. This reminder is a courtesy and can not be used as an opportunity to cancel the appointment. PRESCRIPTION REFILLS Call 410-740-3240 and select option #1 for Medication Refills. Give three (3) day notice. If you need a prescription refill in between appointments with your Psychiatrist, please notify us three (3) days in advance by calling 410-740-3240 and selecting option #1 for Medication Refills. This permits us to insure the best service and efficiency in processing your prescription. You can pick up the prescription from our front desk or we can mail it to you. For some prescriptions, we can call or fax a prescription directly to your pharmacy. PROFESSIONAL FEES Professional time for scheduled appointments and for auxiliary services is charged at the practitioner s hourly rate. Each provider charges an hourly fee for appointments and for other professional services you may need, charged on a pro-rated basis. Other services include report writing, telephone conversations lasting longer than ten (10) minutes, attendance at meetings you have authorized, consultation with outside professionals you are working with or have worked with in the past, preparation of records or treatment summaries, and the time spent performing any other service you may require. Prorated hourly fees can be charged for requested work or phone calls that last longer than, ten (10) minutes outside the scheduled appointment. If you become involved in legal proceedings that require your provider s participation, you will be expected to pay for their professional time even if the person is called to testify by another party. [Because of the difficulty of legal involvement, most practitioners charge an additional fee per hour for preparation and attendance at any legal proceeding.] When you are in crisis or require urgent care, it is common for you, your family or friends, or other health care clinicians, to communicate with your THRIVE provider outside of your scheduled time. This contact is critical and essential to ensuring your safety and providing competent thorough care. Check-ins less than ten minutes long will not be charged. Longer conversations with you or your family / friends / other clinicians, conversations / consultations among THRIVE practitioners and with the case manager (Rick Silver, MD or Emily Wells, PsyD) to coordinate emergent/urgent care will be charged at the providers rate in 15-minute increments. BILLING AND PAYMENTS Payment is expected at the time of service. We provide statements to submit for insurance reimbursements. 3

We are a fee-for-service provider, which means payment is collected at the time of service. At the time of service, we provide detailed statements you can submit to your insurance company for reimbursement. Please note: If someone other than you is paying for your treatment, they receive invoice statements regarding appointments which include information including the date of appointment and whether it was attended or missed. If someone other than yourself is financially responsible for payment to Thrive, we require a signed, limited release of information for disclosure of attendance and financial information. INSURANCE REIMBURSEMENT Payment at the time of service and submitting for reimbursement is your responsibility, and we are available to assist and support that process in any way we can. We will fill out a pre-authorization form if required and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled. It is very important that you find out exactly what mental health services your insurance policy covers. CONTACTING YOUR PRACTITIONER Administrative Office Hours: Mon-Thurs 8am to 5pm, and Friday 8am to 4 PM. Answering Service takes after-hours calls. Our providers have varied schedules; please make note of his or her scheduled. We provide front desk staff between the hours of 8 AM and 8:30 PM Monday through Thursday with phones answered until 5 PM and 8 AM to 4 PM Friday. After business hours, the answering service takes messages and can reach a practitioner in cases of emergency. For emergencies, the practitioner will contact you as quickly as possible. Messages left with the answering service may not be used for meeting the two (2) business day advance cancellation. We make every effort to return your call within one business day, with the exception of weekends and holidays. To facilitate calls back, please inform the front desk or answering service of some times when you will be available. If you feel that you can t wait for us to return your call, contact your family physician or the nearest emergency room and ask for the psychologist [psychiatrist] on call. If one of your practitioners will be unavailable for an extended time, we provide you with the name of an on-call colleague to contact, if necessary. PROFESSIONAL RECORDS You may request record copies or summaries. Mental health professionals are required to keep treatment records. You are entitled to receive a copy of the records unless we believe that seeing them would be emotionally damaging, or injurious to your well, being. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. At your request we can provide your records or a treatment summary to another health care clinician who is authorized to treat you (or the client) for the same condition and trained to interpret the records. At your request we can provide you a treatment summary, and a copy of that 4

