Psychotherapy Associates
of North Reading
Initial Information

Below is the initial paperwork we give to clients prior to their first visit. If you would like you can save time by printing this out and bringing a signed copy to your first appointment. If you would prefer, you can come 15 minutes early to your first appointment and fill this out at our office.

Information Sheet and Consent to Treatment

Please print your name here:______________________________________

Welcome to Psychotherapy Associates. We would like to give you a little more information about ourselves, and what to expect during the counseling sessions here.

CONFIDENTIALITY Everything that is discussed in the sessions here will be kept in the strictest confidence. We will not disclose any information to anyone without your permission. There are a few possible exceptions to this:

1. If you are paying by insurance, your insurance company may require certain clinical and administrative information to determine payment of the claim. In addition, HMOs and managed care companies sometimes require detailed clinical information to determine medical necessity of services. By signing this form, you agree that we are permitted to disclose the requested information to insurance companies, HMOs and EAPs for the purpose of administering benefits and managing care.

2. In certain rare circumstances we could be called upon (subpoenaed) to testify about you in court. This could happen if there was reason to believe we knew of certain types of criminal activities. This is a very unlikely occurrence, but we felt you deserved to be informed of the possibility.

3. We are bound by the State's mandatory reporting laws. This includes situations where we believe child abuse or neglect may be occurring, or if you indicate to us a serious intent to harm yourself or someone else. In these cases, we are required by law to take the appropriate action to prevent the harm or abuse from occurring or continuing. This may include notifying State authorities or other individuals who may be in danger of harm.

4. We have a system of peer consultation at Psychotherapy Associates, whereby cases are, at times, discussed between the clinicians working here. This is for the purposes of receiving additional input, and all parties are bound by the confidentiality rules outlined above.

TIME OF APPOINTMENTS Unless we make other arrangements, our appointments are scheduled to last 50 minutes. If an appointment starts late due to our running behind, we will still keep the full 50 minutes. If you arrive late for an appointment, we will have to end the meeting 50 minutes after it was scheduled to begin. The charge to you for these shortened meetings will be for the full amount. You will not be charged for a session if you cannot keep it and let us know at least 24 hours in advance. You will be charged a $60.00 cancellation fee for any appointments that are cancelled with less than 24 hours notice, or for which you do not show up. This $60.00 fee is generally not billable to insurance and will need to be paid by you directly. This policy is strictly enforced.

EMERGENCIES We maintain 24 hour on-call emergency coverage. If you call at a time when there is no one in the office you will have the option of leaving a confidential message for your therapist on voice mail or paging the on-call clinician. To page the on-call clinician, in an emergency, press 1 at the prompt and follow the directions. If an emergency arises, including suicidal feelings, and you are unable to contact us or feel it is not safe to wait, please call the emergency room of the nearest hospital. These emergency rooms are equipped to handle this kind of problem on a 24 hour basis. Please also leave a message for us so we will be aware of the crisis and can contact you to follow up.

MEDICAL CHECKUP Please get a physical examination from your personal physician as soon as possible. This is important to make sure that none of the problems to be discussed here are the result of physical health difficulties. We work closely with physicians, and we would like to request your permission to contact your doctor. Please indicate if it is all right with you to send periodic updates to your doctor by initialing below:

I do______

I do not_____ give permission to send periodic updates to my physician.

Physician Name:______________________________________________

Address:____________________________________________________

FEES AND PAYMENT Please click here to see a copy of our fee schedule. Payment is expected at the time of each visit. If the sessions are to be billed to insurance, please understand that the payment for these sessions ultimately remains your responsibility. If the insurance company does not pay in full, you agree to be responsible for any unpaid balance. Please be aware that most insurance companies have deductibles, co-payments and limited mental health coverage. We will do our best to be aware of these payments due from you, and to keep you informed of any changes. However, it is your responsibility to keep track of the number of sessions, dollar amount limits, changes in co-payments, etc. that may be due. Please inform us right away if your insurance coverage changes. If any checks submitted by you are returned for lack of payment by the bank (bounced checks), you will be responsible for reimbursing us for any charges made to us by banks to cover these costs.

