Treatment Agreement

Treatment Agreement and Notice of Privacy Practices

This document is an overview of important subjects relevant to our mutual participation in the psychotherapeutic relationship. Though it is long it is important that you read it carefully and that we discuss any questions or concerns you have. I will ask you to sign a form acknowledging that you have received and agree to the terms outlined in this document before our first session. You have the right to revoke this agreement in writing at any time and I will be legally bound to respect that revocation unless I have taken action in reliance on it or to clear up remaining insurance queries or if you have not satisfied your financial obligations to me.

Assessment and Diagnosis:

During the first few sessions we will spend time getting to know one another and discussing both your history and the reasons you are coming in to therapy. Together we will set goals for treatment and we will discuss the symptoms you are experiencing and how they fit into a clinical diagnosis. At any time you request, I will share the diagnosis I am using to bill your insurance and we can discuss the meaning of diagnosis in general and your experience in particular. At any time during treatment you may suggest that we reassess your diagnosis or treatment goals.

If you are participating in a therapy group or paying out of pocket, you will not have a diagnosis or treatment plan though I will keep progress notes as required by my licensing board.

Confidentiality:

Our meetings will be confidential. This means that your identity and the content of our meetings is protected by law and by ethical practice guidelines. However, there are a number of exceptions to this confidentiality:

If I suspect physical abuse or neglect of a child, elderly or disabled person I am legally required to report this to The Department of Health and Human Services (DHHS).
I am legally required to do my best to protect you and others from serious harm. Actions I might take under these circumstances include involuntary hospitalization, contacting the police or the intended victim.
If you are involved in a court case and the court subpoenas your records I may be required to release them. I will usually fight this request wherever possible but cannot go against a court order.
When given a voluntary release of information I can talk about your treatment with the subject of that release until one year has passed or the release is revoked, whichever comes first.
If you are using insurance to pay for psychotherapy your insurance company has access to your name, diagnosis, treatment plan and other information related to the claim.
In defense against legal action or formal complaints which a client makes before a court or regulatory board.
Wherever possible I will notify you of my need to breach confidentiality before I do so.
I consult regularly with a few other psychotherapists in order to learn more and to refine my work. When I discuss cases with them I do my best to disguise your identity. The others that I consult with are also legally bound to maintain confidentiality regarding case information.

Court:

Because I believe so strongly that your counseling experience should be entirely for your benefit and because I feel that therapy deals in emotional experiences rather than in facts, I will not willingly go to court. I will not go to court either on your behalf or against you. If my records or myself are subpoenaed I will do everything I can to quash that subpoena. I am not trained in Forensic Assessment and have no desire to do that work so please bear this in mind if you are hoping to have an advocate in an upcoming court appearance. At my discretion I may be willing to provide you with a letter attesting to your presence in treatment but that is usually the limit of my voluntary participation. Please let me know if you have any questions or concerns about this.

Records:

Your record will contain copies of any signed forms, insurance related documents as necessary and any notes I take related to our work together. I tend to keep more detailed notes from the initial assessment period and then the minimum required by my licensing board.

Your rights as outlined in the Health Insurance Portability and Accountability Act (HIPAA) of 1995:

The right to request that I place additional restrictions on my use or disclosure of your clinical information. I am not required to agree to these additional restrictions, but if I do, I will abide by our agreement (except in the case of an emergency).
The right to request that I communicate with you about your clinical information by different means or at an alternative location (within reason).
The right to request to inspect and obtain a copy of clinical information that is a part of the “designated record set”. The “designated record set” includes your clinical and billing records. Psychotherapy notes (notes collected and maintained separately by a psychiatric health care provider) and information compiled for certain civil, criminal, or administrative actions or proceedings are not subject to this right. If you request a copy of the information, I may charge a reasonable fee to cover the costs of labor, supplies and postage associated with your request. You may request that I provide the information in a format that you prefer, as long as I am able to accommodate that request.
The right to request that I amend information that you feel has been inaccurately or incompletely included in your clinical information. You have a right to request an amendment to such information for as long as the information is retained by Ellyson Psychotherapy. I may deny your request if you ask me to amend information that is no longer available to make the amendment.
The right to request an “accounting of non-routine disclosures”. This is a list of disclosures to individuals or organizations that were made outside of the usual billing, consulting with other providers etc. that is a normal part of this business.
The right to a paper copy of this Notice upon request.

Please follow this link for up to the minute, thorough information about HIPAA. https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html

Payment:

My fee for an initial individual session is $170 and then $150 per hour session after that. I will ask you to sign a fee agreement during our first session. If you are joining a group, the fee is $270 payable to me at the time of our initial interview if we decide the group will be a good fit for you.

Because my practice is small I must ask that full payment be made each time we meet. I also take credit cards, PayPal and checks.

If you choose to use your Anthem, Patient Advocates, Maine Behavioral Health or Maine Community Health Options insurance, I will bill them for you and ask you to pay your copay or deductible at the time of service. For all other insurances I will ask you to pay me the full fee each week and will give you a SuperBill (if requested) and you may bill your insurance for whatever they will reimburse you of that amount. It is important to call your insurance before coming in for your first session to find out what your in and out of network benefits are for outpatient mental health services.

Appointments:

Appointments are generally 50-60 minutes long. Group sessions will be 90 minutes.

We will decide together over the course of treatment how often we will meet. However, during the initial evaluation period I find it most helpful to meet every week to establish continuity and build the relationship.

I charge $100 for last minute cancellations and no-shows. It is important to note that insurance companies do not pay for sessions which have not occurred so this fee would come out of your pocket. Because my time is very limited, I am reserving your session time for you carefully. I therefore require 24 hours notice of a cancellation except for an unavoidable event such as illness or family crisis. If you cannot give me 24 hours notice you may be charged the no-show fee. If you do not call at all then you will be charged the no-show fee if your insurance company allows it. I reserve the right to terminate treatment after two no-shows.

Since the group therapy fees are paid up front, there is no charge for a no show or cancellation but the expectation is that you will attend every session for the sake of the group. There is no refund if you drop out of the group.

My hours vary throughout the weekdays but I make an effort to check my voicemail every morning by 10:00. In cases of emergency you should go to the hospital then leave me a message letting me know what’s going on and how to reach you. I will get back to you as soon as possible.

Telehealth:

From time to time it may make sense for us to use a video platform rather than meeting in person. The video conferencing technology that will be used won’t feel the same as a person to person visit but together we can try to make it close. In some cases, it might have conveniences that in person therapy does not. It’s important to understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. Either one of us can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation. Please feel free to ask me any questions or discuss concerns with me. At present my video platform is through my HIPAA compliant electronic health record: Simple Practice.

Filing a complaint:

Psychotherapy is at best an intense experience and there will be times when you may feel angry or upset about me or about the way your treatment is progressing. These feelings frequently signal important work that can further your therapeutic growth and so are best talked about in therapy. However, if you feel you have truly been wronged and feel you cannot talk to me about it or if you feel that I have acted unethically or unprofessionally, you can contact the Board of Counseling Professionals Licensure, 35 State House Station, Augusta, ME 04333 – phone # (207) 624-8674. I am licensed as an LCPC in the state of Maine – CC3038.