Welcome to my practice! Entering therapy is a significant step and one not taken lightly. I look forward to our work together. This agreement contains important information about my professional services and business policies. I am required to obtain your signature acknowledging that I have provided you with this information. Please read this Agreement and the HIPAA notice carefully. Your signature on this document represents an agreement between us.
Please initial each section on the blank line following that section indicating that you have read and understand that section.
1. Psychological Services It is difficult to describe Psychotherapy in general statements. Much of it depends on the personalities of the psychologist and the patient and the particular concerns the patient may be experiencing. At its heart, nevertheless, psychotherapy is a collaborative process; the relationship between the therapist and the patient is vital to the success of therapy. It is important to note that psychotherapy can have both benefits and risks. Since therapy often involves grappling with unpleasant aspects of life, patients may experience uncomfortable feelings during the course of therapy. Therapy, however, is a process that often leads to greater self-understanding, improved relationships, and more effective ways of dealing with stressors and life problems. There are, nevertheless, no guarantees of outcomes. If you do not appear to be benefitting from therapy, we will explore different courses of treatment.
Most people find lasting benefit with 8 to 12 sessions. Some people decide they can benefit from longer term therapy. Typically, termination of treatment is mutually agreed upon between therapist and client. You may voluntarily terminate at any time. If either you or Dr. Partington feel this form of treatment is no longer beneficial, other treatment options will be discussed. Dr. Partington will provide you with referrals if needed.
During the first session, Dr. Partington will talk with you about your reasons for seeking therapy. If she feels that she cannot adequately assist you, she will refer to other mental health practitioners. She will also discuss this service agreement and answer any questions you may have. Initial_________
2. Psychotherapy Sessions Psychotherapy sessions are 55 minutes long unless your insurance plan covers 30-45-minute sessions only or we negotiate a different length of time. Your appointment time is allotted for you only. Dr. Partington does not double-book sessions. You are responsible for late cancellation and missed appointment fees as detailed in Section 4 of this service agreement. Initial:_______
3. Contacting Dr. Partington You are welcome to contact Dr. Partington by telephone at any time. Her work schedule often prevents her from answering your call at the time that you make it. She monitors her messages frequently, so please leave a message, including a call-back number. All messages are confidential. She will return your call as soon as possible. Note: If she will be unavailable for an extended period, she will provide you with contact information of a colleague. Messages left after 6:00 p.m. or on weekends may not be returned until the next business day. Initial______
Dr. Partington does not provide crisis services.If you are experiencing a crisis, please call 988 or the valley-wide mental health Crisis Line at 480-784-1500.You may also contact your local hospital emergency room and ask for the psychologist or psychiatrist on call. Initial_______
You may contact Dr. Partington through text and email; however, confidentiality cannot be guaranteed. Use of text and email is at your risk and discretion. Lengthy email messages disclosing personal information are strongly discouraged. Dr. Partington does not provide text and email consultations. Initial________
4. Professional Fees and Billing Dr. Partington works on a fee-for-service basis. Full payment, or guarantee thereof through an insurance plan, is expected at time of service. You are expected to have a valid credit card on file.
Late Cancellations & Missed Appointments: A late cancellation is a cancellation made within 48 hours of scheduled appointment time. Insurance does not cover late cancellations and missed appointments. Because a full hour was reserved for you, you will be charged $100.00 fee for missed appointments and late cancellations. Initial__________
Private Payment: For Private paying clients, Dr. Partington charges $130.00/hour for sessions. Dr. Partington will give at least 30-day notice of any increase in fees. Initial _____
Insurance Plan Payment: If you use your insurance coverage to pay for services, Dr. Partington accepts the rate set by your carrier. IT IS YOUR RESPONSIBILITY to know the terms and limits of your health insurance coverage, including deductibles, coinsurance, and copay charges. These charges are due at time of service. Please understand that you, not your insurance company, are responsible for full payment of fees. She will submit claims to your insurance company. Initial _________
Additional Professional Services: Additional professional services, include, but are not limited to, telephone calls lasting more than 10 minutes, report writing, and consultation with other professionals at your request. These types of services are not covered by your insurance carrier. Charges for additional services are based on the $130/hour rate. Initial__________
Legal Proceedings Charges: If you become involved with legal proceedings that require Dr. Partington’s participation, you will be charged for her professional time, including case preparation, transportation costs, and attendance at legal proceedings, even if another party calls her to testify. Charge for legal proceedings is $250/hour. Initial________
Nonpayment of Account: Please let Dr. Partington know if you have difficulty paying for your psychological services. She will work with you to arrive at a payment plan. She retains the right to use legal means to secure payment, such as using a collection agency or small claims court, even if treatment has been terminated. You will be responsible for collection and legal costs accrued in securing payment. NOTE: These measures will allow Dr. Partington to disclose otherwise confidential information. Initial: _________
5. Limits on Confidentiality The law protects the privacy of communications between a patient and a psychologist. In most situations, Dr. Partington can release information to others about your treatment only after you provide specific written authorization.
