WELCOME TO MY PSYCHOTHERAPY PRACTICE
I hope that this information will answer some of the questions
that you may have about my professional services and office
policies. I would also like to acquaint you with some of
your rights and responsibilities while in treatment with
me. I encourage you to read this document carefully.
Together, we can further discuss any of the information detailed
here and/or questions that you may have about it. Your signature
& initials are an indication of your acknowledgment that you have
received this information.
MY PSYCHOLOGICAL SERVICES
I am a licensed New York State clinical social worker and I
provide individual (counseling or therapy) to children,
adolescents, and adults. I provide trauma-informed care
through a social justice lens for humans regardless of their
sexual identity, age, or religion.
In our first one to three meetings, I will do a thorough,
detailed evaluation of your history and psychological
needs. When the evaluation is complete, I will offer you an
initial summary of my impressions of the psychological issues
bringing you in and how we might be able to work on them
together.
I hope that we will establish a professional relationship. In
addition, if you could benefit from treatment that I do not
offer, I will discuss this with you and recommend other
professional resources for you. I will also let you know about
possible alternative forms of treatment to the best of my
knowledge.
Since therapy involves a large commitment of the self, as well as
time, money, and energy, you should be very thoughtful about the
therapist you select. If it seems that our work together
may fit your needs, you should assess your comfort with me
through our conversations and interactions in order to determine
if you would like to begin therapy with me. In fact,
throughout our therapeutic work, it is important for us to
cultivate honest and direct discussions about the therapy
process.
Therapy is a way for people to attend to emotional,
circumstantial, interpersonal, past trauma, and behavioral
struggles in a supportive and non-judgmental space. It
requires both of us to dedicate significant and sustained effort
and involvement both during and in between sessions.
In my ongoing treatment, I help individuals concretely and
effectively cope with their present pain, concerns, stressors,
and conflicts. I also try to help people consider and
better understand their feelings, thoughts, and interpersonal
patterns, as well as the past and familial roots of their current
difficulties. In addition, I strive to understand each person's
cultural experiences that have formed their identity, which I
believe is frequently evolving. I believe a combination of
these approaches helps most people move beyond their current
difficulties and successfully experience healing and growth to
ultimately reach the best versions of themselves.
I am not a medical doctor and so I do not prescribe psychotropic
medication. However, I regularly work with psychiatrists
who can provide this service to you, and/or I am willing to
consult with a psychiatrist whom you already may be in contact
with in order to best coordinate your care. I may also recommend
that you meet with additional health providers (like a physician
or nutritionist) as part of our treatment.
My services are by appointment only. Individuals usually
attend 45-minute weekly sessions. If possible, I prefer to
allow 60 minutes for the initial evaluation session.
Psychotherapy can have benefits and risks. Since it often
involves discussing difficult aspects of life, upsetting feelings
like sadness, guilt, anger, frustration, loneliness, and
helplessness can emerge and people may feel worse temporarily
before they feel better. Sometimes people also experience
distress caused by changes that they may decide to make in their
life as a result of therapy. On the other hand,
psychotherapy has also been shown to have many benefits,
including improved relationships, solutions to specific problems,
and a significant reduction in feelings of distress. While
you should expect benefits from therapy, no particular outcome
can be guaranteed.
Since each individual's therapeutic process is different, it is
not possible to predict the exact duration of treatment at this
moment. In addition, though you should expect benefits from
treatment, no particular outcome can be guaranteed.
However, we will evaluate your goals and progress regularly and
whenever else you may desire. You are free to discontinue
treatment at any time, but it would be best to discuss any plans
to end therapy with me before doing so.
CONFIDENTIALITY
As summarized by the National Association for Social Work Code of
Ethics Section 1.07, it is my duty to respect your right to
privacy and confidentiality. Your private information will not be
released to a third-party entity without your authorization.
