Welcome to the Palm Harbor Counseling Team (PHCT). This document contains important information about our professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us.

COUNSELING PSYCHOTHERAPY SERVICES

Psychotherapy is not easily described in general statements. It varies depending on the personalities and of the therapist and client, and the problems you hope to address. There are many different methods therapists may use to deal with those problems. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. Research clearly shows for the therapy to be most successful; you will have to work on things we talk about both during our sessions and at home.

Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings or thoughts like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people who actively engage in it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in negative thoughts and subsequent feelings of distress. When you change how you think, you will change how you feel. However, there are no guarantees as to what you will experience.

Our first meeting(s) will involve an assessment of your concerns and what is troubling you. By the end of this, as your therapist, I will be able to offer you some first impressions of what our work will likely include and an initial plan that you agree you want to work on if you decide to continue with therapy. Identifying and addressing specific problems is much more effective that addressing general problems. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. Generally, by the end of our first meeting, I will ask if you believe we can work effectively together and likewise I will inform you if I believe that I am not the therapist that can be most effective for you and, if so, I will give you referrals to other practitioners whom I believe are better suited to assist you.

Therapy involves a large commitment of time, money, and energy, so it can be very important to feel comfortable with the therapist you select. If you have questions about procedures, you can discuss them whenever they arise. If your doubts persist, about my therapy approach, I will be happy to help you set up a meeting with another mental health professional as an alternative option.

MEETINGS

Much of the first meeting is generally geared toward gaining a good understanding what you are concerned about and thoughts and feelings you are experiencing. If a mutual agreement is reached to begin psychotherapy, we generally schedule one [45-60 minute] session (one appointment hour of [45-60] minutes duration) per week, at a time we agree on, although some sessions may be longer or more frequent. Once an appointment time is scheduled, you will be expected to pay for it unless you provide 24 hours [1 day] advance notice of cancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. [If it is possible, we will try to find another time to reschedule the appointment.]

PROFESSIONAL FEES

If you are utilizing your health insurance, your personal financial responsibility will vary based on specific plan and is determined by your insurance company. It will also vary based on the specific service being provided, any unmet deductibles and co-pays also determined by your insurance policy. If you are not insured and paying out of pocket the Palm Harbor Counseling Team individual standard hourly fee is $95 - $115 and is usually set upon scheduling your first appointment with our intake staff or if you talk to your therapist directly.

BILLING AND PAYMENTS

Our therapists may advise our intake staff to offer various discounts, such as out of network discounts, 3 or more prepaid sessions and the like at their discretion and you will be advised of the set fee in advance. If we meet more than the usual time or provide a specialized service, charges may be modified accordingly with your agreement in advance. In accordance with the No Surprises Act, (cms.gov/no surprises) as defined by Federal Statutes and the State of Florida, you are entitled to a written good faith estimate of costs (described in detail in the No Surprises Billing document provided you). Your therapist will give you this form to sign when you first meet.

You will be expected to pay toward your insurances deductible or required co-pay each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when such services are requested. [In circumstances of financial hardship, rates may be adjusted as agreed to by you and your therapist].

INSURANCE REIMBURSEMENT

In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, most policies now provide some coverage for mental health treatment, however deductibles and copays can vary greatly. We will fill out forms and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of fees. It is very important that you find out exactly what mental health services your insurance policy covers and if there is a limit on number of sessions. We may also use electronic services such as Headway or Alma which will be explained to you at your first meeting.

You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, we will provide you with whatever information we can based on our experience and will be happy to help you in understanding the information you receive from your insurance company. If necessary, our staff are willing to call the insurance company on your behalf to obtain clarification depending on when a problem was encountered.

Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans frequently require authorization before they provide reimbursement for behavioral health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. Though a lot can be accomplished in short-term therapy, some clients feel that they need more services after insurance benefits end.

Some managed-care plans will not allow us to provide services to you once your benefits end. If this is the case, we will try to assist you in finding another provider who will help you continue your psychotherapy.]

You should also be aware that most insurance companies require that we provide them with your clinical diagnosis. Sometimes we must provide additional clinical information, such as treatment plans, progress status or brief listings or summaries of problems being addressed. This information will become part of the insurance company files.

You understand that, by using your insurance, you authorize me or business associates of Palm Harbor Counseling Team LLC to release such information to your insurance company. This is standard procedure for most payors although most do not request much, if any information. We try to keep that information limited to the minimum necessary.

