Welcome to Sacred Space Therapy. This document contains important information about our 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 rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment; payment; and health care operations. Although these documents are long and complex; it is important that you understand them. When you sign this document; it will also represent an agreement between us. You can discuss any questions you have when you sign them or at any time in the future.
Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in psychotherapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.
Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings; such as sadness, anxiety, guilt, anger, frustration, loneliness, and helplessness because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, grater personal awareness and insight, increases skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy requires a very active effort on your part. In order to be the most successful, you will have to work on things we discuss outside of sessions.
The first session will involve a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some initial impressions of what our work might include. At that point; we will discuss your treatment goals and crate an initial treatment plan. You should evaluate this information and make your own assessment about whether you feel comfortable working with a member on our team. If you have any questions about our procedure, we should discuss them whenever they arise. If your doubts persist, I will be happy to set up a meeting with another mental health professional.
Appointments will ordinarily be 45-50 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide your therapist with 24 hours notice. If you miss a session without cancelling, or cancel with less than 24 hours notice, my policy is to collect the amount of your co-payment [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus; you will be responsible for the portion of the fee as described above. If it is possible, I will try to find another time to reschedule the appointment. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.
Our fees reflect our specialized training and experience. Unless arranged in advance or dictated by insurance agreements, our fees for typical sessions are as follows: $100 for Individual Psychotherapy and $100 for Couples/Family Therapy. You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by zelle. I am not able to process credit card charges as payment at this time. If utilizing insurance, I will make every effort to help you figure out insurance deductibles, copays, and/or coinsurance. I can also supply you with a receipt of payment for services, which you can submit to your insurance company for reimbursement. Please note that not all insurance companies reimburse for out-of-network providers. In addition to regular appointments, it is our practice to charge this amount on a pro-rated basis (I will break down the hourly cost) for other professional services that you may require such as report writing, telephone conversations that last longer than 15 minutes, attendance at meetings or consultations which you have requested, or the time required to perform any other service which you may request from your therapist.
I am required to keep appropriate records of the psychological services that we provide. Your records are maintained in a secure location. I keep brief records noting that you were here, your reasons for seeking therapy, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records I have received from other providers if requested, copies of records I send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them with your therapist, or have them forwarded to another mental health professional to discuss the contents. If I refuse your request for access to your records, you have the right to have my decision reviewed by another mental health professional, which I will discuss with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request.
My policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled Notice of Privacy Practices. You have been provided with a copy of that document and we have discussed those issues. Please remember that you may reopen the conversation at any time during our work together.
While privacy in therapy is crucial to successful progress, parental involvement can also be essential. It is my policy not to provide treatment to a child under the age of 13 unless s/he agrees that I can share whatever information I consider necessary with a parent. For children 14 and older, I request an agreement with the child and the parents allowing the clinician to share general information about treatment progress and attendance, as well as treatment summary upon completion of therapy. All other communication will require the child’s agreement, unless I feel there is a safety concern, in which case I will make every effort to notify the child of my intention to disclose information ahead of time and make every effort to handle any objections that are raised.
Clinicians will be working telephonically and often not immediately available by telephone. Therapists do not answer their phones when they are with clients or otherwise unavailable. At these times, you may leave a message on your therapist’s voicemail and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters. If, for any number of unseen reasons, you do not hear from your therapist or your therapist is unable to reach you, and you feel you cannot wait for a return call or if you feel unable to keep yourself safe, 1) call the Safe Center L.I. at (516) 542-0404, 2) LI Crisis Center at (516) 670-1111, or 911. You can also go to your local hospital emergency room.
If you are unhappy with what is happening in therapy, I hope you will talk with either your therapist or myself, so that I can respond to your concerns. Such comments will be taken seriously and handled with respect and care. You may also request that I refer you to another therapist and are free to end therapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my/your therapist’s specific training and experience. You have the right to expect that we will not have any inappropriate relationships with clients or former clients.
Your signature below indicates that you have read this agreement and the Notice of Privacy Practices and agree to their terms.
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