Confidentiality does not apply when disclosure is necessary to
prevent serious, foreseeable, and imminent harm to a client or
others. Additionally, there may be times when I may need to
disclose information about you. Some examples are as follows
(please note this is not an exhaustive list):
Child or Elder Abuse: As a licensed social worker in New York
State, I am required by law to report suspected child abuse or
neglect to the proper authorities.
Criminal Activity such as danger to others: If you tell me you
intend to harm another person, I must try to protect that person,
including by telling the legal authorities such as the police or
the person or other healthcare providers.
Danger to Self: If you threaten to harm yourself, or your life or
health is in any immediate danger, I will try to protect you,
including by telling others such as your relatives (or your
listed emergency contacts) or other health care providers, who
can assist in protecting and assisting you.
Judicial proceedings; If you are involved in certain court
proceedings, I may be required by law to reveal information about
your treatment. These situations may include but are not
limited to child custody disputes, cases where a therapy
patient's psychological condition is an issue, lawsuits or formal
complaints against the psychotherapist, civil commitment
hearings, and court-related treatment.
Health Care Activities: If your health insurance plan will be
reimbursing you or paying me directly, they will require that I
waive confidentiality and that I give them information about your
treatment.
Business Associates: In order to provide you with the highest
quality of treatment, I may consult with other psychotherapists
about your treatment, but in doing so, I will not reveal your
name or any other information that would identify you unless
specific consent to do so is obtained. Further, when I am
away or unavailable, another psychotherapist might answer calls
and so will need to have access to information about your
treatment.
Financial Responsibilities: If your account with me becomes
overdue and you do not pay the amount due or work out a payment
plan, I will reveal a limited amount of information about your
treatment in taking legal measures to be paid. This
information would include your name, social security number,
address, dates, types of treatment, and the amount due.
Professional Collaboration on Your Behalf: If you want me to
share information about your treatment with others, with your
signed consent, I can do so.
Add consultation sessions...
PROFESSIONAL FEES (Non-Negotiable)
My fee for an initial intake evaluation is $200 (60 minutes), for
a 45-minute individual psychotherapy session is $150,
professional consultation sessions for mental heath professionals
is also $150; and for a thirty-minute session, it is $75. Many
clients elect to pay for their sessions monthly ($600 for four
(4) 45-minute sessions/month or $340 for four (4) 30-minute
sessions).
Additional fees may occur for additional professional services,
which may include:
Individual psychotherapy sessions of more than 45 minutes,
Telephone calls of more than 10 minutes,
Preparation of records, letters, forms, and/or treatment
summaries as requested and with your written permission.
It is beyond the scope of my professional expertise to work with
court-involved cases. However, if you are engaged in legal
proceedings requiring my involvement in the future, the fees for
my participation will be different from the above and will be
discussed if necessary.
INSURANCE
It is important that you find out exactly what mental health
services your insurance policy covers. All plans have
certain rules, limits, and procedures.
I am a participating provider on Aetna's Behavioral Health
Network, Cigna, United Healthcare, Oxford, and OSCAR.
If you have out-of-network mental health coverage, I can provide
you with a bill to submit to your insurance company, which may
reimburse you as per your policy. Sometimes a
pre-authorization for services is required and often a deductible
needs to be met before any reimbursements. In addition, there may
be a limit to the number of visits allowed per year and a maximum
amount of allowed charges per year and in a lifetime. Please note
that I do not become involved in any disputes about
insurance coverage between you (the client) and your
insurance company.
In one of our first few sessions, we will discuss your options
for continuation of treatment when and if your session limit is
met or your insurance company decides to no longer cover your
treatment. Please remember, knowing the details of your insurance
coverage is your responsibility.
PAYMENTS
E-Payments via PayPal, ACH transfer, or Square are accepted at
this time. Payments are due prior to your appointment.
If you are not going through your insurance company or if you
will be using out-of-network mental health benefits, full payment
is made to me directly, not through your insurance
company.
