Abounding Joy Counseling & Wellness Services LLC

                                                                                        Carla S. Perkins, LCSW, BC-TMH

                                                                                                Phone: (317) 643-4997

                                                                                         carla.s.perkinslcsw@gmail.com

PROFESSIONAL SERVICES AGREEMENT

Welcome to my practice!  This document contains important information about my 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 clients' 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 I 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, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail.  The law requires that I obtain your signature acknowledging that I have provided you with this information.  

Although these documents are long and sometimes complex, it is very important that you read them carefully before our next session.  We can discuss any questions you have about the procedures at that 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 me unless I have taken action in reliance on it; if there are obligations imposed on me 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.

The content areas included in behavioral health services is broad and may include counseling/treatment, consultation, and/or evaluation.  Counseling is not easily described in general statements.  It varies depending on the personalities of the clinician and client, and the particular problems you are experiencing.  Counseling calls for a very active effort on your part.  In order for counseling to be most successful, you will have to work on things we talk about both during our sessions and at home.  Counseling can have benefits and risks.  Since counseling often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness.  On the other hand, counseling has also been shown to have many benefits.  Counseling often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress.  

Our first few sessions will involve an assessment of your needs.  By the end of the assessment, I will be able to offer you some first impressions of what our work will include, if you decide to continue with counseling.  You should evaluate this information along with your own opinions of whether you feel comfortable working with me.   If you have questions about any of my procedures, we should discuss them whenever they arise. 

I normally conduct an assessment that will last for 2 sessions.  During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals.  If counseling is begun, I will usually schedule a 45-minute session per week at a time we agree on, although some sessions may be longer or more frequent.  Once an appointment hour is scheduled, you will be expected to pay for the session at the time it is held through the patient portal, unless you provide 24 hours advance notice of cancellation, rescheduling, or due to circumstances beyond your control that prevented your attendance.  It is important to note that insurance companies do not provide reimbursement for cancelled sessions, and thus the Full Charge will be your sole responsibility.  An hour is set aside for you out of my schedule and a 24-hour cancellation will allow for another client in need of services to be accommodated.  

PROFESSIONAL FEES

My fee is $125 for initial intake sessions; $95 per forty-five minutes/ongoing individual therapy sessions; $105 per fifty minute couples/family sessions.  In addition, 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 (lasting more than ten minutes), attendance at meetings or consultations with other professionals which you have authorized, preparation of records or treatment summaries or the time required to perform any other service which you may request of me.  If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party.  Because of the difficulty of legal involvement, I charge $200 per hour for attendance at any legal proceeding including court testimony and depositions.  Returned payments will be assessed a $25 office administrative fee as well as any bank charges.

You will be expected to pay for each session after each session is held. Payment for other professional services will be agreed to at the time these services are requested. If your account has not been paid for more than 60 days and suitable arrangements for payment have not been agreed to, I have the option of using legal means to secure payment.  This may involve hiring a collection agency or going through small claims which will require me to disclose otherwise confidential information.  In most situations, the only information I release regarding a client's treatment is her/his name, the nature of services provided, and the amount due.

INSURANCE REIMBURSEMENT

If you have a health benefits policy, it will usually provide some coverage for mental health treatment.  However, you, not your insurance company, would be responsible for full payment of fees to which we have agreed.  Therefore, it is very important that you find out exactly what mental health services your insurance policy covers.  You should carefully read the section in your insurance coverage booklet, which describes mental health services.  If you have questions, you should call your plan and inquire.  Of course, I will provide you with whatever information I can, based on my experience and will be happy to try to assist you in deciphering the information you receive from your carrier.

You should also be aware that insurance payment agreements require 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.

CONTACTING ME

I am often not immediately available by telephone.  While I am usually in my office from 3:00 PM to 9:00 PM on Mondays through Thursdays and 3:00 PM to 6:00 PM on Fridays, I am not available for phone calls when I am with a client.   I only respond to emergency calls after hours. For non-emergencies, I will make every effort to return your call on the same day or at least within 24 hours from the time that you make it if you call on a weekday morning.  Otherwise, it may be the next day before I can respond to a non-emergency call.If you are difficult to reach, please leave some times when you will be available.  If it is an emergency, and you feel that you cannot wait for me to return your call, you should call your family physician or the emergency room at the nearest hospital and ask for the psychologist or psychiatrist on call.  If I am unavailable for an extended time, I will provide coverage through a trusted colleague who will be contacted for you if necessary. 

MINORS

If the child is under eighteen years of age, please be aware that the law may provide the parents (in the case of divorces, the custodial parent(s)) with the right to examine the client's treatment records.  I will usually provide parents only with general information on how the client's treatment is proceeding, unless I feel that there is a high risk that the client will seriously harm himself or another, in which case I will notify them of my concern.  I will also provide them with updates of the client's treatment.  Before giving them any information, I will discuss the matter with the client and will do the best I can to resolve any objections the client may have about what I am prepared to discuss.

CONFIDENTIALITY

In general, the confidentiality of all communications between a client and a clinician is protected by law, and I can only release information about our work to others with the written authorization from the client or her/his guardian that meets certain legal requirements imposed by HIPAA.  However, there are a number of exceptions.

In most judicial proceedings, you have the right to prevent me from providing any information about your treatment.  However, in some circumstances, such as child custody proceedings and proceedings in which your emotional condition is an important element, a judge may require my testimony if she/he determines that resolution of the issues before her/him demands it. When there is a court order for my services, generally the court will expect a report of attendance and progress.  

