Treatment Contract – Resolutions Professional Counseling

Contact Information*

Resolutions Professional Counseling. PLLC
Tara Fleis, LPC
906-282-3130
tfleis@resolutionsprofessionalcounseling.com

9885 State Hwy. M95, Republic, MI 49879
308 Cleveland Ave., Ste. 302, Ishpeming, MI 49849

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PSYCHOTHERAPY TREATMENT CONTRACT*

Welcome to my psychotherapy practice. This document contains important information about my professional services and business policies. Please read it carefully and note questions you have so we can discuss them at our next session. When you sign this document, it will represent an agreement between us and it will become part of your Clinical Record.

Children Services Only: I certify that I have the legal right to approve mental health and/or substance abuse services for the above-named minor. I agree to provide the legal documentation proving my rights of custody by the next clinic visit. I understand that in case of joint legal custody, my ex-partner has the right to access material in my child’s chart.

Assessment &amp; Treatment: I am voluntarily requesting and consent to receive treatment. I understand I will receive services from a qualified professional, and may request information about my clinician’s qualifications at any time. The service available and the benefits and risks of these services will be explained to me by my clinician. I agree to respect the confidentiality of other clients at the agency.

Treatment: I understand that I have the right to participate in the development of my treatment plan, and that in order to maximize the benefit of my treatment I need to attend scheduled sessions as established in my treatment plan. However, either party retains the right to discontinue treatment at any time. I realize that discussing the risks and benefits of terminating treatment is to my benefit. I understand that drinking/drug usage, combative behavior, or sexual acting out will result in my immediate dismissal from the program.

Cancellations and No Shows:  I understand that it is my responsibility to keep appointments with my therapist. If I must cancel or reschedule an appointment, I will do so with at least a 24 hour notice. I will not be charged for canceled appointments.

Release of Records for Billing and/or Payment Purposes: I hearby authorize release of any relevant clinical information (written, and/or verbal) to whomever is responsible for billing and/or payment of services. I understand that it may be necessary to release clinical information to a biller and/or insurance company or other funding sources as well as various external auditing or licensing bodies, to assure the quality of care and to obtain reimbursement.

Insurance/Medicaid Title XIX Authorization:  I understand that my therapist will assist me with obtaining payments for services. If Medicaid is a source of payment for treatment services, understand that I have specific rights and responsibilities under the Medicaid Rules. I authorize payment for insurance benefits directly to Tara Fleis, LPC. I understand that I am personally responsible for charges not covered by the payer, regardless of the source of funding, and understand that I retain full  responsibility for all payments unless payment is guaranteed by a third party in writing.

Returned Checks: I will be assessed a $25 fee, plus all applicable collection costs. I understand that my account may be turned over to a collection agency if non-payment or failure to adhere to an agreed upon payment plan occurs.

Medicare Authorization: I certify that information given by me in applying for payment under Title 1.8 of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or any Medicare Claims. I request payment of authorized benefits be made in my behalf. I understand I am responsible for any Medicare deductibles and co-pays.

Breach of Contract: In understand that failure to pay my bill on time can constitute a breach of the Admission Agreement. In that event, Tara Fleis, LPC will not be held responsible for the continuing to offer counseling.  After consultation, or written notification, services can be terminated.

Confidentiality: I understand that my therapist will not release any information about my presence or progress in the facility to any individual or agency without my permission with the exception that information may be exchanged between those programs specified in a signed qualified services organization or business associate agreement between the agencies or information needed in a medical/health emergency. I understand that the information given in therapy is considered confidential and my privacy will be respected. I understand that there are some limitations, as identified by state and federal law. The confidentiality of all client records maintained by this program is protected by Federal Law and Regulations, and any release of information will be made in accordance with Federal Rule 42 CFR Part 2 and HIPPAA rule and the privacy policy. I acknowledge the posted Notice of Privacy Practices and may have a paper copy if requested.

