Psychologist – Client Services Agreement Form

PSYCHOLOGIST- CLIENT SERVICES AGREEMENT

Welcome to Breakthru Counseling and Consulting, P.C. (“BCC”), the psychological counseling practice of Dr.
Quincy L. Warner. This document contains important information about BCC’s 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 (“client”) 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 BCC provide you with a Notice of Privacy Practices (“Notice”) for use and
disclosure of PHI for treatment, payment and health care operations. The Notice, which accompanies this Agreement,
explains HIPAA and its application to your personal health information in greater detail. The law requires that BCC
obtain your signature acknowledging that BCC has provided you with this information. Although these documents
are long and sometimes complex, it is very important that you read them carefully. You can discuss any questions you
have about this document or any other BCC policies and/or procedures with your therapist . When you sign this
document, it will also represent an agreement between BCC and you. You may revoke this agreement in
writing at any time. That revocation will be binding on BCC unless BCC has taken action in reliance on it; if
there are obligations imposed on BCC by your health insurer in order to process or substantiate claims made
under your policy; or if you have not satisfied any financial obligations you have incurred: or as BCC is
required by law.

PSYCHOLOGICAL SERVICES
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the
psychologist and client, and the particular problems you are experiencing. There are many different methods that may
be used to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead,
it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on
the identified issues both during sessions and between sessions. Psychotherapy can have benefits and risks. Since
therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like
sadness, guilt, anger, frustration, loneliness, and helplessness.

On the other hand, psychotherapy has also been shown to have many benefits. Therapy often leads to better
relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no
guarantees of what you will experience.

At your first meeting, the agenda will include getting to know your therapist and coming up with a starting diagnosis
and treatment goals that will be based on the information you share and the therapist’s observations. The evaluation
of your needs will continue throughout your work and your goals and plan for your treatment will be modified as
needed together. After the first meeting, you should evaluate this information along with your opinion of whether you
feel comfortable working with the therapist. Therapy involves a large commitment of time, money, and energy, so
you should be very careful about the therapist you select. If you have questions about the therapist’s procedures,
discuss them whenever they arise. If your doubts persist, BCC will be happy to help you set up a meeting with
another mental health professional for a second opinion or for transfer of your care.

MEETINGS

If psychotherapy is begun, BCC will usually schedule one 45-minute session (one appointment of 45 minutes
duration) per week at a time agreed on, although session frequency and length can vary depending on the issues and
treatment progress. Except in cases of illness or emergency, appointments not kept (no shows) or canceled with
less than one business days’ notice, will be subject to a charge of half the regular session fee (=$87.50), payable
before your next appointment. It is important to note that insurance companies do not provide reimbursement
for canceled sessions. Your time is important so your therapist will do their best to start sessions on time and BCC
asks that you do the same. In order for counseling to be effective, sessions need to be consistent. If the client begins to
come late for appointments and / or misses appointments frequently, the effectiveness of the counseling can be
compromised. Your signature below serves as your acknowledgement that if you (or your child), as an ongoing
therapy client, miss a scheduled appointment, and do not reschedule within 45 days, your therapist will understand
that, as notice, you have voluntarily terminated BCC services and your file will be closed. However, you can call and
discuss re-starting services at any point thereafter.

FINANCIAL POLICY AND PROFESSIONAL FEES

The initial session fee is $200.00. Following sessions of 45 minutes duration are $175.00 per session. Your payment
is due at time of service. Payment is by credit, debit, HSA, FSA only for TeleMental Health sessions. In person
sessions can also be paid by check or cash. Please also be aware the return check fee is $50.00. In addition to
weekly appointments, BCC charges for other professional services you may need. Other services include report writing,
telephone conversations, reading your emails, consulting with other professionals with your permission, and the time
spent performing any other service you may request. Such fees are charged on a pro-rated per session fee rate. Please
be advised that records release charges have separate costs which will be outlined at the point a client requests these
services.

If you become involved in legal proceedings that require BCC’s participation, consultation, deposition, and/or
testimony, you will be expected to pay for all BCC professional time, including preparation and transportation costs,
even if your therapist is called to testify by another party. Because of the difficulty of legal involvement for BCC, BCC
charges $300.00 per hour for any service provided for any legal proceeding. A retainer is required for any such services.
If you need BCC to provide such consultation/participation, notify your therapist and you will be provided with the
details regarding legal proceedings fees.