If a government agency is requesting information for health oversight activities, files a complaint or lawsuit against me, or a client files a worker's compensation claim, I may disclose relevant information.  

If you are pursuing medical or mental health disability payments, you may end up signing a document with that agency or company waiving confidentiality to your records.  In that situation, if you have provided such a waiver or authorization to that other agency or entity, I will then honor their request for your records without further consent from you. 

If you are (or may be) involved in litigation, you should consult with your attorney about the likelihood that I would be ordered to disclose information.

There are some situations in which I am legally required to take action to protect others from harm, even though that may require revealing some information about a client's treatment.

If I know or have reasonable cause to suspect that a child under 18 has been or is likely to be abused or neglected or that a vulnerable adult has been abused, neglected, or exploited and is incapacitated or dependent, the law requires that we file a report with the appropriate government agency, usually the Department of Children's Services.  Once such a report is filed, I may be required to provide additional information. 

If I determine that the patient poses a direct threat of imminent harm to the health or safety of any individual, including himself/herself, I may be required to disclose information in order to take protective action(s).  These actions may include notifying the potential victim, contacting the police, seeking hospitalization for the patient, or contacting family members or others who can assist in providing protection. 

I will also obtain an authorization from you before using or disclosing Protected Health Information (PHI) in a way that is not described in this Notice.

I may occasionally find it helpful to consult about a case with other professionals regarding clinical and administrative issues.  In these consultations, I make every effort to avoid revealing the identity of my client.  The consultant is, of course, also legally bound to keep the information confidential.  Unless you object, I will not tell you about these consultations unless I feel that it is important to our work together.

While this written summary of exceptions to confidentiality should be helpful in informing you about potential problems, it is important that we discuss any questions or concerns, which you may have at our next meeting.  As you might suspect, the laws governing these issues are quite complex and I am not an attorney.  While I am happy to discuss these issues with you, should you need specific advice, formally legal consultation may be desirable.

The laws and standards of my profession require that I keep Protected Health Information (PHI) about you in your Clinical Record.  These records contain information, which can be misinterpreted by someone who is not a mental health professional.  However, if you request, I will provide you with a treatment summary unless I believe to do so would be emotionally damaging.  If that is the case, I will be happy to forward the summary to another appropriate mental health professional who is working with you.  You should be aware that this will be treated in the same manner as any other professional (clinical) service and you will be billed accordingly.  If your records are provided for purposes of a court procedure, the cost of copying a complete record is $0.50 per page.

RECALL POLICY

If a client does not show up for a scheduled appointment, the following procedures will be implemented:

The clinician will make a follow-up call to determine the reason for the missed appointment.  If the client wishes to schedule another appointment, one will be scheduled.  If the client wishes to terminate counseling, the case will be closed.

If the client cannot be reached personally, a phone message will be left.  If it is not possible to leave a message for the client, a follow-up email/text will be sent. If the client does not respond to these follow up attempts, the case will be closed.

TERMINATION POLICY

Clinical services will be considered terminated under the following circumstances:

Treatment goals are considered to be accomplished by the client and the clinician.

The client wishes to discontinue services for any reason. If the client wishes to receive a referral to another clinician, this clinician will provide appropriate referrals.

The clinician believes that another mental health provider or type of treatment would be more appropriate for the client or that progress toward treatment goals has ceased.  In this case, the client and the clinician would discuss the relevant issues and come to a joint decision about the termination of treatment.

The client is not complying with the structure of treatment (i.e., does not show up for scheduled appointments, repeated cancellations at the last minute) or does not follow through with essential recommendations (i.e., psychiatric evaluation, substance abuse treatment) made by the clinician.  In this instance, the clinician will consult with professional colleagues and possibly insurance company case managers in order to determine the best course of action.  In some instances, after professional consultation, the client may be sent a "discharged from treatment" note.  This note may contain reasons for termination, recommendations, and referrals, if appropriate.

               The clinician will not terminate a client who is in crisis or at risk.  If possible, a final session will be set in order to discuss gains                     made in treatment, recommendations, and possible referral to other treatment providers. A termination note will be placed in                    the client's file.

Thank you for your consideration.

Carla S. Perkins, LCSW, BC-TMH

INFORMED CONSENT CHECKLIST FOR TELETHERAPY SERVICES

Prior to starting video-conferencing services, we discussed and agreed to the following:

         There are potential benefits and risks of videoconferencing (e.g. limits to patient confidentiality) that differ from in-person sessions.

         Confidentiality still applies for teletherapy services, and nobody will record the session without the permission from the others person(s).

         We agree to use the video-conferencing platform selected for our virtual sessions, and the therapist will explain how to use it.

         You need to use a webcam or smartphone during the session.

         It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session.

         It is important to use a secure internet connection rather than public/free Wi-Fi.

         It is important to be on time. If you need to cancel or change your tele-appointment, you must notify the therapist in advance by phone or email.

         We need a back-up plan (e.g., phone number where you can be reached) to restart the session or to reschedule it, in the event of technical problems.

         We need a safety plan that includes at least one emergency contact and the closest ER to your location, in the event of a crisis situation.

         If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in teletherapy sessions.

         You should confirm with your insurance company that the video sessions will be reimbursed; if they are not reimbursed, you are responsible for full payment.

         As your therapist, I may determine that due to certain circumstances, teletherapy is no longer appropriate and that we should resume our sessions in-person.

Therapist Name / Signature: _____________________________________________

Patient Name: ____________________________________

Signature of Patient/Patient's Legal Representative: ______________________________

Date: ____________________________________