(Client Informed Consent / Service Agreement)
Welcome to Amy Serafin Counseling, LLC. This document contains important information about my professional services and business policies. A separate document about the Health Insurance Portability and Accountability Act (HIPAA), and my practice policy about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations, can be found in the footer of this website and here: HIPAA policy.
Both the Service Agreement and HIPAA policy documents will be provided when you agree to services, and will require your written signature.
Although these documents are long and sometimes complex, it is very important that you understand them. Signing this document would represent an agreement between us. We can discuss any questions you have when you sign or at any point in the future.
I. CONFIDENTIALITY
In general, the confidentiality of communications between a client and a therapist is protected by law. This means your therapist can only release information about your work to others with your written permission. However, there are a number of exceptions:
In some judicial proceedings, you may have the right to prevent information about your treatment being provided. However, in some circumstances, such as child custody proceedings and proceedings in which your emotional condition is an important element, a judge may require a therapist’s testimony if he/she/they determines that resolution of the issues before him/her/they demands it.
There are some situations in which your therapist would be legally required to take action to protect others from harm, even though that requires revealing some information about a client’s treatment:
- If there is reason to believe that a child, an elderly person, or a disabled person is being abused, your therapist must file a report with the appropriate state agency.
- If there is reason to believe that a client is threatening serious bodily harm to another, your therapist is required to take protective actions, which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization.
- If a client threatens to harm themself, your therapist may be required to seek hospitalization for the client, or to contact family members or others who can help provide protection. Should such situations occur, your therapist will make every effort to fully discuss it with you before taking any action.
- If an insurance claim is filed, the claims payer may require certain information such as your diagnosis, types of treatment provided and dates of service.
- If you are under 18 years of age, your parents or legal guardians are legally privy to information disclosed during treatment. Your therapist will discuss and clarify issues of privileged information regarding the treatment.
II. BILLING & PAYMENTS
I offer 50-minute appointment sessions for individual therapy, as well as 90-minute appointment session for group therapy.
• 50-min individual appointments: $180.
• 90-min group appointments: $65.
Sliding scale fees are offered at the therapist’s discretion. Fees are subject to change and clients will be notified verbally and in writing at least one month prior to changes; client’s written consent will be required. If such changes are prohibitive to continue services, clients are encouraged to discuss their concerns and collaborate with therapist on how to continue care. If the fees for services are unmanageable, referrals to other mental health providers will be provided.
All fees are payable at the start of the session. Payment is conducted through Ivy-Pay, which accepts credit, debit, and HMAs. If an alternative payment type is preferred, please contact your therapist.
III. CLIENT RESPONSIBILITIES
Please arrive on time for appointments. To avoid being charged for missed sessions, you must provide your counselor verbal notification of cancellation 24 hours prior to your scheduled appointment. If you require special accommodations due to a disability, please let your counselor know as soon as possible. I ask that you do not come to sessions under the influence of alcohol or illegal drugs. Being intoxicated is counterproductive during a therapy session. If you do arrive under the influence, I have the right to cancel the session and charge you for it.
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 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. Psychotherapy requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions.
One of the most important joint responsibilities is communication. Taking an active role in counseling involves being as open and honest as possible, making appropriate efforts outside of sessions, and providing feedback to your counselor about how you think our counseling is going. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion or ongoing care.
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. You have the right to expect that I will not have social or sexual relationships with clients or former clients.
IV. EMERGENCIES
Medical and psychological emergencies should be directed to 911 if life or safety is threatened. I check my voice mail frequently and attempt to return all calls in a timely manner. If I am not available when you urgently need to speak with me, please call the free 24-hour Crisis Hotline (512-472-4357). You should take yourself to the nearest emergency room or call 911 if you feel you are in danger of hurting yourself.
V. APPOINTMENTS & CANCELLATIONS
Cancellation of scheduled appointments is required 24 hours in advance. Cancellations will only be accepted by phone, text or email. Without a 24-hour advance notice, you will be charged the full hourly fee. Monday appointments must be cancelled on the preceding Friday. Clients who are more than 15 minutes late to their session are subject to cancelation and will be charged the full hourly fee. Exceptions to this policy may be made for unforeseen emergencies but must be discussed on a per-case basis.
