to be completed before our first appointment

Therapist Client Service Agreement



     This is all important information for your work as a client. Please take the time to read this document in its entirety. This document (the Agreement) contains important information about professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient/client rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and healthcare operations. HIPAA requires that we provide you with a Notice of Privacy Practices and Patient Rights (the Notice) for use and disclosure of PHI for treatment, payment, and healthcare operations. The Notice explains HIPAA and its application to your personal health information. The law requires that we obtain your signature acknowledging that we have provided you with this information. Although these documents are long and sometimes complex, it is very important that you read them carefully. You can discuss any questions you have about the procedures with Mr. Friedler.  


      When you sign the Acknowledgement form, the Therapist–Client Services Agreement will represent a formal agreement between you and your therapist, David Friedler, LMHC, LLC. You may revoke this Agreement in writing at any time. That revocation will be binding in so far as the therapist has taken action in reliance on it; if there are obligations imposed on the therapist by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.


I. COUNSELING SERVICES

    

      David Friedler, LMHC holds an MS in Counselor Education and MPH in Health Services Administration with competencies in various areas and psychological skills.  He licensed in Massachusetts as a Licensed Mental Health Counselor and in New Hampshire as a LIcensed Clinical Mental Health Counselor. As a mental-health professional he adheres to statutes of the States of MA and NH and ethical principles of his discipline.

Psychotherapy is not easily described in general statements. It varies depending on (for example) the personalities of the therapist and client, the therapist’s style of communication, or the particular problems the client is experiencing. Further, there are many different methods or strategies your therapist may use to deal with the problems that you hope to address.           


     Psychotherapy is not like 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 you and your therapist talk about both during your 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. 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.


     Your first few sessions will focus on an evaluation of your strengths, needs, presenting problems, and goals. By the end of your first couple of sessions, your therapist will be able to offer you some first impressions of what your work will include and a treatment plan to follow. Research shows that positive outcomes in therapy are strongly linked to the quality of the relationship with the therapist.


     Clients may terminate treatment at any time. If you desire to discontinue therapy before the agreed upon or recommended time- frame, please discuss this desire in your counseling session. Your therapist may also terminate treatment if he determines this to be necessary or in the best interest of the client or himself. Any such termination will be discussed with you in advance and referrals to other therapists will be offered.


II. APPOINTMENTS

     Appointments are based on the clinical hour, which is 45-50 minutes. In the event that you are less than 20 minutes late for a scheduled appointment, you will be seen for the remainder of the time allotted. If you are more than 20 minutes late, it will be treated as a missed appointment.

A 24-hour notice from your scheduled appointment time is required for all cancelled or rescheduled appointments. This must be done by phone/voicemail with your therapist. Otherwise, you will be charged a missed appointment fee of $80 that session.

 

     It is important to note that insurance companies do not provide reimbursement for cancelled or missed sessions. Therefore, you would be responsible for the full cost of the session.


III. PROFESSIONAL FEES

     Standard Fees. The standard hourly fee is $150 for the initial evaluation and $125 per hour for individual sessions, $140 per hour for couples sessions. You may be charged a pro-rated portion of the hourly fee for sessions that are less than the hour. The same hourly fee applies to other services of less than one hour, such as report writing, telephone conversations, consulting with other professionals preparation of records or treatment summaries, and the time spent performing any other related service you may request of your therapist.


Sliding Scale Fees: If you do not have (or do not wish to use) insurance benefits, a fee can be arranged. These reduced rates are set by your therapist at the first session and may be subject to change based on changes to any of the above factors. Proof of income may be required.


Legal Matters: Be aware that therapists are not specialists in Forensic Psychology or other areas related to legal matters. We recommend that specialists in these areas be sought for this type of work. Because of the difficulties associated with legal involvement, should your therapist be involved in any legal proceedings the charge will billed $250 per hour for preparation and attendance at any legal proceeding on your behalf.


IV. BILLING AND PAYMENTS

     Fees will be expected at the beginning of each session, unless you have another agreement with your therapist (e.g.,phone sessions require pre-payment) or have insurance coverage that requires another arrangement. Cash and checks and app payments (Venmo, PayPal)  are the preferred method of payment; however, credit cards are also accepted.

Your therapist reserves the right to turn delinquent accounts over to a collection agency in order to collect unpaid balances. In most collection situations, the only information that would be released regarding a client’s treatment is his/her name, the nature of services provided, and the amount due. If legal action is necessary, its costs will be included in the claim. There will be an additional $20 fee for returned checks.


V. INSURANCE REIMBURSEMENT

     If you have insurance benefits, and your therapist is listed as a provider, s/he will be happy to file your insurance claims and in some cases even obtain “authorizations” or “certifications” from your insurance company for treatment. However, we cannot guarantee payment by your particular plan. In some cases, for example, a client may not have a diagnosis that is covered by mental-health insurance although counseling is still needed.


     It is the client’s responsibility to be knowledgeable about his/her health insurance policy’s mental-health benefits and limitations. The client is responsible for payment of amounts not paid by insurance.


