Going beyond traditional types of talk therapy
KAROL A. BAILEY, Ph.D.
A PSYCHOLOGICAL CORPORATION
Breakthrough Solutions for Individuals and Organizations
Billing / mailing address: 6475 E. Pacific Coast Highway, #414, Long Beach, CA 90803
Telephone: (562) 431-3423
OUTPATIENT SERVICES CONTRACT
Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them. When you sign this document, it will represent an agreement between us.
PSYCHOLOGICAL SERVICES
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the problems you bring forward. There are many different methods I may use to deal with the problems that you hope to address.
In our first session, I will focus on getting to know you and understanding what you want to address. By the end of our first meeting, we will establish together what we’re going to clear up for you.
MEETINGS and CANCELLATIONS
Our initial meeting will normally last 53 minutes to one hour. Our subsequent sessions will normally be for 53 minutes or 90 minutes depending on what we are addressing.
Since scheduling an appointment involves the reservation of time specifically for you, a minimum of 24 hours (1 day) notice is required for rescheduling or canceling an appointment. The full fee will be charged to you for sessions missed without such notification. Please note that insurance companies do not reimburse for missed sessions.
PROFESSIONAL FEES
Fees for individual consultations are in most cases charged at the time the service is provided. Other services to individual clients may include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. These will be discussed if and when they are requested by you.
Fees for couples intensives are paid in advance – half of the fee to reserve your retreat on our calendars and the second half approximately two weeks prior the beginning of your retreat. These payments will be discussed when you request your intensive retreat.
I DO NOT MAKE COURT APPEARANCES.
However, if you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $500 per hour for preparation for, attendance at, and commuting to any legal proceeding.
BILLING AND PAYMENTS
Thank you for paying for each session at the time it is held. Payment schedules for other professional services will be agreed to when they are requested.
INSURANCE REIMBURSEMENT
If you would like to seek reimbursement from your insurance company, I can provide you with a superbill showing what was charged, what was paid, and what procedures were used. You can submit this document to your insurance company for reimbursement. They will send the check directly to you.
NOTE: If you have Medicare as your insurance, you will not be able to bill for reimbursement for our sessions. I have “opt-out” status with Medicare which means they cannot be billed. I will ask you to sign a separate form stating your understanding of this and informing you that you may have benefits from Medicare if you work with another provider – one who is contracted with them.
It is important for you to know that insurance companies require a clinical diagnosis and, therefore, your superbill I generate for you will include a code that indicates to your insurance company the diagnosis for which you are being seen.
This information will become part of the insurance company files and will be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank.
Insurance benefits are continuing to become increasingly more complex. It is increasingly difficult to determine exactly how much mental health coverage is available and for what services. Your insurance carrier’s customer service department is your best resource in facilitating your claims submission process.
CONNECTING WITH ME
I am often not immediately available by telephone. My regular office hours are on Tuesdays, Wednesdays and Thursdays (other days and times are available as needed). I will not answer the phone when I am with a client. When I am unavailable, my telephone is answered by confidential voice mail that I monitor frequently. I will make every effort to return your call on the same day you make it, except for weekends. If you are difficult to reach, please inform me of times when you will be available. If you are unable to reach me and feel that you can’t wait for me to return your call, call 911 or contact your family physician or the nearest emergency room and ask for the psychologist on call.
TELEHEALTH via VIDEO CONFERENCING
After intake and establishing a relationship, it may be determined — due to convenience, distance, or other circumstances — that “face-to-face” or interactive video-conferencing may be the preferred method of receiving treatment. Video conferencing is a real-time interactive audio and visual technology that allows for delivery of service via computer, phone, or other electronic device. the VC system we use (www.zoom.us) meets standards of encryption and privacy protection. You will not have to purchase a plan nor provide your name when you “join” our meeting. VC may be used when the clinician and client are in different locations. Licensure regulations only allow us to practice within the state that both client and clinician are located. There are some exceptions.
HYPNOSIS
One method I sometimes use is hypnosis and I do so because it has been scientifically proven to accelerate the changes in behavior, attitude, and thinking that you seek. The experience of hypnosis is what you’ve had daydreaming or finding yourself emotionally reacting to a movie. You are in complete control and will never do anything you do not wish to do. I will explain this in more depth prior to using this technique with you. Of course, if you are not comfortable with it after my explanation, we will not use this approach.
ANIMAL-ASSISTED THERAPY
During your work with me you will meet my dog Gizmo. He is certified by the American Kennel Club as a Canine Good Citizen and is also a certified Therapy Dog. His coat is hair not fur and is non-shedding and hypoallergenic.
PROFESSIONAL RECORDS
The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of the records unless I believe that seeing them would be emotionally damaging, in which case I will be happy to send them to a mental health professional of your choice. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. I recommend that you review them in my presence so that we can discuss the contents. Patients will be charged an appropriate fee for any time spent in preparing information requests.
MINORS
If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from parents that they agree to give up access to your records. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. I will also provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss.
CONFIDENTIALITY
In general, the privacy of all communications between a patient and a psychologist is protected by law, and I can only release information about our work to others with your written permission. But there are a few exceptions.
In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it.
There are some situations in which I am legally obligated to act to protect others from harm, even if I must reveal some information about a patient’s treatment. For example, if I believe that a child, elderly person, or disabled person is being abused, I must file a report with the appropriate state agency.
If I believe that a client is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If the patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection.
These situations have rarely occurred in my practice. If a similar situation occurs, I will make every effort to fully discuss it with you before taking any action.
I may occasionally find it helpful to consult other professionals about a case. During a consultation, I avoid revealing the identity of my client. The consultant is also legally bound to keep all information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together.
ACKNOWLEDGEMENT AND CONSENT OF CONTRACT
Your e-signature on my on-line New Client Information form indicates that you have read the information in this document and agree to abide by its terms and conditions during our professional relationship.