Frequently Asked Questions

Therapist-Client Services Agreement

Welcome to our practice. This notice 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 (client) rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The notice explains HIPAA and its application to your personal health information in greater detail. 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. We can discuss any questions you have about the procedures at any time. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on us unless we have taken action in reliance on it; if there are obligations imposed on us 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.

CANCELLATIONS/MISSED APPOINTMENTS

If you need to cancel an appointment, please provide 24 business hours advance notice of cancellation. Late cancellations or missed appointments are subject to a fee. Insurance companies do not provide reimbursement for cancelled or missed sessions. The fee for late cancellations or missed appointments is $95 and is to be paid in full before scheduling your next appointment.

Professional Fees

In addition to your appointment fees, we charge for other professional services you may need, though we will break down the hourly cost if we work for periods of less than one hour. Other services include report/letter writing, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of your therapist. If you become involved in legal proceedings that require our participation, you will be expected to pay for all of our professional time, including preparation and transportation costs, even if your therapist is called to testify by another party. Because of the difficulty of legal involvement, we charge double our rate per hour for preparation, travel and attendance at any legal proceeding. Insurance companies do not pay or reimburse for these services, and this will billed as an out-of-pocket cost to you.

Contacting Your Therapist

Due to our varied work schedules and the improbability of your therapist answering the phone when with a client, your therapist is often not immediately available by telephone. When therapists are unavailable, please leave a detailed message with your name and phone number where you can be reached on our office voicemail. Your therapist will make every effort to return your call within 24 hours, with the exception of weekends and holidays. If you are difficult to reach, please inform us of some times when you will be available. EMERGENCIES - If you need to speak to your therapist due to an emergency, please call the office at 562-542-0040 and your call will be returned within 24 hours. If you are unable to reach your therapist and feel that you can’t wait for the return call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If you are experiencing a life-threatening emergency, call 911. You can also contact the PET Team 800-854-7771. If your therapist will be unavailable for an extended time, we will provide you with the name of a colleague to contact, if necessary.

Professional Boundaries

Licensed psychotherapists are obligated to establish and maintain appropriate professional boundaries (relationships) with present and past clients (and, in some cases, client’s family members). For example, therapists should not socialize or become friends with clients and should never become sexually involved with a client.

Conflicts of Interest

From time to time, actual or potential conflicts of interest may arise. In the event that your therapist becomes aware of a conflict of interest in providing treatment to you, they may be required to refer you to another therapist. Regardless of the existence of conflict of interest, you can be assured that any information will remain confidential.

Limits of Confidentiality

The law protects the privacy of all communications between a patient and a therapist. In most situations, we 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 require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows:

• We may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, we make every effort to avoid revealing the identity of the patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, we will not tell you about these consultations unless we feel that it is important to our work together.

• We also have a privacy contract with our accountants, billers, and office administrative staff. As required by HIPAA, we have a formal business associate contract with them, in which they promise to maintain the confidentiality of data except as specifically allowed in the contract or otherwise required by law.

• If a patient seriously threatens to harm himself/herself, we may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. California law provides that a professional may disclose confidential information only to medical or law enforcement personnel if the professional determines that there is a probability of imminent physical injury by the patient to the patient or others, or there is a probability of immediate mental or emotional injury to the patient.

There are some situations where we are 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 your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. We cannot provide any information without your (or your legal representative’s) 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 us to disclose information.

If a government agency is requesting the information for health oversight activities, we may be required to provide it for them.

• If a patient files a complaint or lawsuit against us, we may disclose relevant information regarding that patient in order to defend ourselves.

• If a patient files a worker’s compensation claim, we must, upon appropriate request, provide records relating to treatment or hospitalization for which compensation is being sought.

There are some situations in which we are legally obligated to take actions, which we believe are necessary to attempt to protect others from harm, and we may have to reveal some information about a patient’s treatment. These situations are unusual in my practice.

• If we have cause to believe that a child under 18 has been or may be abused or neglected (including physical injury, substantial threat of harm, mental or emotional injury, or any kind of sexual contact or conduct), or that a child is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect or exploitation, the law requires that your doctor makes a report to the appropriate governmental agency, usually the Department of Protective and Regulatory Services. Once such report is filed, we may be required to provide additional information.

• If we determine that there is a probability that the patient will inflict imminent physical injury on another, or that the patient will inflict imminent physical, mental or emotional harm upon him/herself, or others, we may be required to take protective action by disclosing information to medical or law enforcement personnel or by securing hospitalization of the patient.

If such a situation arises, we will make every effort to fully discuss it with you before taking any action, and we will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and we are not attorneys. In situations where specific advice is required, formal legal advice may be needed.

Clinical Records & Release of Information

Your Clinical Record includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that we receive 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 others, you may examine and/or receive a copy of your Clinical Record if you request it in writing. You should be aware that pursuant to California law, psychological test data are not part of a patient’s record. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them in our presence, or have them forwarded to another mental health professional so you can discuss the contents. California law (Health & Safety Code §123110) allows health care providers to charge a patient or their legal representative a maximum of $0.25 per page or $0.50 per page for records copied from microfilm. A reasonable clerical fee for preparation and supplies is also allowed. We charge a flat clerical feel of $5.00 in addition to $0.25 per page copied. If you request that we release you clinical records to another healthcare provider, you will need to complete a “Consent to Release Information” form with our office. If we refuse your request for access to your Clinical Record, you have a right of review, which we will discuss with you upon your request.

ADDITIONAL FORMS/LETTERS

Any forms and/or letters that you may need your therapist to complete and filled out will be charged to you according to the length/detail of the form/letter. Please Note - Forms/Letters will be completed only at the discretion of the therapist. The therapist has the right to not fill out a form or write a letter based on the length of treatment or what is needed.

Patient (Client) Rights

HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health information. 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 protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and our privacy policies and procedures. You can request a copy of your Patient Rights from our office by sending an email to: info@mindfulrestorationtherapy.com

Minors and Parents

Patients (Clients) under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. However, if the treatment is for suicide prevention, chemical addiction or dependency, or sexual, physical or emotional abuse, the law provides that parents may not access their child’s records. For children between 16 and18, because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is our policy to request an agreement from the patient and his/her parents that the parents’ consent to give up their access to their child’s records. If they agree, during treatment, the therapist will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. Any other communication will require the child’s Authorization, unless the therapist feels that the child is in danger or is a danger to someone else, in which case, the therapist will notify the parents of the concern. Before giving parents any information, the therapist will discuss the matter with the child, if possible, and we will do our best to handle any objections he/she may have.

Termination

Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. Your therapist may terminate treatment after an appropriate discussion with you and a termination process if determined that the psychotherapy is not being effectively used or a consistent pattern of failure to attend therapy sessions begins to negatively affect treatment progress. We will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, we will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.

Should you fail to schedule an appointment for 3 consecutive weeks or “miss/no show” to 2 scheduled sessions, unless other arrangements have been made in advance between us, for legal and ethical reasons, we must consider the professional relationship discontinued.