Psi Client Information Form (Page 4 of 6) in pdf

SYCH

TRATEGIES

Office Policies

Legal and Ethical Policies -

Without pressure or coercion, I, the client/guardian, consent to treatment for myself

and/or my legal dependent. All information disclosed in sessions and the written records pertaining to those sessions are

confidential and may not be revealed to anyone without my, the client/guardian’s, written permission, except where

disclosure is required by law.

The reporting of information disclosed in session is required by law under the following circumstances:

 If a client presents an imminent danger to self or others or is gravely disabled (severely disoriented or in

danger due to a psychiatric condition) authorities must be notified.

 If a client expresses a serious threat of harm to an identifiable person, that person must be warned and the

police must be notified.

 If there is reasonable suspicion of child, dependent, or elder abuse or neglect, authorities must be notified.

The reporting of information disclosed in session may be required:

 If the client’s mental status is placed at issue in litigation initiated by me, the client/guardian.

 In the event of a court order or subpoena, information, records, or testimony about the client may have to be

produced.

I, the client/guardian, have the right to review and/or receive a copy of the client’s protected health

information. If the treating clinician deems that releasing such information might be harmful in any way, the

clinician will either deny my request or provide the records to an appropriate and licensed mental health

professional of the client/guardian’s choice.

I, the client/guardian, may end treatment at any time by notifying the therapist in person or by

telephone.

Financial Policies – I, the client/guardian, assume primary financial responsibility for all professional services

rendered and understand that any balance due will be billed to me on a monthly basis. I, the client/guardian, am

responsible for the standard fee of $_______ per session. Payment is due at the time that services are provided.

An additional charge may be added for payments received after the date of service.

Insurance co-payment per session is $___________.

Cancellation Policy - If the client misses an appointment or cancels an appointment without giving 24 hours

notice I, the client/guardian, will be charged $_________for the missed session. Missed appointments and late

cancellations are not covered by insurance.

Services provided outside of the client’s usual scheduled session (i.e., telephone consultations, site

visits, travel time, longer sessions, etc.) may be charged to me, the client/guardian, at the clinician’s standard fee

unless otherwise agreed upon.

If payment of the client’s account is over 120 days late, or if it goes to collection, all fees including

collection and attorney fees will be my, the client/guardian’s, responsibility.

Insurance Policies - I, the client/guardian, consent to have claims submitted to the client’s insurance

company. Yes _____ No_____

I, the client/guardian, am ultimately responsible for charges incurred even though services will be

billed to the client’s insurance. PsychStrategies will bill the client’s primary insurance only. PsychStrategies

will not bill a secondary insurance (except when MediCare is the primary insurance). A receipt for services can

be provided upon request. I, the client/guardian, understand that not all issues/conditions/problems that may be

the focus of treatment are reimbursed by insurance companies. I understand that the client’s insurance benefit

may only provide for crisis intervention, and that, therefore, a brief therapy model with solution-focused therapy

or problem-solving techniques may be used by the clinician.

Page 1 of 2

Client/Legal Guardian Signature ______________________________

revised 08/07

Revised 061912

Psi Client Information Form Page 4

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