If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon,
BCC has the option of using legal means to secure the payment. This may involve hiring a collection agency and/ or
going through small claims court and/or the Georgia Office of Insurance and Safety Fire Commission in an effort to
be paid for services rendered to you which will require BCC to disclose otherwise confidential information. In most
collection situations, the only information BCC releases regarding a client’s treatment is: his/her name, the nature of
services provided, dates of service, insurance company data and the amount due. By signing this contract, you are
giving BCC permission to release any information necessary to obtain payment in full for BCC services
rendered to the client(s). If legal action is necessary to receive payment in full, you agree by your signature
below, for those costs to be included in the claim.

INSURANCE REIMBURSEMENT

In order for you to set realistic treatment goals and priorities, it is important to evaluate what resources you have
available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for
mental health treatment. You will need to check with your insurance company to determine if they will pay benefits
for psychological services. It will be your responsibility to obtain any precertification your insurance may require
before your first appointment and for any other service you wish provided to you. BCC will provide you with
whatever assistance we can in helping you receive the benefits to which you are entitled; however, YOU (not your
insurance company) are responsible for full payment of BCC’s fees. It is very important that you find out exactly
what mental health services your insurance policy covers. If you have questions about the coverage, call your plan
administrator. If it is necessary to clear confusion, BCC will be willing to call the company on your behalf with
charges for any therapist time made according to BCC’s professional services rate as explained above.

Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes
difficult to determine exactly how much mental health coverage is available.

Some managed-care and EAP plans will not allow BCC to provide services to you once your benefits end. If this is
the case, your therapist will do their best to find another provider who will help you continue your psychotherapy.
You should also be aware that your contract with your health insurance company requires that BCC provides it with
information relevant to the services provided to you. BCC is required to provide a clinical diagnosis. Sometimes BCC
is required to provide additional clinical information such as treatment plans or summaries, or copies of your entire
Clinical Record. In such situations, BCC will make every effort to release only the minimum information about you
that is necessary for the purpose requested. This information will become part of the insurance company files and will
probably be stored in a computer. Though all insurance companies claim to keep such information confidential, BCC
has no control over what any insurance company does. In some cases, insurance companies may share the
information with a national medical information databank. BCC will provide you with a copy of any report
submitted, if you request it.

Once BCC has all of the information about your insurance coverage, discuss with your therapist what can you expect
to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end
your sessions. It is important to remember that you always have the right to pay for BCC services yourself to avoid
the possible problems described above [unless prohibited by contract]. By signing this Agreement, you agree that
BCC can provide information to your insurance carrier and/or collection agencies, small claims courts and/or
the Georgia Office of Insurance and Safety Fire Commission to pursue payments owed to BCC and to comply
with provider agreements BCC has and any legal requirements.

CONTACT INFORMATION

Due to the nature of counseling, therapists are often not immediately available by telephone. When unavailable, the
telephone is answered by an administrative assistant who can help you. If she is unavailable, you will have the option
of leaving the assistant or your therapist a voice mail. Every effort will be made to return your call within a business
day. Any call over 5 minutes will incur charges pro-rated per session fee rate. Please note that insurance rarely pays
for a telephone consultation. Also, we need to alert you if you choose to communicate with us by electronic
transmission (faxes, cell phone, texts and/or emails), that, in this day and age of hackers, there is no 100% guarantee
of confidentiality for any of us via electronic transmission. Thus, privacy of electronic transmissions cannot be
assured. If you indicate on BCC”s “Prospective Client Data” form, “Adult Intake Information” form, “Information,
Authorization, & Consent to TeleMental Health” form, and/or on the “Child/Adolescent Intake Information” form
that we may contact you through Phone, Voicemail, Text and/or Email, then you assume the risk this may pose to
your client confidentiality. However, we’ll do our utmost to preserve client confidentiality on our end. Your
signature below serves as your agreement to assume the risks to client confidentiality involved in electronic
communication.

EMERGENCY COVERAGE

BCC is considered to be an outpatient facility and is set up to accommodate individuals who are reasonably
safe and resourceful. Your psychologist does not carry a beeper nor is she available at all times. If at any time
this does not feel like sufficient support, please inform your therapist, to discuss additional resources or
transfer of your case to a therapist or clinic with 24-hour availability. Your therapist will return phone calls,
and/or emails within One (1) Business day. However, your therapist does not return calls or any form of
communication on weekends or holidays. If your therapist will be unavailable for an extended time, you will be
provided with the name of another therapist for consultation.