CANCELLATION AND LATENESS POLICY
Your time is valued and I strive to see everyone promptly. With
that said, I kindly request you respect my time as well. It is
important for you to be punctual because if you are late,
additional time cannot be added to your appointment. Each
time slot is essential and cannot be recovered if a client
chooses not to keep his/her/their appointment. Please
remember that each skipped or missed appointment is not just time
lost but also when another client cannot be seen. I commit to
maintaining appointment times. If due to unforeseen
circumstances, I am running late, I will allow you the full
45-minute session if at all possible or, if this is not possible,
I will adjust the time if possible.
Please familiarize yourself with the following guidelines.
Each same-day missed appointment and or late cancelation will be
documented. In addition, you are responsible for the cancelation
fee ($100 in addition to the paid session fee). My professional
services necessitate fixed appointments that are difficult to
reschedule. Understandably, occasionally everyone must
cancel an appointment. If you need to cancel an
appointment, please do so (by calling or messaging me) me 24
hours before your appointment time at 551-275-5179. If you
miss or cancel less than 24 hours before your scheduled
appointment, you will be responsible for the full session payment
PLUS the no-show/cancellation fee.
If you have behavioral health insurance and are choosing to use
it to pay for your sessions, please note that your insurance
company will not reimburse fees for missed sessions. No-show &
cancelation fees are $100 plus the session fee.
Rescheduling a no-call/no-show appointment is not possible.
Additionally, THREE (3) no call/no shows within a two (2 month)
period will result in loss of your allotted time and this may
also result in the termination of our therapist/client
relationship.
Virtual & In-person Lateness: Since we will be working virtually,
for the time being, it remains important for you to commit to
being on time. Yes, even for a virtual meeting. As a courtesy, I
allow a 15 minute grace period for you to join your session. From
there, you will be allowed the remaining time of your session. If
after 16 minutes, you have not joined the session & have not
reached out to me to inform me of your lateness, the session will
be marked as a no-show and you will be charged a no-show fee
($100, in addition to your paid session).
While I understand that situations occur. If this is the
case, please call and discuss such situations with me as soon as
possible. As a one-time courtesy, I will attempt to accommodate
you by rescheduling within the same week. This courtesy will only
be extended as long as you do not have a history of repeated
canceling. Please note, if rescheduling is not feasible based on
my availability, you are still responsible for cancelation or
no-show fees.
CONSENT TO TELEMENTAL HEALTH TREATMENT
I consent to participate in telemental health (virtual) services.
I am aware that participating in tele video or phone conferencing
can be beneficial as well as imperfect. I have been given the
telehealth informed consent form associated with this practice
and completed it accordingly.
I understand that I have the right to refuse telemental health
(virtual) services and be informed of alternative services that
may be available to me. If I request alternative services, I
understand that C. Hurst, LCSWR may not be able to provide those
services and that I may experience delays in treatment, the need
to travel, or any other risks associated with not having services
provided via telemental health, as well as risks associated with
receiving telemental health services in an off-site location. I
understand that telehealth may result in certain risks that are
less likely to occur with in-person services, such as technology
failure, need for specialized electronic security systems, and
less visibility of verbal cues. I acknowledge that the use of
teletherapy as service delivery as one part of my mental health
and wellness needs can also provide benefits not present with
in-person services, such as creating greater flexibility for when
and where services may be provided.
By engaging in telemental health sessions, I agree to arrive
fully dressed, in a secure & private location, free from
distractions to the best of my ability, sober & not driving a
moving vehicle. I understand that failure to engage as such will
result in termination of the session as scheduled and will result
in a cancelation fee.
Should telemental health virtual (video) sessions become
unavailable for any reason (such as poor connectivity), and you
would like to proceed using the phone, please initial that you
consent to telehealth treatment and to the use of a phone session
should tele video sessions be unavailable at the time of your
session.
THERAPIST AVAILABILITY & CONTACTING ME
I provide psychotherapy services for approximately 11 months (or
45 weeks) out of the year.
