Consent for Services Information
CAROL A. PORTER, MSW, P.L.L.C.
THIS DOCUMENT PROVIDES INFORMATION ABOUT THE PROFESSIONAL SERVICES AND BUSINESS POLICIES OF CAROL A. PORTER, MSW, P.L.L.C.
Welcome. The Board of Mental Health Practice regulations, including the Mental Health Bill of Rights, require all licensed mental health professionals to provide clients certain basic information. To avoid confusion or misunderstanding, I am providing additional important information about my professional services and business policies. Please read it carefully and jot down any questions that you might have so that we can discuss them. By signing the signature page you are agreeing to all the policies outlined and it becomes a contract between us.
Psychotherapy is not easily described in general statements. It varies depending on the personality of both the therapist and the client and the particular problems you hope to address. It is not like visiting a medical doctor, in that it requires a very active effort on your part. In order to be most successful, you will have to work on the things we talk about both during our sessions and at home.
Psychotherapy has both benefits and risks. Risks sometimes include experiencing uncomfortable feelings such as sadness, guilt, anxiety, anger, frustration, loneliness or helplessness. Psychotherapy also often requires recalling unpleasant aspects of your life. Psychotherapy has also been shown to have benefits for people who undertake it. Therapy often leads to a significant reduction in feelings of distress, better relationships, and resolutions of specific problems. But there are no guarantees about what will happen.
LICENSE AND CODE OF ETHICS
I am a Licensed Clinical Social Workers, licensed in the State of New Hampshire and in the State of Massachusetts. I am governed by the Code Of Ethics of the National Association of Social Workers. A copy can be provided to you at your request. I will provide information regarding training, qualifications and experience at the initial meeting upon request.
MENTAL HEALTH BILL OF RIGHTS
Pursuant to the New Hampshire Mental Health Bill of Rights, clients have certain rights. A copy of the Mental Health Bill of Rights is included with this form and posted in the waiting area. Please review the bill of rights carefully and let me know if you have any questions.
MEETINGS & CANCELLATION FEES
Appointments are usually 45-50 minutes in duration. If you are not able to keep your appointment for any reason, you will be expected to give 24 hours notice to cancel it. Your insurance does not cover an appointment that you do not cancel in time. A fee of $45.00 is assessed for an appointment not cancelled within the 24 hour time frame. Payment will be expected at your next scheduled appointment.
The cost of each session is $125.00. The first session is billed at a higher rate of $195.00 due to the additional requirements of the intake process. It is my practice to charge this amount on a prorated basis for other professional services you may require, such as report writing, telephone conversations which last longer than 10 minutes, attendance at meetings or consultation with other professionals thatyou have authorized, preparation of records, treatment summaries, or the time required to perform any other service that you may request. If you become involved in a litigation situation that requires my participation, you will be expected to pay for the professional time required, even if I am compelled to testify by another party. Because of the complexity and difficulty of legal involvement, the per hour charge is usually higher, and can vary with each situation. Payment is required in advance.
BILLING AND PAYMENTS
If you have insurance, I will bill your insurance company directly. You are responsible at the time of your visit for any co-pays or deductibles. You will be expected to pay for each session at the time it is held if you are not using insurance. My billing service is Claims Express and you will receive statements directly from them. A $25.00 fee is assessed for checks returned by the bank and must be paid prior to resuming therapy.
In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources are available to pay for your treatment. If you have health insurance, it will usually provide some coverage for mental health treatment. I will provide you with whatever assistance you need to facilitate receipt of the benefits to which you are entitled, including filling out forms as appropriate. However, you, and not your insurance company, are ultimately responsible for full payment of the fee. Therefore, it is very important that you find out exactly what mental health services your insurance policy covers and obtain any initial authorizations needed.
The escalation of the cost of health care has resulted in an increasing level of complexity about insurance benefits. Sometimes it is difficult to determine exactly how much mental health coverage is available. Many insurance plans have a managed care component. They often require advance authorization before they will provide reimbursement for mental health services. These plans are often oriented towards a short-term treatment approach designed to resolve specific problems that are interfering with one's usual level of functioning. It may be necessary to seek additional approval after a certain number of sessions. Many plans require detailed information about the problem, gains in therapy, and future goals. In my experience, while quite a lot can be accomplished in short-term therapy, many clients feel that more services are necessary after insurance benefits are no longer available. Some managed care plans will not allow us to provide services to you once your benefits are no longer available. If this is the case, your therapist will do their best to find you another provider who will help you continue your psychotherapy.
