AMY L. VENEZIA, LICSW
274 Main St. Suite 307
Reading, MA 01867
Phone:781-462-7037 Email: amyvenezia@horizontherapycenter.com
OUTPATIENT SERVICES CONTRACT
Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully. When you sign this document, it will represent an agreement between us.
PSYCHOLOGICAL SERVICES
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the therapist and client in addition to the particular problems you bring forward. There are many different methods I may use to deal with the issues that you hope to address. Psychotherapy is not an exact science. It calls for a very active effort on your part. In order for therapy to be the 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 on occasions. On the other hand, psychotherapy has also been shown to have many benefits such as better relationships, solutions to specific problems and significant reductions in the feelings of distress. But there are no guarantees of what you will experience. Our first few sessions will include an evaluation of your needs. By the end of the evaluation, I will be able to offer some first impressions of what our work will include and a treatment plan to follow if you decide to continue with therapy. You should evaluate this information along with your own opinion of whether you feel comfortable working with me. Therapy involved a commitment of time, energy and money so you should be careful in the therapist you choose. If you have questions about my procedures, we should discuss them whenever they arise.
SESSIONS
Therapy sessions are 45 minutes. Once an appointment is scheduled, you will be expected to pay for it unless you provide 48 hour advance notice of cancellation unless we both agree that you were unable to attend due to circumstances beyond your control. If an appointment is missed without a cancellation, you will be responsible for payment for this visit. Insurance companies do not cover any missed or cancelled appointments.
PROFESSIONAL FEES
My hourly fee is $150 for evaluation and $125 for individual/ family sessions. I charge this amount for other professional services you may need though I will break down the hourly cost if I work for periods less than an hour. Other services include report writing, telephone conversations lasting more than 10 minutes, attending meetings with other professionals you have authorized, preparation of records and treatment summaries. If you become involved in legal proceeding that requires my participation, you will be expected to pay for all of my professional time. I do not do legal work.
CONTACTING ME
I am often not immediately available by telephone. While I am usually in my office during normal business hours, I cannot answer the phone when I am with a client. When I an unavailable, my phone is answered with a confidential voicemail that I monitor frequently. I will make every effort to return your call on the same day you make it with the exceptions of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you have a clinical emergency during evening or weekend hours, you can contact me at the number provided in my office outgoing message. If you are unable to reach me and feel that you cannot wait for me to return your call, contact your family physician or go to the nearest emergency room and ask for the 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.
I am also available by email. It is important to note that email may NOT be a completely confidential means of contacting me. Counseling is not provided over email and is generally used for scheduling appointments or very brief questions.
PROFESSIONAL RECORDS
The laws and standards of my profession require that I keep records. Your record may be stored “on paper” and/or electronically. Your clinical record can include information about your reasons for seeking therapy, description of the ways in which your issues impact your life, your diagnosis, treatment goals, your medical, social, family and past treatment history, progress towards your goals, any treatment reports that I receive from other providers, billing records and reports sent to your insurance carrier. You are entitled to receive a copy of your records or I can prepare a summary instead. Because these are professional records, they can be misinterpreted 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. You will be responsible for payment for this visit and not your insurance company as this is not a therapy session. This payment will include my hour rate to review you record and copying/administrative fees.
MINORS
Clients under the age of 18 who are not emancipated should be aware that the law allows parents to examine their child’s treatment record unless I believe this review would be harmful to the client and his/her treatment. Because privacy in psychotherapy is often crucial to successful progress especially with teenagers, it is sometimes my policy to request an agreement from parents that they consent to give up access to their child’s record. I do provide them with general information about the progress of their child’s treatment goals, attendance record and summary of their child’ treatment. Any other communication will require the child’s authorization unless I feel that the child is in danger towards him/herself or someone else in which case the parents are immediately notified.
BILLING AND PAYMENTS
You will be expected to pay for each session at the time it is held. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which requires me to disclose confidential information. In most collection situations, the information I release is his/ her name, the nature of the services provided and the amount due which will include the cost of the claim. If we have to refer your account to collections, you will be responsible for ALL costs of collections including reasonable collection agency fees, attorney fees and court costs.
