INSURANCE OPTIONS

Practice Policies & Informed Consent

• General Information: The therapeutic relationship is unique in that it is a highly personal and, at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding of how our relationship will work and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

• Voluntary Participation: All clients voluntarily agree to treatment and accordingly may terminate at any time without penalty. Counseling involves a large commitment of time, money, and energy, so you should be thoughtful about the therapist you select. In the first couple of sessions, you should be deciding whether I am the right therapist for you. If you feel it is not a good match, then I will be happy to provide referrals for other therapists.

• The Therapeutic Process: You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. Although the majority of people do get better in therapy, some do get worse. Accordingly, your therapist makes no guarantee of results. It is not possible to guarantee results such as: becoming happier, saving marriages, stopping drug abuse, becoming less depressed, and so forth. I cannot promise that your behavior or circumstances will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

•  Colleague Consultation: In keeping with standards of practice, your therapist may consult with other mental health professionals regarding the care and management of cases. The purpose of this consultation is to ensure quality of care. Your therapist will maintain complete confidentiality and protect your identity by not using real names or any identifying information.

• Confidentiality The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client-held privilege of confidentiality exist and are itemized below:

  • If a client threatens or attempts to commit suicide or otherwise conducts him/herself in a manner in which there is a substantial risk of incurring serious bodily harm.

  • If a client threatens, grave bodily harm or death to another person.

  • If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.

  • Suspicions, as stated above, in the case of an elderly person who may be subjected to these abuses.

  • Suspected neglect of the parties named in items #3 and # 4.

  • If a court of law issues a legitimate subpoena for information stated on the subpoena.

  • If a client is in therapy or being treated by order of a court of law, or if the information is obtained for the purpose of rendering an expert’s report to an attorney.

• You should be aware that most insurance companies require you to authorize us to provide them with a clinical diagnosis for benefits to pay for services. If you wish me to provide information to your insurance company concerning your treatment, only the minimum necessary information will be communicated to the carrier. Upon your request, I will release information to any agency/person that you specify. I have no control or knowledge about what insurance companies do with the information I provide or who may access that information. It is important to realize that there is a certain amount of risk to your confidentiality and privacy associated with submitting a mental health invoice for treatment.

• Neither party can record sessions without consent.

• If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

•  Therapist’s Incapacity or Death In the event the therapist becomes incapacitated or dies, it will become necessary for another therapist to take possession of client records. By signing the Informed Consent and Privacy Practices Receipt, you give your consent to another licensed mental health professional that Kelly Daugherty has designated in her Professional Will (Cheri Davies, LCSW-R) to take possession of your files and records and provide you with copies upon request or to deliver them to a therapist of your choice.

• I, Kelly Daugherty, LCSW-R, GC-C can be reached during normal business hours at (518) 219-8625. Please leave a message on my confidential voicemail. I will do my best to return phone calls in a timely manner. Be advised that I may not be available for several hours and, therefore, may not be able to return your call immediately. Please note that I am not in the office on Wednesdays or Thursday afternoons. However, in the event of a mental health emergency, call 911 or go to your closest emergency room.

• HIPPA-compliant communication is provided through Simple Practice, IPlum, and the client portal. All other methods of communication are not considered HIPPA compliant.

If you need support and it is not an emergency, you may consider calling one of the following resources:

Suicide and Crisis Lifeline: 988

Child Protective Hotline: 800-273-8255

Hopeline: 800-784-2433

NYS Domestic and Sexual Violence Hotline: 800-942-6906

Rape/Sexual Violence Hotline: 800-656-4673

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APPOINTMENTS, CANCELLATIONS, AND FEES: Please remember to cancel or reschedule 24 hours in advance by calling or texting (518) 219-8625. I require at least 24 hours notice for non-emergency cancellations. I will make an allowance for one late cancellation (less than 24 hrs)/no-show at no charge. For the second and third late cancellations, I will charge you $25.00. For subsequent cancellations that happen within 24 hours of no-shows, the full amount of the session of $135.00 will be charged to you and will need to be paid in full at or before your next appointment. After 4 Late Cancellations in a 12-month period, you will be discharged from therapy. After 2 no-calls/no-shows, you will be discharged from therapy.

The standard meeting time for psychotherapy is between 45 to 53 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the session need to be discussed with the therapist for time to be scheduled in advance.  If you are feeling ill or have a child who is ill, your appointment can be moved from in-person to virtual. Please contact Kelly to switch to a virtual session, so your appointment is not missed.  
A $10.00 service charge will be charged for any checks returned for any reason for special handling.

Frequent or extended phone calls, reports, letters, preparation of clinical notes for mailing, faxing, etc., and all other outreach to third parties are billed at my direct therapy rate, which is $135 per hour. I bill in 15-minute increments.

Unless otherwise agreed upon, all payments, such as copay and coinsurance amounts or private payments, are due at the time of service. If you have a deductible that has not been satisfied, the full amount of the session as determined by your insurance company, is due at the time of service. Claims will be submitted in a timely fashion, and any issues will be discussed directly with you. If your insurance denies payment for any reason, you are responsible for the payment. Balances that are not paid within 45 days will be charged to the credit card on file unless other arrangements have been determined between Kelly Daugherty and the client.

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SOCIAL MEDIA AND TELECOMMUNICATION: Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet, and we can talk more about it.

RECORDS REQUEST:
The HIPAA Privacy Rule defines psychotherapy notes “as notes recorded by a healthcare provider who is a mental health professional documenting or analyzing the contents of a conversation during a private counseling session or a group, joint or family counseling session and that are separate from the rest of the patient’s medical record.” Psychotherapy notes under HIPAA law are not part of the medical record and are not released to clients.
Mental health records, on the other hand, are considered to fall within general protected health information (PHI) and are part of the general health record. Progress notes are inclusive of medications, session start and stop times, frequency of treatment, diagnosis, symptoms, prognosis. Progress notes under HIPAA law are allowed to be released if therapist determines it is appropriate.  Access to certain records and documents may be limited if the information is expected to be harmful to the individual receiving services or others. Medical records may be “redacted” or edited to withholder or delete information determined by the therapist to be harmful to the subject of the clinical record of others (MHL Section 33.16(c).
Client can request a treatment summary in place of the progress notes and can check that box on the request form as a treatment summary will provide more detail than the progress notes.

A written request and an authorized signature are required to request your records and the form provided by Greater Life Grief Counseling needs to be mailed to:
Kelly Daugherty
Greater Life Grief Counseling, LCSW
100 Saratoga Village Blvd, Suite 21
Malta, NY 12020

Additional practice policies will be provided at the time of intake paperwork being completed.