This document outlines the professional relationship between Therapist and you, the client. It is designed to ensure you are fully informed about our policies and procedures, in compliance with the laws of New York, New Jersey, and federal regulations like HIPAA. Please read it carefully and ask any questions you may have. Your signature at the end of submitted documents indicates your informed consent and agreement to these terms.
1. Description of Services & Qualifications
- Provider Information: Services will be provided by a licensed professional Therapist and/or a pre-licensed supervised limited permit holder. All practitioners are licensed in good standing with the relevant state licensing boards. You have the right to verify credentials with the NYS Office of the Professions or the https://www.njconsumeraffairs.gov.
- Therapeutic Approach: Our practice utilizes an integrated approach tailored to your specific needs and goals. We will discuss your treatment plan with you, including potential benefits, risks, and alternative treatments (including no treatment). You have the right to refuse any recommended services.
- Serious Mental Illness (NYS): If we determine you have a serious mental illness not responding to psychotherapy, we will inform you of the requirement for a medical evaluation by a licensed physician to determine if medical care is indicated.
- Serious Mental Illness (NJ): A medical evaluation (screening) can be initiated by a mental health professional, family members, or law enforcement. For involuntary commitment to treatment to occur; within specified criteria; as per New Jersey law.
2. Confidentiality and Privacy
- Confidentiality: All communications and records are highly confidential. Personally identifiable information generally cannot be revealed without your written consent.
- Limits of Confidentiality: By law, confidentiality has specific exceptions. We must disclose information if we have reason to suspect:
- Imminent risk of serious harm to yourself or others.
- Abuse or neglect of a child, elderly person, or disabled person.
- A court order or subpoena legally compels disclosure.
- In the event of a medical emergency where you are unable to provide consent.
- Client Rights (HIPAA): You have specific rights regarding your Protected Health Information (PHI) under HIPAA. These include the right to:
- Inspect and copy your records.
- Request an amendment to your records.
- Receive an accounting of non-routine disclosures.
- Receive a paper copy of our Notice of Privacy Practices.
- Data Security: Client records are maintained in a secure, HIPAA-compliant system with robust administrative and technical safeguards.
3. Financial Arrangements & Sessions
- Fees: Our current session fee is $100 for an individual 50 minute session. And, $160 for a 1 hour and 15 minute couples session.
- Payment & Billing: Payment is due at the time of service. We accept all major credit cards, Zelle, cash app for self-pay clients and couples. Most major commercial insurance plans are accepted for individual clients. You are responsible for all co-pays, deductibles, and non-covered charges (payable prior to session)
- Insurance: We are an [In-network/Out-of-network] provider. If you plan to use insurance, you are responsible for verifying your specific mental health benefits with your insurer.
- Cancellation Policy: We require 24 hours' advance notice for cancellations or rescheduling. Sessions canceled with less than this notice will be charged the full session fee, as your insurance company will not reimburse for missed appointments. For self pay client's you will be charged 50% of your fees.
- Therapist Cancellations: If your therapist needs to cancel, you will not be charged and will be offered an alternative time.
4. Telehealth Services (NY & NJ Specifics)
- Location Requirement: You must be physically located in either New York or New Jersey during all telehealth sessions unless your therapist is also licensed in your specific location at the time of the session.
- Emergency Contact: For all telehealth sessions, you must provide the name and phone number of a local emergency contact near you who can assist in a crisis.
- Privacy & Environment: You are responsible for ensuring your physical environment is safe, private, and free from distractions during sessions.
- No Recording: Sessions may not be recorded (audio or video) by either the client or the therapist without prior written consent from all parties.
- Platform: We use a secure, HIPAA-compliant telehealth platform for all virtual sessions.
5. Crisis and Emergencies Therapist is an outpatient practice and not equipped to handle immediate crises or emergencies. If you are experiencing a life-threatening emergency or thinking about harming yourself or others, please take one of the following actions:
- Call 911 or go to your nearest emergency room.
- Call or text the 988 Suicide & Crisis Lifeline at 988.
- In NJ, you can also reach out to New Jersey's mental health crisis hotline 1-866-202-HELP (4357).
- In NY, you can also reach out to Call 1-800-273-8255 or text ‘GOT5’ to 741741
- Therapist has a dedicated 24/hr line
- 6. Consent and Acknowledgement
As per signed completed intake, request/acceptance of services for MH and HIPPA forms