VI. TELEHEALTH
This practice is currently offering psychotherapy and consultation via phone or telehealth via a secure online videoconference service platform. Telehealth services have potential benefits including easier access to care, continuity of care, and the convenience of meeting from a location of the client’s choosing. Potential risks to this technology include interruptions, unauthorized access, and technical difficulties, which cannot be predicted. Telehealth sessions will not be audio or video recorded at any time and device-generated recording capabilities will be disabled.
It is important for telehealth sessions to be conducted from a quiet room, with limited interruptions, where privacy is more likely to be achieved. guaranteed. Questions about the risks, benefits, logistics and any practical alternatives can be discussed with me at any time. If telehealth services hinder therapy or interfere with progress and an alternative method cannot be provided, the therapist will offer referrals to other mental health providers with in-person or other accommodations.
VII. COURT APPEARANCES, LETTERS, AND OTHER SERVICES
Court appearances are billed at $400 per hour with a minimum charge of eight (8) hours, for a total of three thousand two hundred ($3200) dollars. Since the client-therapist relationship is built on trust with the foundation of that trust being confidentiality, it is often damaging to the therapeutic relationship for the therapist to be asked to present records to the court, testify whether factual or in an expert nature, in court or deposition. The therapist asks that clients only request a court appearance in extreme cases. Court appearance will likely result in the need to terminate therapy and refer you to another therapist. In such cases as the therapist is ordered to testify by the court about his/her counseling with you, the therapist will be monetarily compensated as set forth below.
In the event that it is necessary for the therapist to testify before any court, arbitrator, or other hearing officer to testify at a deposition, whether the testimony is factual or expert, or to present any or all records pertaining to the counseling relationship to a court official, the client agrees to pay the therapist for his or her services, including travel, preparation, and necessary expenditures at the rate of $400 per hour, rounded to the nearest half hour.
These expenditures include but are not limited to copies, parking, meals, and the like. The client agrees to pay the $3200 two weeks prior to the appearance, presentation of records, or testimony requested. All additional expenditures will be billed after the court appearance. Other letters and paperwork requested by the client will be assessed a charge of $50 per hour, rounded to the nearest hour, with a minimum 1 hour charge. This does include letters to court officials or attorneys, short-term disability paperwork and any other documentation requested by the client. This does not include copies of your bill, missed work or school letters, Release of Information Forms, nor any other documents used in the day-to-day operation of the office. It is the responsibility of Amy Serafin, MA, LPC to alert you to any additional charges assessed at the time of the client request.
VIII. PROFESSIONAL RECORDS
The therapist is required to keep appropriate records of the psychological services provided. Your records are maintained in a secure health recording system. Notes are brief and document basic data including date of service, primary concerns, goals and progress with treatment, your diagnosis, significant topics discussed, medical, social, and treatment history, released info (if any) from other providers, and billing records.
Except in unusual circumstances that involve danger to one’s self, clients have the right to a copy of their file. Because these are professional records, they may be misinterpreted and/or upsetting to untrained readers. For this reason, it is recommended that any review of notes is conducted with the therapist.
If your request for access to your records is refused, you have the right to that decision reviewed by another mental health professional. You also have the right to request that a copy of your file be made available to other health care providers.
IX. TERMINATION
You have the right to terminate counseling work at any time. I ask that you make all possible efforts to attend a final session after you decide to terminate. I reserve the right to conclude the counseling work or refer you to a more appropriate provider at any time, but will do so only after communicating with you regarding the reasons for ending the working relationship.
X. CONSENT TO PSYCHOTHERAPY
If or when this document is provided to you for the start of services, you will have the opportunity to agree to the following: “I have read and understand the office policies listed above. I understand that therapy is a joint effort between therapist and client and agree to discuss with my therapist any questions I may have about the process of therapy. By signing this, I am giving full consent for the completion of an evaluation and provision of treatment as necessary until otherwise notified.”
Amy Serafin Counseling, LLC 