CONTACTING THE THERAPIST

Therapists are often not immediately available by telephone. When no one is available, our telephone is answered by an electronic recording device [it is monitored frequently during regular business hours and reported to the clients’ therapist by email. We will make every effort to return your call on the same day you make it, if possible, except for weekends and holidays. If you are difficult to reach, please inform us of sometimes when you will be available. [it is the option of each independent therapist as to providing their cell number.] If you are unable to reach anyone and think that you cannot wait for a return call, contact your family physician or the nearest help line or call 211 and ask for help or suggestions. If a therapist will be unavailable for an extended time, they may provide you with the name of a colleague to contact, if necessary.

CONFIDENTIALITY [for adult clients]

In general, the privacy of all communications between a client and a therapist is protected by law, and they can only release information about our work to others with your written permission. However, there are a few exceptions.

In most legal proceedings, you have the right to prevent the therapist from providing any information about your treatment. In some legal proceedings, a judge may order testimony if he/she determines that the issues demand it, and we must comply with certain specific court orders.

There are some situations in which we are legally obligated to take action to protect others from harm, even if we must reveal some information about a client’s treatment. For example, if the clinician believes that a child, elderly person, or disabled person is being abused or has been abused, they must [as required by Florida law] make a report to the appropriate state agency. This is usually the State Abuse Hotline.

If a therapist believes that a client is threatening serious bodily harm to another, they may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client. If the client threatens to harm himself/herself, the therapist may be obligated to seek involuntary assessment under Florida’s Baker Act or to contact family members or others who can help provide protection. If a similar situation occurs in the course of our work together, we will attempt to fully discuss it with you before taking any action.

We may occasionally find it helpful to consult other professionals about a case. The consultant is also legally bound to keep the information confidential. Ordinarily, we will not tell you about these consultations unless they believe that it is important to your work together.

Although this written summary of exceptions to confidentiality is intended to inform you about potential issues that could arise, it is important that we discuss any questions or concerns that you may have at our next meeting. Your therapist will be happy to discuss these issues with you and provide clarification when possible. However, if you need specific clarification or advice, we are unable to provide, formal legal advice may be needed, as the laws governing confidentiality are quite complex and we seek to follow the law, not interpret it.

We do not use search engines to find additional information about our clients and will not make contact in social media including Facebook, twitter or the similar social media with any clients or accept invitations to join or friend clients.

as an independent practitioner, who is associated with and offices at Palm Harbor Counseling Team LLC to provide such care, treatment, or services as are considered necessary and advisable.

I understand and agree that I will participate in planning of my care, treatment, homework or services and that I may withdraw consent for such care, treatment, or services that I receive through Palm Harbor Counseling Team LLC at any time.

By signing this Informed Consent, I, the undersigned client, acknowledge that I have both read and understood all the terms and information contained herein. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me.

I agree and understand that by typing (or drawing) my Signature electronically, that this electronic signature is the legal equivalent of my manual/handwritten signature.

As a client(s) of the Palm Harbor Counseling Team Inc, you have the following rights:

1. Services shall not be denied to any person on the grounds of race, ethnicity, age, color, religion, gender, nationality, sexual orientation, handicap, or developmental disability.
2. To be treated with courtesy and respect by all staff.
3. To receive appropriate mental health care or to be provided with a referral to another qualified provider, if necessary.
4. To participate in the planning of your treatment throughout the counseling process.
5. To ask questions and learn about the counseling process, and the qualifications of your provider(s).
6. As a competent individual, consent to or refuse treatment.
7. To confidentiality of your records and the right to inspect your records.
8. To be informed of your condition and to know the costs of services.

And the following responsibilities:

1. To make your payment at the time of service (whether self or co-payment or deductible).
2. To have your insurance company billed for covered services. You are responsible for all co-payments, deductibles, and/or coinsurance payments as required by your insurance policy.
3. To schedule and keep appointments. Should you need to cancel or reschedule an appointment, we require at least 48 hours’ notice when possible. Should you not provide this notice, or not show for an appointment, you will be charged $55. We will automatically bill this to the credit card you list in the payment policy form below.
4. To not come to any appointment under the influence of any mood-altering substances, unless prescribed and only as prescribed by a physician. If you do, you will be asked to reschedule and charged $45.
5. To give your treatment provider the necessary information about you, and to be involved in the planning of your treatment.
6. To follow the recommendations of your treatment provider, including those for psychiatric evaluations for medication therapy and testing, and to follow the agreed upon treatment plan.

