CLIENT/THERAPIST SERVICE AGREEMENT and PAYMENT CONTRACT
Welcome into psychotherapeutic services with Lisa Brandi LCSW. I provide psychotherapy (sometimes known as “therapy” or “counseling”) to youth, adolescents, adults, families, and couples. I do this as a Licensed Clinical Social Worker or LCSW in the state of New York. This document contains important information about my professional services and business policies. It is important for you to understand what it means to enter into therapy, and know the rights and responsibilities of both you and I. When you sign this document, it will represent this understanding and agreement between us. We can discuss any questions you have when you sign them or at any time in the future.
PSYCHOLOGICAL/BEHAVIORAL HEALTH SERVICES
Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, 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 a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. The first few sessions will involve a comprehensive evaluation of your needs. During these sessions, I will be able to offer you some initial impressions of what our work might include. We will then discuss your treatment goals and ways to achieve them. If you have questions about my procedures or your treatment, we can discuss them at any time. If you require a different level of professional care than I can provide, I will refer you to an appropriate community agency/resource.
APPOINTMENTS and CANCELLATIONS
Appointments will ordinarily be 45 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 me with 24 hours notice. If you miss a session without canceling, or cancel with less than 24-hour 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.
The standard self-pay fee for an initial intake is $120.00 and each subsequent session is $100.00. If you request it, a sliding scale fee can be arranged based on your ability to pay (as assigned below). You are responsible for paying your fee or co-payment at the time of your session unless prior arrangements have been made. Payment and co-payments may be made with case or by check (please make checks out to Lisa Brandi LCSW PLLC). I also accept PayPal payments over $50 through a designated email. All PayPal payments will include a $2 service fee. Any checks returned to my office are subject to an additional fee of up to $25.00 to cover the bank fee that I incur. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment. In addition to weekly appointments, it is my practice to charge this amount on a prorated basis 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 of me.
If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will assist you in ascertaining insurance payment information as much as I can, however, you are ultimately responsible for knowing your coverage and for letting me know if/when your coverage changes. Your insurance company may not pay for services they consider to be not medically or therapeutically necessary, or services not covered by my policy, or if the policy has expired or is not in effect at the time of services rendered. Additionally, your policy may require you to meet a deductible prior to insurance payment. Most insurance companies require you to authorize me to provide them with a clinical diagnosis. (Diagnoses are technical terms that describe the nature of your problems and whether they are short-term or long-term problems. All diagnoses come from a book entitled the DSM-V. There is a copy in my office and I will be glad to let you see it to learn more about your diagnosis, if applicable.). By signing this Agreement, you agree that I can provide requested information to your carrier if you plan to pay with insurance.
I am required to keep appropriate records of the psychotherapeutic services that I provide. Your records are maintained in a secure location in my office. 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 receive from other providers, 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 (requests must be made to Lisa Brandi in writing).
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 (Health Insurance Portability and Accountability Act, or HIPAA). A copy of the Notice of Privacy Practices is available upon request and can be found for your perusal in the waiting room. Please speak with me if you have any questions regarding HIPAA or your confidentiality.
PARENTS & MINORS
While privacy in therapy is crucial to successful progress, parental involvement can also be essential. There will be times when the child or adolescent will work alone with the therapist and times when family involvement will be necessary and appropriate to reach therapy goals. As a general rule, I will keep information shared with me in sessions by children/adolescents confidential, unless certain circumstances prevail (see below):
Confidentiality is withheld or suspended when:
- The minor reports plans to cause serious harm or death to him or herself, and I believe they have the intent and ability to carry out this threat in the very near future. I must take steps to inform the parent or guardian of what has been disclosed to me and how serious I believe this threat to be.
- The minor tells informs me of plans to cause serious harm or death to someone else who can be identified, and I believe they have the intent and ability to carry out this threat in the very near future. In this situation, I must inform the parent or guardian, and I must inform the person whom they intend to harm.
- The minor informs me that they are doing things that could cause serious harm to himself or herself or someone else, even if they do not intend to harm himself or herself or another person. In these situations, I will need to use my professional judgment to decide whether the parent or guardian should be informed.
- The minor reports being abused-physically, sexually or emotionally-or have been abused in the past. In this situation, I am required by law to report the abuse to Child Protective Services of Suffolk County, NY, as a mandated reporter.
- The minor is involved in a court case and a request is made for information about their counseling or therapy. If this happens, I will not disclose information without written agreement unless the court requires me to. I will do all I can within the law to protect your confidentiality, and if I am required to disclose information to the court, I will inform you that this is happening.
I am often not immediately available by telephone, for instance, when I’m with clients or otherwise unavailable. At these times, you may leave a message on my confidential voice mail and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters. You may also text or email me your questions/concerns. If, for any number of unseen reasons, you do not hear from me or I am unable to reach you, and you feel you cannot wait for a return call or if you feel unable to keep yourself safe, 1) contact Response Hotline of Suffolk at 631-751-7500, 2) go to your Local Hospital Emergency Room, or 3) call 911 and ask to speak to the mental health worker on call. I will make every attempt to inform you in advance of any planned absences on my part.
If you are unhappy with what is happening in therapy, I hope you will talk with me so that I can respond to your concerns with care and respect. 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 specific training and experience.