summary becomes part of your medical record. Clients will be charged an appropriate fee for any professional time spent in responding to information requests, including preparation of records, fee per page for photocopying, and postage and handling. MINORS Parents of minors (under 18) have certain rights regarding child s treatment. If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. Unless we feel there is a high risk that you will seriously harm yourself or someone else, we will provide them only with general information about our work together. In this case, we will notify them of our concerns. Before giving them any information, we will discuss the matter with you, if possible, and do our best to handle any objections you may have with what we are prepared to discuss. Under Maryland law, a minor who is 16 years or older has the same capacity as an adult to consent to consultation, diagnosis, and treatment of a mental or emotional disorder by a physician, psychologist, or a clinic, but may not refuse the same if a parent, guardian, or custodian of the minor has given consent. CONFIDENTIALITY In general, law protects the privacy of all communications between a client and a mental health clinician, and we can only release information about our work to others with your written permission. But there are a few exceptions, including the following situations: 1. When ordered by a judge during legal proceedings In most legal proceedings, you have the right to prevent us from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order our testimony if he/she determines that the issues demand it. 2. When there is suspected abuse or neglect of a child (a minor under 18 years old) or a vulnerable adult (elderly person, or disabled person) In some situations, we are legally obligated to take action to protect others from harm, even if we have to reveal some information about a client s treatment. For example, if we believe that a child, elderly person, or disabled person, is being abused or neglected, we must file a report with the appropriate state agency. 3. Risk of Harm to Self or to others If we believe that a client is threatening serious bodily harm to self or to another, we are required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client. If the client threatens to harm himself/herself, we may be obligated to seek hospitalization or contact family members or others who can help provide protection. Communication Among THRIVE Practitioners: At the THRIVE Center for ADHD and Comprehensive Mental Health, we utilize a team approach where there may be multiple 5

clinicians, such as Psychiatrists, therapists, and coaches, involved in your care. We find it helpful to consult with other professionals on our team in order to provide the highest level of coordinated care. Each provider at THRIVE acting as a consultant is also legally bound to keep the information confidential unless one of the above noted three situations above occurs. We generally don t need to tell you about these consultations unless we feel that it is important to our work together. At times, this consultation occurs via email. On the signature page of this contract, you will be asked to give permission for email communications between you and your practitioner and among your treatment team. To further ensure confidentiality, it is our policy to only use first names and last initials in emails and to include the following statement, or one similar, in all emails. The following message, or one similar, is included in all our email communications: This message and accompanying documents are covered by the Electronic Communications Privacy Act, 18 U.S.C. 2510-2521, and contain information intended for the specified individual(s) only. This information is confidential. If you are not the intended recipient or an agent responsible for delivering it to the intended recipient, you are hereby notified that you have received this document in error and that any review, dissemination, copying, or taking of any action based on the contents of this information is strictly prohibited. If you have received this communication in error, please notify us immediately by E-Mail, and delete the original message. ** E-mail is not a secure form of communication, so I cannot ensure your confidentiality.** While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any issues, questions or concerns you may have at our next meeting. We can discuss these issues with you if you need specific advice, but formal legal advice may be needed because the laws governing confidentiality are quite complex. If you request, we will provide you with relevant portions or summaries of the state laws regarding these issues, which are also available online at the State of Maryland government website. 6

Please initial that you read and understand THRIVE s Informed Consent & Clinical Policies and agree to abide by its terms during my professional relationship with THRIVE practitioners. Psychotherapy takes hard work and should follow a plan designed by client & provider. (p1) The Intake Evaluation is the first step towards a treatment plan. (p2) Schedule recommended appointments. (p2) Attend appointments consistently. (p2) Cancelling appointments requires two (2) business days notice. (p3) Call 410-740-3240 & select option #1 for Medication Refills. Give three (3) days notice. (p3) Professional time for scheduled appointments and for auxiliary services is charged at the practitioner s pro-rated hourly rate. (p3) Payment is expected at the time of service. We provide statements to submit for insurance reimbursements. (p4) If I am not the bill payer, I understand and give a limited Release of Information for the bill payer to receive statements which include appointment date, cost and appointment attendance. (p4) Payment at the time of service and submitting for reimbursement is your responsibility, and we are available to assist and support that process in any way we can. (p4) Office Hours, Mon-Thurs 8a-8:30p, phones till 5p and Friday 8a to 4p. Answering Service takes after-hours calls. (p4) You may request record copies or summaries. (p5) Parents of minors (under 18) have rights regarding child s treatment. (p5) In general, law protects the privacy of all communications between a client & a mental health clinician, and we can only release information about our work to others with your written permission. (p5) Please initial for your approval: It is OK for my practitioner(s) to communicate with me via e-mail It is OK for my clinical team of THRIVE clinicians to communicate via e-mail PRINTED Client s name Signature (or Legal Guardian) Date Clinician s signature Date 7