Download Report

AGREEMENT FOR ADULT TREATMENT
This document contains important information about the
professional services and business policies of APPLE
FamilyWorks (a California 501-C-3 corporation). Please read
this information carefully. Make note of any questions you
have so they can be discussed with your therapist.
APPLE FamilyWorks offers services to individuals, families,
couples and groups for the purpose of achieving more
adequate, satisfying and productive relationships. We have
state registered interns and trainees in our program who are
either in Masters' programs in the counseling services or
already have their Masters' degrees. We also have licensed
psychotherapists who provide supervision to intern therapists
and provide direct services.
Interns and trainees serve APPLE FamilyWorks for a one-year
to four-year contract period. At the end of their therapist
contract, you will be referred to another therapist. Referrals
will be based on your best interest.
As in all counseling/psychotherapy training centers, interns and
trainees will discuss cases in their case consultation group, and
with their group and individual supervisor, and other
professional staff, all who will maintain confidentiality.
BENEFITS, RISKS AND ALTERNATIVES TO
TREATMENT
The majority of individuals who obtain therapy benefit from
the process. Success may vary depending on the particular
problems being addressed. Therapy requires a very active effort
on your part. Self-exploration, gaining understanding, finding
ways for dealing with problems, and learning new skills, are
generally quite useful. Some risks do exist, however.
While the benefits of therapy are well known, you may
experience other feelings such as unhappiness, anger, guilt, or
frustration. These are a natural part of the therapy process and
often provide the basis for change. Important personal
decisions are often a result of therapy and are likely to produce
new opportunities as well as unique challenges. Sometimes a
decision that is positive for one family member will be viewed
negatively by another family member. There are no
guarantees; however, commitment to the process should assist
in a helpful outcome.
Evaluation and assessment help us to understand why
behaviors occur. Initial impressions about treatment plans,
suggested procedures and goals should be discussed. Your own
feelings about whether you are comfortable working with the
therapist is an important part of the process. You should
5/19/15
discuss all these issues with your therapist. If you have
questions about the services being provided at any time
during treatment, you should ask for clarification. Your
therapist will help you secure an appropriate consultation
with another mental health professional whenever it is
requested.
HOURS/AVAILABILITY
A variety of services are provided by the APPLE
FamilyWorks from 8 a.m. to 9 p.m. seven days a week.
Therapy is usually scheduled as one fifty minute session (one
"appointment hour" of fifty minutes duration) per week or
more as your treatment needs dictate and as we agree. In the
event of an urgent need after hours, you can call the county
mental health emergency number: 499-6666, your primary
care physician, or the local hospital emergency room. For a
non-urgent and confidential message you can call the voice
mail number provided by your therapist. at (415) 492-0720,
ext. _______.
CONFIDENTIALITY
The confidentiality of communications between the patient
and therapist is important and, in general, is legally protected.
Normally, information can be released only with your written
permission. There are, however, some exceptions. For
example, reports may be required in suspected cases of abuse
of a child, elderly or disabled person or where a person may
be a danger to him/herself or another. In most legal
proceedings, you have the therapist-patient privilege to
protect information about your treatment. However, certain
court proceedings, actions before the Board of Behavioral
Sciences, or other legal activity may limit your ability to
maintain confidentiality. Where treatment/evaluation is done
for or paid for by another party, or evaluations performed as
part of a court procedure, the information may be released.
APPLE FamilyWorks will furnish only the information
necessary to obtain reimbursement when you expect a third
party to pay for some part of the costs of services and/or
when processing your client payments.
In addition, when your therapist is away, another therapist
will be on call and will be advised of specific treatment issues
that could arise. Occasionally, your therapist may find it
helpful to consult on your case with other professionals. Such
consultations are also legally bound by laws of
confidentiality. In the event group therapy services are
provided, it is acknowledged that the therapist cannot be held
responsible for a breach of confidentiality on the part of the
group members.
©2010 APPLE FamilyWorks. All Rights Reserved
Treatment/Evaluation Agreement continued:
When payment for services is past due (not paid within 8 days
of service or before the last day of the month in which service
was provided, whichever is less) the client information
regarding their past due account may be released to a collection
agency.
RELEASE OF INFORMATION
Most insurance agreements require you to authorize your
therapist to provide clinical information, a diagnosis, a
treatment plan or summary. Once the insurer has this
information, the therapist will have no control over what the
insurance company does with the information.
In order to more appropriately provide care, it is important that
we obtain records or a summary from any previous treating
professionals. Your agreement to the release of previous
treatment records will assist in our work together. Please
provide information on previous services received on the client
release forms provided.
When treatment is part of a legal agreement, a court order, an
agreement with Social Services, or a third party referral, the
clients shall inform the therapist, provide copies of appropriate
documents, and including the names of contact persons on a
signed release form provided by APPLE FamilyWorks.
You are entitled to receive a copy or a summary of your
Protected Health Information, unless your therapist believes
that seeing it would have negative consequences to you. In
that case, he/she will provide the record to an appropriate
mental health professional of your choice. Professional records
can be misinterpreted and/or upsetting, therefore we
recommend that if you wish to see your records, you review
them with your therapist so you can discuss any questions you
may have.
PAYMENT AND FEES
Fees are to be paid at the time of services. You are responsible
for payment of the fees to which we have agreed. It is your
responsibility to bill your insurance company. It is very
important for you to find out exactly what mental health
services your policy covers. In some cases, advance
authorization may be necessary.
You are responsible to pay a fee of $.10 per page and $24.00
per hour for clerical services to photocopy, collate and/or mail
documents. Please allow a minimum of five (5) working days
for processing your request.
Services provided by your therapist including preparation
and/or creation of the documents to be photocopied,
communication regarding your treatment, or other therapeutic
services will be charge at the therapist hourly fee at the time of
the provision of services.
5/19/15
Application for a fee reduction requires completion of
certain forms which will be part of your client file. Sliding
scale is based on all sources of income and expense
reduction benefits for the household/family.
Individual/Family Therapy 50 minute session fee:
$____________
Other services such as home visits (including travel time),
attendance at meetings, authorized consultations, or
telephone conversations longer than 5 minutes, or other
services you may request, are billed in a prorated basis.
There is a $25 charge on all returned checks. When payment
for services is past due (not paid within 8 days of service or
before the last day of the month in which service was
provided, whichever is less) the client information regarding
their past due account may be released to a collection
agency. Interest of 12% per annum will apply to balances
over 60 days.
The same hourly rate will be billed for any appointment
missed or canceled without 24-hour notice. Please call me
directly at (415) 492-0720, ext. _____ to cancel an
appointment. (The telephone automatically records the time
and date of the call.)
 Yes, you may provide APPLE FamilyWorks’ program
updates by mail or email:
_____________________________________________
Yes, cellular phones may be used for communication
between my therapist and me.
ACKNOWLEDGMENT OF AGREEMENT
I have read and I understand the above information. I agree
to its terms for myself, family, and/or my minor children for
counseling services with APPLE Family Works’ staff.
1. _____________________________
(Signature of Client/Parent if Minor)
______________
(Date)
Name (printed):__________________________________
2. _____________________________
(Signature of Client/Parent if Minor)
______________
(Date)
Name (printed):__________________________________
_____________________________________________
(Signature of Therapist)
(Date)
Name (printed)__________________________________
©2010 APPLE FamilyWorks. All Rights Reserved