Psychotherapist-Client Contract Becca McConnell, MA, LPC-S Outpatient Services Contract Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down and questions you might have so that we can discuss them at our next meeting. When you sign this document, it will represent a binding agreement between us. Psychological Services Psychotherapy is not easily described in general statements. It varies depending on the personalities of the therapist and the client and the particular problems you bring forward. As a therapist, I will use my knowledge and professional training of human development and behavior in order to make observations about situations as well as suggest for new ways to approach them. There are many different methods I may use to deal with the problems that you hope to address. It is important for you to discuss any questions you may have regarding the treatment recommended and to have input into setting the goals of your therapy. Psychotherapy is not alike a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, 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 experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness before you experience progress. In some situations, a possible risk of marriage counseling is the decision to divorce. More often though, therapy leads to better relationships, solutions to specific problems, and significant reductions in feelings of stress. However, there are no guarantees of what results or feelings you will personally experience. Counseling Sessions Once we begin psychotherapy, I will usually schedule one 50-minute session (one appointment hour of 50 minutes duration) per week at a time we agree on. Please arrive for your session on time. I will begin and end precisely at our agreed upon scheduled time so that our sessions do not intrude on my next client’s session. In the event that a client is 15 or more minutes late for any reason, I will cancel the appointment. This is due to the fact that 35 minutes is insufficient time to properly process what we need to before the close of our session, and also since I am required to meet with those paying with insurance for a minimum of 45 minutes in order to claim your session. Cancellations Once an appointment is scheduled, that time will be reserved just for you and you will be expected to pay for it unless you provide a minimum 24 hours advance notice of cancellation. You will be required to pay my private counseling rate of $120.00 for any late cancellations or missed sessions. However, I will gladly waive this policy in the event of a true emergency that would physically prevent you from being here (such as a death in the family, personal illness, or unsafe driving conditions due to severe inclement weather). In the event of an unfortunate but non-emergency circumstance (such as getting caught in traffic or childcare arrangements falling though) I will waive the policy for you one time. All other subsequent late cancellations of this sort as well as all other reasons for missing an appointment will be billed as stated above. In the event that I must cancel your appointment because you are running 15 or more minutes late (as described in the previous section) this would also be considered a late cancellation and you would be responsible for paying for the session at my private rate of $120.00. You can cancel and/or reschedule your appointment by logging in on the scheduling page on www.BeccaMcConnell.com or by calling 512.608.2563. Please note that this number does not receive text messages. Professional Fees My private fee for therapy is $120.00 per 50-minute session and $185 per 90-minute session. 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 my involvement in your court case requires the closing of my office that day for you as well as the cancellation of all appointments scheduled on that day, I charge a flat rate of $975 for each day that you request for me to be available to you in court. Full payment for my time in court is required up front and prior to any court participation on my part. In addition to my professional time spent in court, I also charge a flat rate of $75.00 to pull, review, prepare, and send your records to anyone you have authorized me to (your attorney or primary care physician, for example). For telephone consultations with anyone you have authorized me to give information to, I charge a flat rate of $80.00 for phone calls lasting 5-30 minutes; and $120.00 for phone calls lasting 31-50 minutes. Comparable fees will be charged to the client for time spent performing other services you may request of me such as report writing, attendance at meetings with other professionals you have authorized, and preparation of records or treatment summaries. All fees described above are the responsibility of the client, parent or Legal Guardian as applicable and are not reimbursable by insurance. Billing and Payment You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment. As part of the intake paperwork, I require each client to fill out a Credit Card Payment Agreement Form which allows me to secure your credit card information for purposes of payment in the event of missed sessions or late cancellations. In this case, I will charge my private rate of $120.00 to your credit card listed on this form on the day of the missed appointment and will email you with notification of this transaction. If for some reason the transaction is unsuccessful, you will be required to pay for the missed session in order to continue receiving services from me. In the event that hiring a collection agency or going through small claims court is necessary to obtain payment, you will be responsible for paying for my expenses for these services in addition to your original balance. Insurance Reimbursement If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however you (not your insurance company) are responsible for full payment of fees. Prior to our first session, it is very important that you find out exactly what mental health services your insurance policy covers. You will need to be able to completely fill out all fields on my insurance information form. Submitting an incomplete insurance form may result in your being responsible for paying my full private rate of $120.oo per session until all requested insurance information is obtained. Once you submit this completed form to me, my billing specialist will verify the information and often this confirmation