You should also be aware that most insurance agreements require you to authorize me to provide a clinical diagnosis and sometimes additional clinical information, such as a treatment plan or summary or, in rare cases, a copy of the entire record. This information will become part of the insurance company files and, in all probability, some of it will be computerized. All insurance companies claim to keep such information confidential, but once it is in their hands, I have no control over what they do with it. In some cases they may share the information with a national medical information data bank. If you request it, I will provide you with a copy of any report that we submit to your insurance company.
I am not usually immediately available by telephone. When I am unavailable, voice mail is available and is confidential. I monitor the voice mail frequently. I will make every effort to return your call on the same day you make it with the exception of weekends and holidays. If you are difficult to reach, please leave some times when you will be available. Please note that sometimes I make calls from my home. My phone number is private and if you have caller ID with call blocking for private calls, my call will not be accepted by your system. In that case, I will contact you the next time I am in the office. If I am unavailable for an extended period of time, a trusted colleague will cover any call which you may make. In case of an emergency, you may call my answering service at 603-890-8670. They will page me immediately. If you are in immediate jeopardy, you should go to the nearest emergency room.
Both law and the standards of our profession require that we keep appropriate treatment records. You are entitled to receive a copy of the records but, if you wish, I can also prepare an appropriate summary. If you wish to see your records, I recommend that we review them together so that we can discuss the contents. Clients will be charged an appropriate fee for any preparation time that is required to comply with an information request.
Under New Hampshire law, communications between client and a licensed psychotherapist are privileged (confidential) and may not be disclosed without the specific authorization of the client except under specific, limited circumstances outlined in the confidentiality agreement.
As part of maintaining a valid license, I am required to regularly discuss cases with colleagues. I also obtain formal supervision on certain cases when I believe it is necessary. In these situations I do not disclose the identity of the client. My colleagues and formal supervisors are, of course, legally bound to confidentiality as well. By signing this document you are acknowledging that you understand that I may discuss your case in consultation and/or supervision and do not object to my doing so.
Treatment records of couple’s sessions contain information about each person. Both clients should be aware that EITHER person has a right to obtain treatment records. It is my policy to ask that couples understand that any records will only be released by joint consent.
Generally, the treatment of a minor child (under the age of 18) must be authorized by a parent or someone else with legal authority. If you are under 18 years of age, please be aware that the law may provide your parents with the right to examine your treatment records. Even parents without residential responsibility for a child retain decision-making authority and access. It is my policy to request that parents consent to give up access to your records so that you will be comfortable sharing information. I will only provide them with general information about our work together unless I feel that a safety risk exists that will result in serious harm to your life or another person's life. Before giving them any information, I will discuss the matter with you and will do the best to resolve any objections you may have.
In very limited circumstances, a minor may prevent parental access to treatment records through a court hearing. In the event you object to either parent having access to your treatment records, I encourage you to raise this issue with your parents or with a guardian ad-litem, if one has been appointed.
When parents with decision-making authority cannot agree on access to, or release of, their child’s confidential treatment information, a court can decide following a hearing. I believe it is best to identify and resolve potential parental agreements before treatment begins. Therefore, it is my policy to treat minors only with the consent of both parents, to the extent both are available. If there is an issue, it is the responsibility of the parents to resolve their differences through a court hearing prior to instituting treatment. If an issue arises regarding parental consent after treatment begins, I will consider whether terminating therapy is appropriate until the issue is resolved in court.
If one parent is unavailable and I determine that it is appropriate to proceed with the consent of only one parent, the absent parent will have a right to the child’s treatment records upon request while the child is a minor unless there is a court order to the contrary. If continuation of treatment becomes an issue, it is the responsibility of the parents to resolve the disagreement in court.
Some insurance companies require that I send billing and other information electronically (e.g., by fax, e-mail or electronic billing). I cannot guarantee the confidentiality of such communications. If you do not consent to electronic communications, please inform me immediately so I can determine whether and how to proceed.
I hope this information is helpful to you.
Carol A. Porter, MSW, P.L.L.C. | 151 Main Street, Suite 2B | Salem, NH | 03079 | 603-898-1695