     Should David Friedller, LMHC,LLC not be listed as a provider with your particular insurance company, Mr. Friedler can help you file for possible “out of network” reimbursement. Mental health coverage and limitations usually differ from your normal medical coverage. If you have questions about your coverage, please call your plan administrator. .


VI. EMERGENCIES 

     David Friedler, LMHC, LLC is not equipped to handle mental health crises. If you experience a psychiatric emergency or find that you cannot guarantee your safety or the safety of others you must dial 911 or go to your nearest Emergency Room.


VII. LIMITS ON CONFIDENTIALITY

     The law protects the privacy of all communications between a client and psychotherapist. In most situations, your therapist can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that only require you to provide written consent in advance. 


Your signature on the Acknowledgement form provides consent for those activities, as follows:

Consulting with Professionals

     Mr. Friedler may find it helpful to consult other health and mental-health professionals about a case. During a consultation, he makes every effort to avoid revealing the identity of the client. The other professionals are also legally bound to keep the information confidential. Your therapist will note all consultations in your Clinical Record.


Other 

     Disclosures required by health insurers or to collect unpaid balances are discussed elsewhere in this Agreement.

There are also some situations where your therapist is permitted or required to disclose information without either your consent or authorization:


•If you are involved in a court proceeding and a request is made for information concerning the professional services provided to you by your therapist, such information is protected by the psychotherapist-client privilege law. Your therapist cannot provide any information without your written Authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order your therapist to disclose information.

•If a government agency is requesting the information for health oversight activities, your therapist may be required to provide it for them in certain circumstances.

•If a client files a complaint or lawsuit against a therapist, the therapist may disclose relevant information regarding that client in order to defend the organization.

•If a client files a worker’s compensation claim, the therapist— upon proper request—provides a report to the appropriate individuals, including the client’s employer.


Further, there are some important situations in which your therapist is legally obligated to take actions which s/he believes are necessary to attempt to protect others from harm. 

   

  In doing so, s/he may be required to reveal some information about a client’s treatment. These situations are relatively infrequent and are as follows:

•Child Abuse 

     If your therapist has reason to believe that someone under 18 years of age has been injured as a result of brutality, abuse, or neglect, the law requires that s/he make a report to Child Protective Services or another appropriate governmental agency. Once such a report is filed, the therapist may be required to provide additional information.

•Vulnerable Adult Abuse. 

     If your therapist has reason to suspect that an adult who is vulnerable physically or mentally has suffered abuse, neglect, or exploitation, the law requires that the therapist report to the Department of Human Services. Once such a report is filed, the therapist may be required to provide additional information.

•Client Threat to Self or Others 

     If a client threatens harm to him/herself, Mr. Friedler may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. If a client has communicated an actual threat of bodily harm against a clearly identified victim, and the therapist believes that the client has the intent—and the ability —to commit such an act, then the therapist required to take reasonable steps to protect the potential victim, including notifying the targeted individual(s), contacting the police, or seeking hospitalization for the client.

If such a situation arises, your therapist will make every effort to fully discuss it with you before taking any action and endeavor to limit disclosure to only what is necessary.


    While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that you discuss any questions or concerns that you may have now or in the future with your therapist. The laws governing confidentiality can be quite 

complex. In situations where specific advice is required, formal legal advice may be needed.


VIII. PROFESSIONAL RECORDS

     

     You should be aware that, under HIPAA regulations, your therapist will keep Protected Health Information (PHI) about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that are set for treatment, your progress towards those goals, your medical and social histories, your treatment history, any past treatment records that were received from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. 


     Except in unusual circumstances that involve danger to yourself and/or others, or when another individual (other than another healthcare provider) is referenced and your therapist believes disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your Clinical Record if you request it in writing. Because these are professional records, they can be misinterpreted and/or potentially be upsetting to untrained readers. For this reason, we recommend that you initially review them in the presence of your therapist, David Friedler, LMHC or have them forwarded to another mental-health professional so you can discuss the contents. 


     We charge a retrieval and copying fee of $15 for the first five pages of a record and 25 cents per page thereafter. The exceptions to this policy are contained in the Notice. If your request for access to your Clinical Record is refused, you have a right of review, which your therapist will discuss with you upon request.


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IX. PATIENT RIGHTS


     As of April 14, 2003, HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of Protected Health Information (PHI). These rights include requesting that your therapist amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of PHI that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about the therapist’s policies and procedures recorded in your records; and the right to a paper copy of this Agreement and the HIPAA Notice. Discuss any questions you may have about these documents with your therapist.


   By signing the Acknowledgement form you agree to allow your therapist to treat you.  You also agree that David Friedler, LMHC LLC can provide necessary information to your insurance carrier. You further acknowledge that you have read, understood and agree to the provisions of Sections I - IX  above.




   


Client Information Form

   This form must be completed when you accept an appointment. It includes your contact information, insurance identification numbers and your emergency contact information.  If the subscriber of your insurance policy is someone other than yourself, please include that person's name, address, and birthdate on a separate Client Information Form. Thank you!