takes some time to receive from your insurance company. In the event my specialist finds a discrepancy between the information she receives from your insurance company and the information you’ve completed on your insurance form, you will be responsible for any back payment required for previous sessions held under the false terms of the information you originally submitted. In the event that you miss a session without giving me 24 hour notice, you will be required to pay my full private rate of $120.00 for the missed session. This is because insurance companies do not reimburse me for missed appointments, and without full 24 hour notice it is unlikely I will be able to fill your previously reserved session time with another client. Insurance coverage plans are often limited to short-term treatment approaches designed to work out specific, targeted problems. It may be necessary to seek approval for more therapy after a certain number of sessions. In this case, I will do what I can to petition your insurance company for additional sessions. While a lot can be accomplished in short-term therapy, some clients feel that they need more services after insurance benefits end. You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. I will provide you with a copy of any report I submit if you request it. It is important to remember that you always have the right to pay privately for my services yourself to avoid the problems described above. Contacting Me I am often not immediately available by telephone, as I will not answer the phone when I am with another client. The fastest and most efficient method to reach me is through my website, www.beccamcconnell.com. From this site you can schedule, cancel or reschedule appointments or email me with questions and concerns through the confidential messaging service I use there. If you would rather contact me by phone, my business voicemail is a confidential line that is checked only by me and I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. Please note that my office phone does not receive text messages. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the clinician/psychologist/psychiatrist on call. If I will be unavailable for an extended time, I will notify you of this ahead of time and provide you with the name of a colleague to contact, if necessary. Professional Records The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of your records upon request, or I can prepare a summary for you instead. Because these are professional records, they can by misinterpreted by 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. Minors If you are under 18 years of age, please be aware that the law gives your parents the right to examine your treatment records. When possible, I will provide them only with general information about our work together, unless I feel that there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. I will also provide them with a summary of your treatment when it is complete, and we will discuss it before I send it to them. Before giving your parents any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have about what I am prepared to discuss. Confidentiality In general, the law protects the privacy of all communications between a client and a counselor, and I can release information about our work to others only with your written permission. But there are a few exceptions. In most legal proceedings, you have the right to prevent me from providing any information about your treatment. However, a judge may order my testimony pertaining to your treatment if he or she determines that the issues demand it. While the nature of therapy is one of confidentiality, the nature of court is one of non-confidentiality. It is up to you to decide what you choose to disclose or not disclose during therapy if you think you may be involved in a court case of some kind. Because of the conflict of interest, I do not provide individual concurrent counseling for members of the same family when a separation or divorce has taken place prior to therapy. In the event that one member of a couple who receives or received marriage therapy from me goes to court (particularly in divorce or child custody cases), I will only release records to that client that pertain to them ALONE if records are requested. If records pertaining to sessions where both clients were present are requested, I need the consent of BOTH parties in order to lawfully release these records to either or both parties. 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 client’s treatment. Examples of this type of situation include but are not limited to the following: child abuse, abuse of the elderly or disabled, abuse of patients in a mental health facility, sexual exploitation, AIDS/HIV infection and the possible transmission’s criminal prosecutions, and child custody cases. If I believe that a client 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, or seeking hospitalization for the client. If the client threatens to harm him/herself, I may be obligated to seek hospitalization for him or her or to contact family members or others who can help provide protection. These situations have rarely occurred in my practice. If a similar situation occurs, I will make every effort to fully discuss it with you before taking any action. Last updated on: 10/15/14 Psychotherapist-Client Contract Becca McConnell, MA, LPC-S Your signature below indicates that you have read the information in this document and agree to abide by its terms for the duration of our professional relationship. (A separate signature is required for each person who will be involved in the therapeutic process.) Signature: ________________________________________________________________ Name (printed): ___________________________________________________________ Date: ____________________________________________________________________ Client #2 (in the case of relationship/marriage/family counseling) Signature: ________________________________________________________________ Name (printed): ___________________________________________________________ Date: ____________________________________________________________________ Client #3 (if applicable) Signature: ________________________________________________________________ Name (printed): ___________________________________________________________ Date: ____________________________________________________________________ Version 10/15/14