If you are having a mental health emergency and need immediate assistance, please follow the instructions
below. In Case of an Emergency
If you have a mental health emergency, do not to wait for communication back from your therapist,
but do one or more of the following:
• Call GA Crisis & Access Line: 800-715-4225 or other 24-hour crisis hotline in your area.
• Call Ridgeview Institute at 770.434.4567 or local hospital
• Call Peachford Hospital at 770.454.5589 or local hospital
• Call Lifeline at (800) 273-8255 (National Crisis Line)
• Call 911.
• Go to the emergency room of your choice.

LIMITS ON CONFIDENTIALITY

The law protects the privacy of all communications between a client and a psychologist. In most situations, BCC 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 other situations that require only that you provide written, advance
consent. Your signature on this Agreement provides consent for those activities, as follows:
• Your therapist may occasionally find it helpful to consult other health and mental health professionals about
a case. During a consultation, every effort to avoid revealing the identity of the client is made. If you don’t
object, BCC will not tell you about these consultations unless your therapist believes that it is important to
your work together. All consultations will be noted in your Clinical Record (which is called “PHI” in the
BCC HIPAA Notice of Privacy Practices).
• You should be aware that BCC contracts with administrative staff. In most cases, your protected information
is shared with these individuals for both clinical and administrative purposes, such as scheduling, billing and
quality assurance. All staff members have been given training about protecting your privacy and have
agreed not to release any information outside of the practice without permission.
• BCC has contracts with several companies for administrative, billing, and TeleMental health services. As
required by HIPAA, BCC has a formal business associate contract with these businesses, in which they
promise to maintain the confidentiality of this data except as specifically allowed in the contract or
otherwise required by law. If you wish, BCC can provide you with the names of these organizations and/or a
blank copy of this contract.
• Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.
• If a client threatens to harm himself/herself, your therapist may be obligated to seek hospitalization for you
which can involve revealing relevant client information to hospital staff and/ or other individuals pertinent
to the process and/ or to contact your family members or others who can help provide protection.
There are some situations where BCC is 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 BCC’s
professional services, such information is protected by the psychologist-patient privilege law. BCC cannot
provide any information without your written authorization or a court order, or certain other situations. See
accompanying “Notice” for further explanation. If you are involved in or contemplating litigation, you
should consult with your attorney to determine whether a court would be likely to order your therapist to
disclose information.
• If a government agency is requesting the information for health oversight activities, BCC may be required to
provide it for them.
• If a client files a complaint or lawsuit against a BCC therapist, BCC may disclose relevant information
regarding that client in defense.
• If a client files a worker’s compensation claim, and BCC is providing treatment related to the claim, BCC
must, upon appropriate request, furnish copies of all psychological records and bills.

There are some situations in which BCC is legally obligated to take actions which your therapist believes are
necessary to attempt to protect others from harm and may have to reveal some information about a client’s
treatment. These situations are rare but include:
 If your therapist has reason to believe that a child (under the age of 18) has been abused, the law requires that
therapist to file a report with the appropriate governmental agency, usually the Department of Family and
Children Services. Once such a report is filed, your therapist may be required to provide additional information.
 If your therapist has reasonable cause to believe that a disabled adult or elder (65 years+) person has had a
physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means,
or has been neglected or exploited, the therapist must report to an agency designated by the Department of
Human Resources. Once such a report is filed, your therapist may be required to provide additional information.
 If your therapist determines that a client presents a serious danger of violence to another, the therapist may be
required to take protective actions. These actions may include notifying the potential victim, and/or contacting
the police, and/or seeking hospitalization for the client.

If such a situation arises, your therapist will make every effort to fully discuss it with you, if appropriate, before
taking any action and will limit disclosure to what is necessary.

If you and another adult are in joint counseling together, permission would be needed from both of you
before any information could be released to anyone other than the exceptions noted above.

While this abbreviated written summary of exceptions to confidentiality should prove helpful in informing you
about potential problems, it is important that you examine the accompanying “Notice” for the specifics of the
HIPAA Notice of Privacy Practices to ensure your informed consent. Please discuss with your therapist any
concerns regarding confidentiality that you may have now or in the future. The laws governing confidentiality can be
quite complex, and your therapist is not an attorney. In situations where specific advice is required, formal legal
advice may be needed.

