INFORMED CONSENT TO PSYCHOLOGICAL SERVICES
Psychological services are based on a relationship between people that works partly because of clearly defined rights and responsibilities held by each person. You have a right to understand the evaluation and treatment procedure being used with you. It is important to be an informed and knowledgeable client and it is always appropriate to ask questions about your psychologist and your progress with the evaluation and/or treatment process. You are free to stop psychological services at any time.
It is often helpful to have a written copy of office policies that you may refer to at your convenience. This document contains important information about my professional services and business policies. If you have any questions after reading this form, please feel free to discuss them with me before signing the attached agreement.
Naturally, I will need to know a great deal about you and/or your child. Except for situations in the attached Notice of Privacy and Practices, you have the right to privacy during our work together. Anyone at my office involved in your care is aware of the importance of confidentiality. Nearly all issues discussed in the course of services are strictly confidential. I cannot share any information about our work together without your prior written permission, except in the Notice of Privacy and Practices. You may direct me to disclose information with whomever you choose, and you can change your mind and revoke that permission at any time.
You may ask anyone you wish to attend a session with you, but let me know in advance so we can decide what information, if any, you want to be kept confidential during that session. Any individual you invite into session is not legally my client, so I cannot have any outside contact with this person without your signed consent.
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 consultant is also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I believe that it is important to the service process.
Benefits and Risks of Psychological Services
Psychological services can have benefits and risks. Since therapy and evaluations sometimes involve discussing difficult aspects of your life, you may at times experience uncomfortable feelings such as sadness, guilt, anger, frustration, loneliness, or helplessness. Obviously I will do my best to support you in coping with these emotional challenges. Although there is no guarantee, psychological services have been shown to have considerable benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. The more truthful you are with me, the easier it will be for me to help you. I do my best to create an atmosphere in which it feels safe to disclose your true thoughts and feelings.
If you are under 18 years of age, please be aware that the law may provide parents with the right to examine your psychological records. Because psychological services require trust and privacy to work effectively, it will be important for the psychologist, parent(s), and minor to agree on how information will be exchanged during the course of evaluations and/or treatment. With adolescents, the clinical goal is typically to maximize privacy, with the exception of issues that compromise the physical safety of the minor. However, information disclosed in psychological evaluations will be provided to parents. If the minor requests, I will do my best to resolve any objections the minor may have about what I am prepared to discuss.
The laws and standards of my profession require that I keep evaluation records. I provide a written, interpretive report for any testing that I conduct. Further, I normally keep brief records, noting your participation and a brief discussion of what occurred during our session. You have a right to review your psychological record and to correct any errors in your file. 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. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents. I maintain your records in a secure location to protect your privacy. Clients will be charged an appropriate fee for any professional time spent in responding to information requests.
I am an in-network provider for some behavioral health/mental health service plans with Anthem Blue Cross Blue Shield, Aetna, CareFirst and Cigna. You are responsible for all co-pays, co-insurance, and meeting your deductible (if applicable). If you're hoping to use insurance to cover our sessions, I encourage you educate yourself about what your particular plan covers (and what it doesn't) because payment for the sessions is ultimately your responsibility. The insurance company may not agree to reimburse all of the services requested. For instance, they may cover personality testing but not psychoeducational testing, or they may cover only a fraction of the hours of testing requested. You remain responsible for paying for any portion of the services that is not covered. The fraction of the fee not actually covered will be billed at my full rate, even if I am on their panel of providers.
If I am not on the panel of your insurance company, or if you do not follow the procedure above and only seek reimbursement after the testing has been completed, or if pre-certification is required but has not been obtained prior to the testing, you must pay me directly and submit the bill to your insurance company to have them reimburse you. Under these circumstances, you will be responsible for the full cost of the services, regardless of insurance company fee schedules and regardless of what portion of the fee the insurance company reimburses.
You should also be aware that most insurance companies require a clinical diagnosis, as well as additional clinical information such as treatment plan or summary. In rare cases, a copy of the entire record may be requested. This information will become part of the insurance company files, and, in all probability, some of it will be computerized. All insurance companies claim to keep such information confidential, but once it is in their hands, I have no control over what they do with it. In some cases they may share the information with a national medical information data bank. If you request it, I will provide you with a copy of any report that I submit.