PROBABLE LENGTH OF TREATMENT
The length of psychotherapy treatment varies considerably depending on the person and the nature of the person’s problem. It is difficult, if not impossible, to accurately pinpoint the amount of time it will take to experience relief. Several factors contribute to the timeline, including
• The nature of the problem itself (simple vs. complicated)
• How long the problem has been a problem (recently developed vs. chronic or longstanding)
• How much support you have from significant others (substantial versus negligible)
• How much work you put into solving the problem outside of therapy

For those seeking relief from troublesome but straightforward problems, therapy can be effective in as little as 8 to 12 sessions. For more complex issues, therapy may last several months to several years.

CONTACTING ME
You may contact me or reach my voicemail. I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voicemail that I monitor frequently during business hours. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are unable to reach me and feel that it is an emergency and you cannot wait for me to return your call, call 911, or go to the nearest emergency room.

SOCIAL NETWORKING AND WEBSITES
I do not engage in relationships via social media networks (Facebook, Twitter, LinkedIn, etc.) with current or former clients. Ethical guidelines, as well as legal statutes of our licensing board have strict regulations with regards to dual relationships, confidentiality, and professional boundaries, which prohibit such contact.

CONFIDENTIALITY
In general, the privacy of all communications between a client and a therapist is protected by law, and I can only release information about our work to others with your written permission. In most situations, I cannot even confirm to a third party that you are being seen in my practice unless you agree to this. However, there are a few exceptions. These situations rarely occur, and if this type of situation occurs, I will make every effort to fully discuss it with you before taking any action. Limits to confidentiality include:

To Protect You. My primary concern is the safety of clients who are working with me. If I have reason to believe that you are at risk for injuring or killing yourself,  I am legally and ethically required to work with you to prevent this from occurring. This may range from contacting family members or others who can help provide protection, arranging for hospitalization with your consent, or even, in the event of an emergency, facilitating involuntary hospitalization.
To Protect the Public. In certain situations, I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a client’s treatment. For example, if I believe that a child, older adult (age 65 and older), or a dependent adult is being neglected or abused, I must file a report with the appropriate state agency. If I believe that a client is threatening serious bodily harm to another, I am also legally and ethically required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the client.

In Legal Proceedings. Although I will make every effort to safeguard your privacy, your records may be subpoenaed by a court of law. In most legal proceedings, you may have the right to restrict access to information about your treatment. In some proceedings, such as those involving child custody and those in which your emotional condition is an important issue, it is possible that a judge may order my records and/or testimony. Confidentiality may also be limited by other situations in which the law requires or directs that confidentiality does not exist.

COMPLAINTS
Although clients are encouraged to discuss any concerns with me, you may file a complaint against me with the organization below should you feel I am in violation of any of these codes of ethics. I abide by the ACA Code of Ethics (http://counseling.org/Resources/aca-code-of-ethics.pdf).

Michigan Department of Licensing and Regulatory Affairs, Enforcement Division, Allegations Section, P.O. Box 30670, Lansing, MI 48909 (517) 373-9196

I have read the above Agreement and Policies and General Information carefully. I understand them and agree to comply with them. I consent to treatment.*

I Agree

RECEIPT OF HIPAA I also certify that I have received a copy of the Notice of Privacy Practices detailing the provisions of HIPAA and my privacy rights.*

I Agree

CONSENT FOR EMAIL COMMUNICATION (optional) If you wish to contact me for basic communication purposes or to schedule appointments, you may call me or email me at [email protected] The decision of whether to have email contact with me is your decision. While email can be useful for scheduling or for exchanging information and resources, I do not recommend using email as a means to convey personal information. I do not offer advice, therapy, or emergency care via email as it is not a secure form of communication and the privacy of email exchanges cannot be guaranteed. I understand that email is not a secure means of communicating, and the confidentiality of communication through e-mail exchanges is not guaranteed. I consent to mutual communication with my therapist via e-mail.*

I Agree

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