INSURANCE REIMBURSEMENT
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. 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 regarding the benefits you are entitled to. However, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. Managed Health Care Plans such as HMO and PPO may require authorizations before they will reimburse for mental health services. You will be responsible for obtaining information regarding copayments and deductible amounts and number of sessions they have initially approved. If your insurance company requires authorization for your visits, please make sure the you have obtains this authorization prior to your first appointment. If you insurance company denies your visits for any reason, you will be responsible for the full fee of each of these visits.
These plans are often limited to short-term treatment approaches designed to work our specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more sessions after a certain number of sessions have occurred. While much can be accomplished in short term therapy, some clients feel that they need more services after the insurance benefits end. In this case, you will have the option of paying for your therapy.
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. This information will become part of the insurance company’s files and will probably be stored in a computer. 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. In some cases, they may share the information with a national medical information bank.
Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you are ready to end our sessions. It is important to remember that you always have a right to pay for my services yourself to avoid the problems described above.
CONFIDENTIALITY
In general, the privacy of all communications between a client and a psychotherapist is protected by law and I can only release information to others with your written permission. But there are a few exceptions. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, this information is protected by the psychotherapist- client privilege law. I would require a written authorization by you or a court order. If you are involved in or contemplating litigation, you should consult with an attorney to determine whether a court would be likely to order me to disclose information. If a client files a complaint or lawsuit against me, I will need to disclose relevant information regarding the client in order to defend myself. There are some situations in which I am legally obligated to take action in order to protect others from harm. In these situations, I have to reveal some information about a client’s treatment. If I have reasonable cause to believe that a child under the age of 18, elderly person or disabled person is being abused, I must file a report with the appropriate state agency. If a client communicates an immediate threat of serious physical harm to an identifiable victim or if a client has a history of violence, the apparent intent and ability to carry out the threat, I am required to take protective action. These actions may include notifying the potential victim, contacting the police, and/or seeking hospitalization for him/her. If a client threatens to harm himself/herself, I am obligated to seek hospitalization and contact family members or others who can help provide protection. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary.
I may occasionally find it helpful to consult other professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The consultant is also legally bound to keep the information confidential. You should be aware that I practice with other mental health professionals and that I employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes such as scheduling, billing. All staff members have been trained about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. Disclosures are required by health insurances and/or collect overdue fees as already discussed in the agreement. While this written summary of exceptions to confidentiality should prove helpful informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex and I am not an attorney. In situations where specific advice is needed, formal legal advice may be needed.
PATIENT RIGHTS
As of April 14, 2003, the Health Insurance Portability and Accountability Act (HIPAA) provided new privacy protections and new patient rights with regard to the use and disclosure of your Protected Health Information (PHI). HIPPA requires that I provide you with a NOTICE OF PRIVACY PRACTICES for use and disclosure of PHI for treatment, payment and health care operations. This NOTICE is attached to the agreement and explains HIPAA along with its applications to your personal health information in greater detail. This law also requires that I obtain your signature of acknowledging that I have provided you with this information. It is very important to read them carefully. We can discuss any questions you may have about the procedures. When you sign this agreement, you are acknowledging that you have received a copy of the NOTICE. YOUR SIGNATURE BELOW INDICATED THAT YOU HAVE TEAD THIS AGREEMENT AND AGREE TO ITS TERMS AND AGREE TO ABIDE BY ITS TERMS DURING OUR PROFESSIONAL RELATIONSHIP.
SIGNATURE__________________________________ DATE__________________________
AMY L. VENEZIA, LICSW
274 Main St. Suite 307
Reading, MA 01867
781-462-7037
Email: amyvenezia@horizontherapycenter.com
OUR APPOINTMENTS
An appointment is a commitment to our work. We agree to meet here and to be on time. If I am ever unable to start on time, I ask for your understanding. I assure you that you will receive the full time agreed upon. If you are late, we will not be able to meet for the full time as it is likely that I will have another appointment after yours. A cancelled appointment delays our work. When you must cancel, I require at least 48 hour notice. You will be charged a fee of $75.00 for sessions cancelled with less than 48 hour notice. Your insurance does not cover this charge. I have read this notice and understand and agree to its terms.
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