PROFESSIONAL RECORDS

You should be aware that, pursuant to HIPAA, your therapist keeps Protected Health Information about you in two
sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for
seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals set for
treatment, your progress toward those goals, your medical and social history, your treatment history, any past
treatment records that BCC receives from other providers, reports of any professional consultations, your billing
records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual
circumstances that involve danger to yourself or others or makes reference to another person (unless such other
person is a health care provider) or your therapist believes that access is reasonably likely to cause substantial harm to
such other person [or if information is supplied to your therapist confidentially by others, (you can elect to put this
information in your psychotherapy notes, see below)] you or your legal representative may examine and/or receive a
copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be
misinterpreted and/or upsetting to untrained readers. For this reason, BCC recommends that you initially review them
in your therapist’s presence during a session, or have them forwarded to another mental health professional so you
can discuss the contents. BCC charges for any record release utilizing the Georgia Department of Community Health
Retrieval Rates and (O.C.G.A. 31-33-3). Related professional services are charged using the above stated
professional services rate.

The exceptions to this policy are contained in the accompanying HIPAA Notice of Privacy Practices Form. If your
request for access to your records is refused, you have a right of review (except for information provided to your
therapist confidentially by others) which will be discussed with you upon request.
In addition, your therapist also keeps a set of Psychotherapy Notes. These Notes are for the therapist’s use and are
designed to assist in providing you with the best treatment. While the contents of Psychotherapy Notes vary from
client to client, they can include the contents of therapy conversations, analysis of those conversations, and how they
impact on your therapy. They also may contain particularly sensitive information that you may reveal that is not
required to be included in your Clinical Record [and information supplied to your therapist confidentially by others].
These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available
to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization.
Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for
your refusal to provide it.

PATIENT/CLIENT RIGHTS

HIPAA provides you with several rights with regard to your Clinical Record and disclosures of protected
health information. These rights include requesting that BCC amend your record; requesting restrictions on what
information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of
protected health information that you have neither consented to nor authorized; determining the location to which
protected information disclosures are sent; having any complaints you make about BCC policies and procedures
recorded in your records; and the right to a paper copy of this Agreement and the accompanying HIPAA Notice of
Privacy Practices Form .Your therapist is available to discuss any of these rights with you.

MINORS & PARENTS/GUARDIANS

Clients under 18 years of age who are not emancipated and their parents/guardians should be aware that the law
allows parents/guardians to examine their child’s treatment records unless the child’s therapist believes that doing so
would endanger the child or it is agreed otherwise. Because privacy in psychotherapy is often crucial to successful
progress, particularly with teenagers, it is [usually] BCC’s policy to request an agreement from parents/guardians that
they consent to give up their access to their child’s records. If they agree, during treatment, the minor’s therapist will
provide parents/guardians only with general information about the progress of the child’s treatment, and his/her
attendance at scheduled sessions. Upon request, the child’s therapist will provide parents/guardians with an oral
summary of their child’s treatment when it is complete. Any other communication will require the child’s
Authorization, unless the therapist believes that the child is in imminent danger or is an imminent danger to someone
else, in which case, the therapist will notify the parents/guardians of the concern. Before giving parents/guardians any
information, the therapist will discuss the matter with the child, if possible, and do their best to handle any objections
the child may have.

Parents and/or guardians when you communicate with your child’s therapist or attend your child’s session, you need
to understand that you do not become a client through such contact with your child’s therapist. Thus, there is no client
– psychologist relationship being formed between your child’s therapist and any parent or guardian signing this
contract. The client-psychologist confidentiality agreement is being formed between the therapist and the minor
whose name is listed below only. It is the minor listed below that becomes the client. The BCC therapist will do their
best to handle any information shared by the parents and/or guardians with the child’s therapist in a discrete and
sensitive manner but will share any information received from parents and /or guardians with whomever is believed
necessary for the best interests of the client listed below.

YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND
AGREE TO ITS TERMS AND CONDITIONS AND AGREE TO ABIDE BY ITS TERMS AND CONDITIONS. IT
ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE OF
PRIVACY PRACTICES FORM DESCRIBED ABOVE THAT ACCOMPANIES THIS DOCUMENT.

I voluntarily choose and ask that my typed name on the signature line(s) of this document legally
represent my electronic signature.





If applicable:




My signature below indicates that I have discussed this form with you and have answered any questions you have
regarding this information.