I agree and understand that by typing (or drawing) my Signature electronically, that this electronic signature is the legal equivalent of my manual/handwritten signature.

Consent to Email or Text Usage for Appointment Reminders and Information Communications

Palm Harbor Counseling Team clients may be contacted via email and/or text messaging to remind you of an appointment and/or to provide general information (therapist illness, loss of power, weather safety alerts, etc.) If at any time I (the client) provides an email or text address to Palm Harbor Counseling Team or my therapist at which I may be contacted, I consent to receiving appointment reminders and other relevant communications/information at that email or text address.

Risk of using email/texting

The transmission of client information by email and/or texting has a number of risks that clients should consider prior to the use of email and/or texting. These include, but are not limited to, the following risks:

1. Email/texts can be circulated, forwarded, stored electronically, on paper, or broadcast to unintended recipients.
2. Email/text senders can easily misaddress an email or text and send the information to an undesired recipient.
3. Backup copies of emails and texts may exist even after the sender and/or the recipient has deleted their copy.
4. Emails/texts can be intercepted, altered, forwarded or used without authorization or detection.
5. Email/texts can be used as evidence in court.
6. Emails/texts may not be secure, and it is possible the confidentiality of such communications may be breached by a third party. The Clinician and PHCT cannot be held responsible for this type of breach.

I consent to receive text messages from PHCT or my therapist at my cell phone and any number forwarded or transferred to that number or emails to receive communication as stated above. I understand that this request to receive emails and text messages will apply to all future appointment reminders/ information unless I request a change in writing (see revocation section below).

PHCT does not charge for this service, but standard text messaging rates may apply as provided in your wireless plan

*Revocation: I understand the Revocation of Consent to texting or email can be submitted at any time by means of providing a written signed request to my therapist.

Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.

I agree and understand that by typing (or drawing) my Signature electronically, that this electronic signature is the legal equivalent of my manual/handwritten signature.

Voluntary Consent to the use of Telehealth:

Thank you for choosing us as your mental health provider. We are committed to providing you with quality and affordable care. Because some of our clients have had questions regarding client and insurance responsibility for services rendered, we have been advised to develop this payment policy. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon request

1. Insurance. We participate in most insurance plans. If you are not insured by an insurance plan, we do business with, payment in full is expected at each visit. If you are insured by a plan, we do business with, but don’t have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.
2. Co-payments and deductibles. All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect co- payments and deductibles from patients can be considered fraud. Please help us in upholding the law by paying your co-payment at each visit.
3. Non-covered services. Please be aware that some – and perhaps all – of the services you receive may be non-covered or not considered reasonable or necessary by your insurer. You must pay for these services in full at the time of visit.
4. Proof of insurance. All patients must complete our client information form before seeing a therapist. We must obtain a copy of your current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim. Insurance providers will not pay any claims submitted 90 days after date of service.
5. Claims submission. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.
6. Coverage changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits.
7. Nonpayment. If your account is over 90 days past due. Please be aware that if a balance remains unpaid, we may have to discharge you from this practice. If this is to occur, you will be referred to another counseling agency. If there is mental health crisis during the referral process, our agency will provide interim emergency services only.
8. Missed appointments. Our policy is to charge a 55-dollar fee for missed appointments that are not canceled 24 hours in advance. There are common sense exceptions such as sudden illness, family emergencies, severe weather warnings or other public emergencies, however you are still expected to contact your therapist or the intake office and notify them. Otherwise, these charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your regularly scheduled appointment.
9. Recurring Credit Card Payment Authorization. It is our policy to obtain credit or debit card information from each patient. This is to ensure that all payments will be collected according to the conditions within our payment policy. By completing the following information, you authorize Palm Harbor Counseling Team LLC to charge the credit card indicated in this authorization form according to the terms outlined above.

This payment authorization is for the goods and services described above. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the business in writing of any changes to my account information or termination of this authorization at least 15 days prior to the next billing date. This payment authorization is for the type of bill indicated above. I certify that I am an authorized user of this care.

For tele behavioral health services, I understand that Palm Harbor Counseling Team LLC providers cannot verify the card in person as would be standard for n-site, in office treatment and accept the process for card charges.

NOTE: If you are using EAP benefits, LEAVE THIS CREDIT CARD SECTION BLANK and simply sign at the bottom indicating you have read the policy.

NOTE: The form below is protected by SSL security encryption. You can safely transmit your credit card details using this form.

Client Signature