Some situations only require that you provide written advance consent. Your signature on this Agreement provides consent for disclosure for the following:
Dr. Partington occasionally finds it helpful to consult other professionals about a case. She will make every effort to conceal your identity. Mental health professionals are legally bound to keep patient information confidential.
Fee Collection: Dr. Partington will disclose information required by health insurers or to collect overdue fees as discussed in Section 4 of this Service Agreement. Initial _______
Crisis Intervention: If you threaten to harm yourself, Dr. Partington may be obligated to seek hospitalization for you or to contact your family members or others who can help provide protection. Initial_______
In the following situations, the law either permits or requires Dr. Partington to disclose information without either your consent or authorization:
Court Proceedings: If you are involved in a court proceeding and the court requests information concerning the professional services provided by Dr. Partington. Please note, if you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order Dr. Partington to disclose information.
Health Oversight: If a government agency is requesting the information for health oversight activities, Dr. Partington may be required to provide information for it
If you file a complaint or lawsuit against Dr. Partington, she may disclose relevant information regarding your services in order to defend herself.
Workman’s compensation: If you file a worker’s compensation claim, and Dr. Partington is providing services related to that claim, upon appropriate request, she must provide appropriate reports to the Workers Compensation Commission or the insurer. Initial______
Dr. Partington may be legally obligated to take action in an attempt to protect others from harm in some situations. In such situations, she may have to reveal information about a patient’s treatment. These situations are unusual in Dr. Partington’s practice.
Minors: If Dr. Partington has reason to believe a minor (an individual under the age of 18) has been a victim of injury, sexual abuse, neglect, deprivation of necessary medical treatment, she is required by law to file a report with the appropriate government agency, usually the Department of Child Safety (DCS). Once she files such a report, she may be required to provide additional information.
Vulnerable Adults: If Dr. Partington has reason to believe that adults who are either vulnerable and/or incapacitated and who have been a victim of abuse, neglect, or financial exploitation, she is required by law to file a report with the appropriate state official. Once she files such a report, she may be required to provide additional information.
Harm to Others: If you communicate an explicit threat of imminent serious physical harm to a clearly identified or identifiable victim, and Dr. Partington believes that you have the intent and ability to carry out such a threat, she must take protective actions that may include notifying the potential victim and contacting the police
Self-Harm: If you threaten to harm/kill yourself, Dr. Partington may be obligated to contact peace officers, seek hospitalization for you, and/or to contact family members or others who can help provide protection. Initial_______________
6.Professional Records The laws and standards of psychology profession require that Dr. Partington maintain clinical records that contain Protected Health Information for her patients. As required by the Arizona Board of Psychologist Examiners (R4-26-106-E), records will be stored for a minimum of 6 years following termination of treatment, after which time, records will be destroyed. Dr. Partington does not keep extensive psychotherapy notes.
Except in unusual circumstances that involve danger to yourself and others or where others have supplied information confidentially to Dr. Partington, you may examine and/or receive a copy of your Clinical Record. Copies clinical records must be requested it in writing. Written requests must include patient’s name, date of birth, social security number, and address of where to send the record. Please note that Dr. Partington will make available only those records that she has generated. If you are not currently in treatment or if Dr. Partington is away temporarily from her practice, it may take up to several weeks for her to process requests for records.
Because these are professional records, they can be misinterpreted and/or contain upsetting content. For these reasons, Dr. Partington recommends that you initially review your records with her. If she refuses your request for access to your records, you have a right of review, which she will discuss with you upon your request.
In the event that Dr. Partington closes her practice, patients will be notified in writing a minimum of 30 days prior to the close of practice. Patients will be given referrals to other treatment providers. In the event of her death, a psychologist will handle patient notification and records. Initial_______
NOTE: This form is posted on Dr. Partington’s website (www.deborahpsyd.com). A paper copy is available upon request.
Your signature below indicates that you have read this agreement, had your questions adequately answered, and you agree to its terms. It also acknowledges that you have read the HIPAA Notice. If you wish a copy of the HIPAA notice, you may request one.
_________________________________________ Printed name of Patient or Legal Guardian ______________________________________________________ Signature of Patient or Legal Guardian