Welcome to my practice. This document contains important information about my professional services and business policies. It also contains brief summary information about the Health Insurance Portability and Accountability Act (HIPAA), a new federal law that provides new privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI). In compliance with HIPAA, I am also providing you with a Notice of Privacy Practices which explains this in much greater detail. It is very important that you read this document carefully, and we can discuss any questions you have at any time. After reviewing this information, please sign this form, which constitutes and agreement between us. You may revoke this Agreement in writing at any time, however.


PSYCHOLOGICAL SERVICES
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you are experiencing. There are many different methods I may use to deal with the problems that you hope to address. Psychotherapy calls for a very active effort on your part to reflect carefully on the problems you are experiencing, to be mindful of your efforts at solutions and why they do or do not work, and to be ready to make some changes in your life that may or may not be easy. To get the most from therapy, you should expect to work on these issues in sessions, but also in between sessions at work 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. On the other hand, psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience.

Our first few sessions will involve me trying to get to know you, understanding your strengths and weaknesses, the current problems you face, and what has been helpful and not so helpful in the past in dealing with these issues. I typically ask clients to agree to work with me for six sessions, and at the sixth session we review the course of therapy, whether we are making progress, and whether you feel comfortable continuing to work with me. If you have questions about my methods, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion.


MEETINGS
I will usually schedule one 50-minute session per week at a time we agree on. Once an appointment hour is scheduled, baring what we both consider an emergency, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation. It is important to note that insurance companies do not provide reimbursement for canceled sessions, and so you will likely be responsible for the entire fee for the missed session.


PROFESSIONAL FEES
My hourly fee is $100 for sessions, and this includes note writing, short telephone conversations, and consulting with other professionals as I deem needed. If you become involved in legal proceedings that require my participation, however, you will be expected to pay for all of my professional time, including preparation and transportation costs to court.


CONTACTING ME
You may telephone me at 773 507-6054. Due to my work schedule, however, I am often not immediately available to receive calls, but my phone will be answered by confidential voice mail. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please leave me some times when you might be available. If there is an emergency, however, and you can not reach me, contact your family physician or the nearest emergency room for crises treatment. In the event that I must be unavailable for an extended period of time, I will provide you with the name of a colleague to contact, if necessary.


LIMITS ON CONFIDENTIALITY
The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA and/or Illinois law. However, in the following situations, no authorization is required:


There are some situations in which I am legally obligated to take some action which will likely involves revealing information about our sessions to an outside party, possibly without your consent. These situations are unusual in my practice, and are limited to situations in which harm is likely, including:



If such a situation arises, I will make every effort to fully discuss it with you before taking any action or releasing any information about you, and I will limit my disclosure of information to what is necessary. Confidentiality issues can be complicated, so if you have any questions about them, please feel free to ask them now or in the future as needed.


PROFESSIONAL RECORDS
I keep two sets of records about you and our work together. One set constitutes your "Clinical Record" and includes, for example, why you are seeking therapy, how your current problems negatively impact your life, your diagnosis, our treatment goals, your progress towards those goals, any medical/mental health and social history I gather, any treatment records or consultations I receive from other providers regarding your case, your billing records and contact information, and any reports that I release to anyone else. This information is available to you, to anyone you authorize to receive it, and to the billing company I work with.

In addition, I also keep a set of Psychotherapy Notes. These notes are for my own use, and help me document the areas we have covered, record important information I should remember later, and track if and how therapy if helping you. These notes can include the dates and contents of our conversations, my analysis of our conversations, and ideas I wish to explore with you in therapy. They also include any particularly sensitive information you reveal in therapy that is not part of your Clinical Record. These Psychotherapy Notes are kept separate from your Clinical Record, and are not available to anyone else unless you specifically authorize their release. Your insurance company can request and receive a copy of your Clinical Record, but they cannot receive a copy of your Psychotherapy Notes without your specific and written Authorization. They further cannot deny you coverage if you refuse to release the Notes to them.

You can see either or both sets of records if you request this in writing. However, because of both the sensitive and the professional information in these records, they can be misunderstood and misinterpreted. Thus I prefer clients to look them over in my office so they have a chance to ask any questions or address any issue that come up for them. After that, you may have a paper copy of them, or I can send them to another professional of your choice directly if you authorize this. There may, however, be a fee for copying and mailing to cover my administrative costs.


PATIENT RIGHTS
HIPAA provides you with a number of rights, which briefly include the right to Amend the information in your record, to limit what is information is disclosed and to whom, to request restrictions as to how you are contacted, and to receive and Accounting of Disclosures, or a list of all information that has been released about you. You also can file a complaint about my policies and procedures regarding your records with the federal Department of Health and Human Services. Please review the Notice of Privacy Practices carefully.


BILLING AND PAYMENTS
Sometimes therapy is a short-term process; this is most often the case when we have very clear and structured goals. Sometimes, however, therapy is more of an open-ended process as goals are more vague or difficult, or change as therapy progresses. As a result, sometimes therapy is easier to afford, and sometimes it can be rather expensive.

You are responsible for the fees for your therapy, and are expected to pay for each session at the time of the session. If you have insurance, we may make other arrangements, such as you paying your co-payment each week and billing your insurance company for the balance of the fee.

Determining what insurance insurance benefits you have is important but sometimes very difficult. Some companies require you to seek their approval before obtaining therapy, while others do not. Some allow you to see whomever you wish for services and pay a fixed amount regardless of how long you are in therapy, while others require a specific kind of therapist and pay a smaller portion if you see a provider who is not on their list. Some may pay a percentage of the fee for as long as you are in therapy, and others pay a fixed amount regardless of the actual fee or amount of therapy you receive. Check with your insurance company, ask questions about your coverage, and carefully document who you talk to and what they say. My billing company often calls insurance companies to make sure the information you received is the same information we receive, and to prevent any errors in billing.

Another reason why understanding your insurance benefits is so important is that they may limit the amount of therapy you can afford. It is best if we can be knowledgeable about this up front, and set priorities and goals accordingly. Shorter-term therapy may require us to focus on smaller and more obtainable goals in the short-run, and discuss how you can best capitalize on these gains after therapy has ended.

Finally, understanding your insurance benefits is very important for another reason. Some insurance companies require extensive paperwork to be completed about your sessions, while others do not. All require a basic diagnosis, however, summarizing the nature and severity of your difficulties, and the dates and types of services I provided. Most all of this information is stored in computer databases, and while all insurance companies claim to maintain the security of this information, lapses in security and careless handling of sensitive information does occur, and often without the client or the provider's knowledge. Once the insurance company has received the information from me, I have no control over how it is treated and stored. Some clients choose not to use insurance benefits because of their concerns about the confidentiality of this information. I will complete paperwork the insurance company requires from me, and will happily provide you with a copy for your own records.

In the event that you encounter some unusual financial hardship, such as loosing your job, I may be willing to negotiate a temporary reduced fee, or arrange some kind of payment plan so you can continue receiving therapy during the difficult time. If your balance due becomes very large, or if no payments are made for two months, I have the option of resorting to legal means to obtain payment if we can not work out a payment plan. This could mean involvement of a collection agency or small claims court, and the cost of this collection effort would be passed on to you. Such efforts typically require disclosure of some otherwise confidential information, but I will limit this to the minimum information necessary. If such legal action is necessary, its costs will be included in the claim.

Your signature below indicates that you have read the information in this document, and agree to abide by its terms during our professional relationship and consent to treatment with me.


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