In signing this form, you agree that we may bill your insurance company on your behalf, and you agree to ASSIGN PAYMENTS to Psychotherapy Associates of North Reading. This means that you give permission for the insurance payments to be made directly to us. Please be aware that if we are billing insurance, we will need to inform the insurance company of a medical diagnosis. We will be happy to discuss this diagnosis with you, if you request.

I have read and discussed the above agreement with my therapist. I understand and agree to all of the points discussed above. If at any point I have questions or problems regarding my treatment here I understand that Psychotherapy Associates has a grievance procedure. This is to first try to resolve any difficulties with your therapist. If this does not prove satisfactory, the next step is to contact either of the two Co-Directors: Donna Whipple or Richard Kaufman.

Please sign:__________________________________ Date________________

Therapist:____________________________________ Date________________

Late Cancellation & No Show Policy

This is to clarify our policy as regards to canceled and missed appointments.

Each of our clinicians only sees a fixed number of clients each week, so that we can devote our full attention and energy to their issues. We do not approve of the policy of overbooking clients. Because we only schedule a limited number of appointments each week, we need to be able to count on these visits in order to successfully operate our practice. Therefore, we have established the following policy as regards to missed appointments.

For any appointment that is canceled with less than 24 hours notice, no matter what the reason, you must pay the cancellation fee, which is $60.00. This fee is not billable to insurance, and must be paid by you directly.

We do realize that sometimes emergencies come up, and appointments cannot be kept. The purpose of the policy, however, is to allow us to reserve your slot, and to enable us to schedule a reasonable number of clients each week. Therefore, even if there is an excellent reason why 24 hours notice was not possible (such as illness, car breaking down, etc.), the cancellation fee will still need to be paid.

In addition, the $60.00 fee will also be due, even if the appointment is rescheduled for later in the week. The reason for this is that without 24 hours notice, we will be unable to fill the earlier time slot.

The only exception to this policy is cancellation for inclement weather. If the driving conditions are very bad, and you do not feel it is safe to drive here, please call us. If you call us and we confirm that the session is cancelled due to inclement weather, the $60.00 fee will not need to be paid. If you do not call, it will still be due. Similarly, if we cancel the session due to inclement weather conditions, you will not be credited for a free session.

Strict enforcement of this policy will allow us to continue to deliver the high quality treatment you deserve.

Insurance Information

Please fill in the information below as completely as possible. Do not leave any sections blank. If you have questions about this form, please ask your therapist for assistance.

Identifying Information

Client Name:_________________________________________

Date of First Visit:_____________________ Marital Status:___________

Address:_________________________________________________________

________________________________________________________________

Home Phone:______________________ Date of Birth:_____________

Work Phone:______________________ Soc. Sec. #:_____________________

Person responsible for paying bill:________________________

Relationship of financially responsible party to patient:_______________

Please indicate how you heard about this practice:__________________

Name of person filling out this form and relationship to client:____________________________________

Insurance Information

Insurance Type:________________________________________________

Card #:___________________________ Group #:_____________________

Name of Insured:_________________________________________________

Address of Insured (if different):____________________________

______________________________________________________________

DOB of Insured:__________ Soc. Sec. # of Insured:___________

Employer of Insured:____________________________________________

Relationship of Insured to Client:____________________________________

Other Information:

Please describe your reasons for seeking treatment, and list the problems for which you want help at this time:

________________________________________________________________

Please describe any previous or current psychological treatment or counseling you have received:

________________________________________________________________

Are you taking any medications (if yes, please list):

________________________________________________________________

For Office Use Only:

Primary Therapist:_______________________ Fee:_________

Diagnosis______________________________________________________

Other Information:_____________________________________________

________________________________________________________________

Psychotherapy Associatesof North Reading Initial Information

Information Sheet and Consent to Treatment

Late Cancellation & No Show Policy

Insurance Information

Identifying Information

Insurance Information

Other Information:

For Office Use Only:

Psychotherapy Associates
of North Reading
Initial Information