I can be reached at 551-257-5179 or via email at
c.hurst.lcsw@gmail.com. I will try, whenever possible, to return
your call within the day, unless it is a weekend or
holiday. I will do my best to respond to your email within
24 hours.
When I am not available for a period of time, I will give you as
much advance notice as possible and provide you with the contact
information of another mental health professional who will be
available to you during my absence.
While you may prefer to communicate with me via email or text
message, email and text messages have inherent privacy and
security risks, and you should be aware of those before sending
me emails and text messages. Errors in the transmission or
interception of messages can occur. Your email or text message is
not a secure communication between us, it is important to remain
mindful of what information you chose to share using these forms
of communication. I chose to refrain from using these forms to
exchange information outside of appointment details. Please note,
by initialing here, you acknowledge that you assume
responsibility for any fees from your cell phone carrier.
At my discretion, your email or text message(s), any and all
responses may become part of your electronic psychotherapy
medical record. Additionally, for an urgent or emergency
situation, you should not rely on email communication, instead,
in those situations, you should call 911 or a mobile crisis unit
(NYC: 888-692-9355).
Initials
EMERGENCY SITUATIONS
My services are limited to outpatient treatment, and I do not
carry an emergency pager of any sort. As such, I cannot
provide emergency service. In case of an emergency, it is
important that you visit the nearest hospital emergency room or
call 911 for help. NYC Mobile Crisis Number is another resource
available to you: 888-692-9355.
HIPAA
NEW YORK NOTICE FORM
Notice of Licensed Clinical Social Worker's Policies and
Practices to Protect the Privacy of Your Health Information
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO
THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Uses and Disclosures for Treatment, Payment, and
Health Care Operations
I may use or disclose your protected health information (PHI),
for treatment, payment, and health care operations purposes with
your consent. To help clarify these terms, here are some
definitions:
"PHI" refers to information in your health record that could
identify you.
"Treatment, Payment, and Health Care Operations"
- Treatment is when I provide, coordinate or manage your health
care and other services related to your health care. An example
of treatment would be when I consult with another health care
provider, such as your family physician or another mental health
provider.
- Payment is when I obtain reimbursement for your
healthcare. Examples of payment are when I disclose your
PHI to your health insurer to obtain reimbursement for your
health care or to determine eligibility or coverage.
- Health Care Operations are activities that relate to the
performance and operation of my practice. Examples of
health care operations are quality assessment and improvement
activities, business-related matters such as audits and
administrative services, and case management and care
coordination.
"Use" applies only to activities within my [office, clinic,
practice group, etc.] such as sharing, employing, applying,
utilizing, examining, and analyzing information that identifies
you.
"Disclosure" applies to activities outside of my [office, clinic,
practice group, etc.], such as releasing, transferring, or
providing access to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
I may use or disclose PHI outside of treatment, payment, and
health care operations when your appropriate authorization is
obtained. An "authorization" is written permission above and
beyond the general consent that permits only specific
disclosures. In those instances when I am asked for
information for purposes outside of treatment, payment, and
health care operations, I will obtain authorization from you
before releasing this information. I will also need to
obtain approval before releasing notes I've made related to your
sessions. "Progress notes" are notes I have made about our
conversation during a private (individual), group, joint, or
family counseling session, which are kept private and
confidential. These notes are given a greater degree of
protection than PHI.
You may revoke all such authorizations (of PHI or psychotherapy
notes) at any time, provided each revocation is in writing. You
may not revoke an authorization to the extent that (1) I have
relied on that authorization or (2) if the authorization was
obtained as a condition of obtaining insurance coverage, and the
law provides the insurer the right to contest the claim under the
policy.
III. Uses and Disclosures with Neither Consent nor
Authorization
I may use or disclose PHI without your consent or authorization
in the following circumstances:
Child Abuse: If, in my professional capacity, a child comes
before me which I have reasonable cause to suspect is an abused
or maltreated child, or I have reasonable cause to suspect a
child is abused or maltreated where the parent, guardian,
custodian, or another person legally responsible for such child
comes before me in my professional or official capacity and
states from personal knowledge facts, conditions or circumstances
which, if correct, would render the child an abused or maltreated
child, I must report such abuse or maltreatment to the statewide
central register of child abuse and maltreatment, or the local
child protective services agency.
