If you are paying out of pocket, please put n/a in the following insurance related questions.
For scheduling changes and cancellations, which communication method would you prefer?
Patient Agreement and Notice of Privacy Practices
This Agreement contains important information on my professional services and
business policies. It also contains summary information about the Health
Insurance Portability and Accountability Act (HIPAA), a federal law that provides
privacy protections and patient rights with regard to the use and disclosure of
your protected health information (PHI) used for the purpose of treatment,
payment, and health care operations.
HIPAA requires that I provide you with a Notice of Privacy Practices for use and
disclosure of Protected Health Information (PHI). The law requires that I obtain
your signature acknowledging that I have provided you with this
information. It is very important that you read this document carefully, and
discuss any questions you have about the procedures with me now or at any
time in your treatment.
Limits On Confidentiality
The law protects the privacy of all communications between a patient and a
therapist. In most situations, a clinician can only release information about your
treatment to others if you sign a written authorization form that meets certain
legal requirements imposed by HIPAA.
There are some situations in which therapists are legally obligated to take action
and reveal some information about a patient's treatment in order to protect the
patient and/or others from harm. In my experience, these situations do not
1. If a therapist has reasonable cause to believe that a child under age 18 is
suffering physical, sexual or emotional abuse resulting in harm or substantial risk
of harm to the child's health or welfare, the law requires that a report be filed
with the Department of Children and Families. Once such a report is filed, the
clinician may be required to provide additional information.
2. If a therapist has reason to believe that an elderly or handicapped individual is
suffering from abuse, the law requires that a report be filed with the Department
of Elder Affairs. Once such a report is filed, the therapist may be required to
provide additional information.
3. If a patient communicates an immediate threat of serious physical harm to an
identifiable victim or if a patient has a history of violence and the apparent intent
and ability to carry out the threat, therapists are required to take protective
actions. These actions may include that the patient write a safety contract,
notifying the potential victim, contacting the police, and/or seeking
hospitalization for the patient.
4. If a patient threatens to harm himself/herself, therapists are obligated to
request a patient to sign a safety contract, to seek hospitalization for him/her, or
to contact family members or others who can help provide protection.
If such situations arise, I will make every effort to fully discuss it with you before
taking any action and will limit the disclosure to what is necessary.
When you sign this document, it will also represent an Agreement between us.
The process of psychotherapy is hard to pin down and is different for each person. The
theories, techniques and implementations all depend on what is being addressed in therapy.
There is no guarantee that psychotherapy will be helpful or have long lasting effect. The
frequency of your sessions depends on your needs. Some like once a week and others feel that
they get further along by seeing me twice a week. Sessions are 50 minutes.
My cancellation policy is 24 hours or you will be billed for the session. It is
important to note that insurance companies do not provide reimbursement
for canceled sessions. Each session fee or co-pay (if using insurance) is paid
at a mutually agreed time decided after the initial meeting. If not using
insurance, invoices will be sent out at end of month to you if you'd like to
submit to insurance for reimbursement.
Your signature below indicates that you have read this agreement and agree to
its terms. Your signature also indicates your agreement that you have received a
copy of the Notice of Privacy Practices within this document explaining your
rights under HIPAA.
Credit Card Information
A credit card is required to hold your first appointment. Your card will not be charged unless you do not show or do not cancel your appointment beforehand.
24 hour notice is required for the cancellation or rescheduling of an appointment. Appointments changed with less than 24 hours notice may incur a $105 fee. The charge will be applied to your credit card, as insurance cannot be billed.
At your appointment, you can choose a different payment arrangement.
By signing, you agree to allow Rachel Kalvert to charge your credit card for missed appointments that are made without 24 hour notice. Exceptions are made for weather and illness and you will be notified before any charges are made.
Please type your name below to indicate consent to treatment, agree to cancellation policy, acknowledgement and permission of informed Consent, insurance information sharing (if using insurance) and HIPPA privacy policies.