I also offer private pay counseling and psychotherapy, which means that I do not bill an insurance company and instead am paid directly by the client. Some people choose to pay out of pocket because they want to know that no personal information will be disclosed to any third party (such as a health insurance company that authorizes services related to mental health or substance abuse, an insurance company that offers disability or life insurance coverage, etc.). Others have decided to meet with me even when they have insurance coverage (though it may not cover our meetings due to my being out-of-network) because they believe that the therapeutic connection is so positive and important, and they find a high "goodness-of-fit" with me.
Outside of services covered by insurance, my hourly fee is $160. I charge for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include additional report writing, telephone conversations lasting longer than 15 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.
If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time and transportation costs, even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $300 an hour for my professional time spent in consultations with attorneys, report writing, preparation and attendance at any legal proceeding and any other duties I perform relating to such legal matters.
Please be aware that balances over 60 days may be referred to an appropriate agency for collection. However, this action will only be taken as a last effort to collect fees after other means of collection have been unsuccessful. No clinical information will be shared with the collection agency in this effort.
Cancellations and No-Shows
Clients can cancel or reschedule an appointment anytime, as long as they provide 24 hours’ notice. If you cancel an appointment with less than 24 hours’ notice, or fail to show up, you will be charged for the appointment. It’s important to remember that insurance will not pay for missed appointments, so you will be responsible for the full reimbursement rate, not just a co-pay.
This cancellation policy is really important for my practice because, while a medical doctor can see 35 patients in a day, a psychologist generally sees a maximum of 6 or 7. I reserve a full hour of my time for the session and clinical notes. If a client cancels with less than a full 24-hour notice, I won’t be able to fill that time slot, and I’ll lose an entire hour from my work schedule.
I want you to know that my cancellation policy in not a penalty or a punishment. Very rarely, I’ll have a client who feels punished when I charge them a late cancellation fee. If you are in therapy long enough, at some point you might forget about an appointment, or something will come up in your schedule that will result in you missing an appointment. Know that I’m never upset with clients when they miss an appointment. My clients understand that scheduling an appointment with me is like buying tickets to an event. If you miss the event, it doesn’t matter why you missed it, or even if it was your first time, you can’t turn in your tickets for a refund.
Emergencies and Phone Calls
I may be unavailable outside regular business hours and cannot guarantee availability in the event of an emergency. If you have an urgent matter after normal business hours that cannot wait until the next business day, you may call me directly at 240.303.2141. I will make the best effort to return your call as soon as possible. If a life-threatening emergency arises, I ask that you seek help immediately from your physician or a hospital emergency room. IF YOU ARE UNABLE TO MAKE IT TO THE HOSPITAL, CALL 911. Most hospitals have psychiatric care available in the emergency room at all times, as do most other community hospitals.
For general calls, leave me a detailed voice mail message with your name and the phone number where I may reach you. I make every effort to return your call within 24 hours, with the exception of weekends, vacation, and holidays.
Ethics and Professional Standards
As a licensed psychologist, I am regulated by the DC Licensing Board and Virginia State Board of Examiners of Psychologists and am accountable for my work with you. If you have any concerns about the course of evaluation and/or treatment, please discuss them with me. I look forward to working with you.
Please electronically sign to indicate that you have read and understand the conditions and policies stated in this document. By signing the agreement, you indicate that you understand you are responsible for fulfilling your therapeutic and financial responsibilities.
I have been given a copy of Dr. David Cranford’s Informed Consent to Psychological Services and Notice of Privacy Practices, which provide information on Confidentiality, Recordkeeping, Fees and Other Financial Issues, Emergencies and Phone Calls, as well as General Office Policies. I understand and agree to the conditions and policies stated in that document. By signing this agreement, I understand I am responsible for fulfilling my therapeutic and financial responsibilities. I also acknowledge receiving a copy of Dr. Cranford’s Notice of Privacy Practices.