Health Oversight: If there is an inquiry or complaint about my
professional conduct to the New York State Board for Social
Workers, I must furnish to the New York Commissioner of
Education,
your confidential mental health records relevant to this inquiry.
Judicial or Administrative Proceedings: If you are involved in a
court proceeding and a request is made for information about the
professional services that I have provided you and/or the records
thereof, such information is privileged under state law, and I
must not release this information without your written
authorization, or court order. This privilege does not
apply when you are being evaluated by a third party or where the
evaluation is court-ordered. I must inform you in advance
if this is the case. Please note, there may be a fee for forms
completion by the therapist.
Serious Threat to Health or Safety: I may disclose your
confidential information to protect you or others from a serious
threat of harm by you.
IV. Patient's Rights and Licensed Clinical Social
Worker's (Therapist's) Duties
Patient's Rights:
Right to Request Restrictions - You have the right to request
restrictions on certain uses and disclosures of protected health
information about you. However, I am not required to agree to a
restriction you request.
Right to Receive Confidential Communications by Alternative Means
and at Alternative Locations - You have the right to request and
receive confidential communications of PHI by alternative means
and at alternative locations. (For example, you may not want a
family member to know that you are seeing me. Upon your
request, I will send your bills to another address.)
Right to Inspect and Copy - You have the right to inspect or
obtain a copy (or both) of PHI in my mental health and billing
records used to make decisions about you for as long as the PHI
is maintained in the record. I may deny your access to PHI under
certain circumstances, but in some cases, you may have this
decision reviewed. On your request, I will discuss with you the
details of the request and denial process.
Right to Amend-You have the right to request an amendment of PHI
for as long as the PHI is maintained in the record. I may deny
your request. At your request, I will discuss the details of the
amendment process with you.
Right to an Accounting - You generally have the right to receive
an accounting of disclosures of PHI for which you have neither
provided consent nor authorization (as described in Section III
of this Notice). At your request, I will discuss with you
the details of the accounting process.
Right to a Paper Copy-You have the right to obtain a paper copy
of the notice from me upon request, even if you have agreed to
receive it electronically.
Licensed Clinical Social Worker's (Therapist's) Duties:
I am required by law to maintain the privacy of PHI and to
provide you with a notice of my legal duties and privacy
practices with respect to PHI.
I reserve the right to change the privacy policies and practices
described in this notice. Unless I notify you of such changes,
however, I am required to abide by the terms currently in
effect.
If I revise my policies and procedures, I will notify (via email)
you in writing of the revisions.
V. Questions and Complaints
If you have questions about this notice, disagree with a decision
I make about access to your records, or have other concerns about
your privacy rights, you may contact me directly.
If you believe that your privacy rights have been violated and
wish to file a complaint with me/my office, you may email your
complaint to c.hurst.lcsw@gmail.com.
You may also send a written complaint to the Secretary of the
U.S. Department of Health and Human Services. I will
provide you with the appropriate address upon request.
You have specific rights under the Privacy Rule. I will not
retaliate against you for exercising your right to file a
complaint.
VI. Effective Date, Restrictions, and Changes to Privacy Policy
This notice will go into effect on the first date of service with
Cheryl Hurst, LCSWR (c.hurst.lcsw@gmail.com, doing business
as Muscles Mind Heart (MMH)).
I reserve the right to change the terms of this notice and to
make the new notice provisions effective for all PHI that I
maintain. As such, I will provide you with a revised notice
by email.
By signing below, you are indicating that you have read and
understood this agreement, agree to abide by its terms and give
your consent to the evaluation and treatment process as described
above. Please note, that when these terms are revised and
updated, you be asked to resign the updated version.
