THERAPY SERVICES

As a Licensed Clinical Social Worker, it is my aim to provide the most efficient, effective, and least restrictive treatment/evaluation intervention possible.  If I do not believe that my skills and experience will be helpful to you, I will provide you with a resource in this community, which to my knowledge offers the services that you need.  Therapy services are not easily described in general statements.  They vary depending on the personalities of the therapist and client, and the particular problems that you hope to address.  Therapy services are not like services received from a medical doctor.  Instead, they call for a very active effort on your part.  For example, if you are receiving therapy from me, in order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.

Therapy services can have benefits and risks.  Since my services often involve discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness.  On the other hand, therapy services also have been shown to have many benefits.  My services often lead to better relationships, solutions to specific problems, and significant reduction in feelings of distress.  However, there are no guarantees of what you will experience.

With regard to therapy, my first few sessions will involve an evaluation of your needs.  By the end of the evaluation, I will be able to offer you some first impressions of what my work will include and a treatment plan to follow, if you decide to continue with therapy.  You should evaluate this information along with your own opinions of whether you feel comfortable working with me.  Therapy involves a large commitment of time, money, and energy, so you should be careful about the therapist you select.  If you have questions about my procedures, we should discuss them whenever they arise.  If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion.

CONTACTING ME

Due to my work schedule, I often am not immediately available by telephone.  When I am unavailable, my telephone is answered by voicemail, that I monitor frequently.  I will make every effort to return your call as quickly as possible.  I do not typically return calls on weekends, during vacations, or on holidays.  If you are unable to reach me, and you have a critical or emergent need that cannot wait, please contact your family physician, the Crisis and Information Center (589-4313), or the nearest emergency room.

LIMITS OF CONFIDENTIALITY

In general, the privacy of communications between client and therapist is protected by law, and I can only release information about our work to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA.  There are other situations that require only that you provide written, advance consent.  Your signature on this agreement provides consent for those activities, as follows:

I may occasionally find it helpful to consult other professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep the 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.  I will note all consultations in your clinical record. Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this agreement. If a client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or other who can help provide protection.

There are some situations where I am permitted or required to disclose information without either your consent or authorization:

If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, I cannot provide any information without your (or your legal representative's) written authorization, or a court order. If a government agency is requesting the information for health oversight activities, I may be required to provide it to them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding the client in order to defend myself.

There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm, and I may have to reveal some information about a client's treatment.  These situations are unusual in my practice.  The law requires that:

If I know or have reasonable cause to believe that a child or vulnerable adult is neglected or abused, the law requires that I file a report with the appropriate governmental agency, usually the Cabinet for Families and Children.  Once such report is filed, I may be required to provide additional information. If a client communicates an actual threat of physical violence against a clearly identified or reasonably identified victim or a threat of a specific violent act, I may be required to take protective action.  These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client.

If such a situation arises, I will make every effort to fully discuss it with you before taking action or as soon as possible after taking any action, and I will limit my disclosure to what is necessary.

PROFESSIONAL RECORDS

The laws and standards of my profession require that I keep Protected Health Information in your clinical record.   You are entitled to receive a copy of your records, or I can prepare a summary for you instead.   Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers.   If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents.  I am sometimes willing to conduct a review meeting without charge.   You are entitled to a free copy of your record; however I am allowed to charge a copying fee of $1 per page (and for certain other expenses) for any subsequent copies.

CLIENT RIGHTS

HIPAA provides you with several new or expanded rights with regard to your clinical record and disclosures of protected health information.  These rights include requesting that I amend your record; requesting restrictions on what information from your clinical record is disclosed to others, requesting an accounting of most disclosures of protected heath information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this agreement and my privacy policies and procedures.  I am happy to discuss any of these rights with you.

MINORS AND PARENTS

I will provide treatment/evaluation to children only with custodial consent to do so.  Clients under 17 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child's treatment records.  Because privacy in therapy is often crucial to successful progress, particularly with teenagers, it is sometimes my policy to request an agreement from parents regarding how children's privacy can be honored.  Information given to me by your child which involves risk to life, incidences of abuse or neglect, or other unlawful activity will be shared with you as soon as reasonably possible, and, if necessary, appropriate actions taken to aid in the protection of your child and any other potential victim.  I will use my clinical judgment to advise you of your child's statements regarding issues outside those stated areas.

BILLING AND PAYMENTS

You will be expected to pay prior to each session, unless we agree otherwise.  In circumstances of unusual financial hardship, I may be willing to negotiate a payment installment plan.  I accept cash, check, or credit card.

If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment.  This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information.   In most collection situations, the only information I release regarding a client's treatment is his/her name, the nature of services provided, and the amount due.  If such legal action is necessary, its costs will be included in the claim.  By signing this agreement, you grant permission for me to seek assistance in collecting unpaid fees.  To avoid having me use legal means to secure payment, please communicate with me about any concerns that you have regarding your ability to pay.

SESSIONS AND PROFESSIONAL FEES

If therapy services are begun, I typically schedule one 50-minute session (one appointment hour for 50 minutes duration) per week, although some sessions may be longer or more or less frequent.  An intake session typically lasts 1 hour.  Your appointment time is reserved for you.  You will be expected to pay for it unless you provide 24 hours advance notice of cancellation, or unless we both agree that you were unable to attend due to circumstances beyond your control.   

My fee for therapy is $75 per 50-minute hour to be paid prior to the session.  The fee for initial intake session is $95.00.  If there are special circumstances you would like for me to consider regarding these fees, you must discuss the circumstance with me prior to the first session.  If you miss an appointment without notice or fail to call more than 24 hours in advance, you may be billed for that time.

In addition to weekly appointments, I charge this amount for other professional services you may need, though I will break down the hourly cost if we work for periods of less than one hour.  Other services include classroom observations, report writing, telephone conversations lasting longer than 15 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service 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.  Due to the difficulty of legal involvement, I charge $200 per hour for preparation and attendance at any legal proceeding.

Please note that failure to no show for an appointment may result in a $30 fee and possibly lead to discontinuing of services.

INSURANCE

I am a contracted provider for several insurance and EAP companies.  Prior to the first session, you must obtain information regarding your mental health benefits, including prior authorization (if required), number of sessions allotted per year, deductible (if applicable), co-pay amount, and whether I am an in-network provider for your insurance.  Upon verification of this information, your co-pay will be collected at the beginning of the session, and I will submit a claim to your insurance company.  If your insurance company refuses to pay for services, you will be responsible for the remaining balance of services provided.

Your signature on this document indicates that you understand and agree to the information provided for the duration of your treatment.  If you are seeking child or family therapy, your signature also gives permission for you minor children to receive therapy services.

I authorize the release of information to process my insurance claims to the insurance company I have disclosed.  Additionally, I authorize the payment of mental health benefits to Andrea Sorsa.  If my insurance company refuses to pay my benefits or if I have a deductible to meet before the insurance company pays, I agree to pay the full session fee directly to Andrea Sorsa.  I agree to pay copays not covered by insurance at each session.

If I do not have insurance, I agree to pay the private pay rate as mentioned in the Client-Therapist Services Agreement.  Payment is due during the time that services are rendered.