Intake Form

R&A Therapeutic Partners
5901 SW 74 Street, Suite 210
South Miami, Florida 33143
Phone 786-452-7352

PSYCHOTHERAPIST/CONSULTANT - CLIENT SERVICES AGREEMENT

I would like to welcome you to my practice! This agreement contains important information about my professional services and business practices. It also contains information about the Health Insurance Portability and Accountability Act (HIPPA), a new federal law that provides new privacy protections and new 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. HIPPA requires that I provide you with a Notice of Privacy Practices (for use and disclosure of PHI for treatment, payment and health care operations. The Notice explains HIPPA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information at the end of the session. Although these documents are long and complex, it is very important that you read them carefully before you sign them. We can discuss any questions you may have during our session. When you sign this document you are entering into an agreement with me. You may revoke this agreement at any time!

Meetings

I normally conduct an evaluation that will last from 1-2 sessions. By the end of the evaluation, I will be able to offer you some impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. If you have any questions about my procedures, we should discuss them as they arise. If your doubts persist, I will be happy to refer you to another mental health professional so you may get a second opinion.

Once I have completed my evaluation and made recommendations for treatment, we can both decide if I am the best person to provide the services that you need to meet your treatment goals. If you agree that we will work together, I will usually schedule sessions of 50 minutes each (one appointment hour of 50 minutes, with 10 minutes allotted for record keeping) at a time we can both agree on. Once an appointment is scheduled, you will be expected to pay for it unless you provide at least 24 hours notice of cancellation. 

Professional Fees

My fee for an evaluation/consultation is $450 and most initial appointments of this nature will take 60-90 minutes. At the end of this evaluation, I will offer you my impressions and recommendations for treatment. This may include recommendations for our services or possibly services with another professional or program, depending on what your needs are. We provide individual therapy, family therapy, customized outpatient programs for substance use and mental health, interventions and therapeutic placement consulting, concierge crisis and case management as well as several other services. The cost of these services will vary based on the type of service, the complexity of your case and what our involvement will be. Normally, once we make recommendations we will then discuss with you the cost of the services being recommended. Often we will provide a separate treatment plan or agreement, which will clearly outline the services we will be providing and the associated fees. The only fee you are committed to right now is the evaluation/consultation. Any other fees will be explained ;to you clearly once we establish what services, if any, we will be providing you. Please ask me any additional questions you may have regarding fees at the time of our evaluation/consultation.

Contacting Me

I am often not immediately available by telephone. While I am usually in my office, I may be in session with another client. When I am unavailable my telephone will be answered by voicemail, which I monitor frequently. I will make every effort to return your phone call the same day I receive it, with the exception of weekends, holidays and scheduled vacations. If you have an emergency and are unable to reach me you should:

• Contact your physician or psychiatrist
• Contact the nearest hospital emergency room
• Contact the Switchboard of Miami at 305-358-4357
• Contact Jackson Memorial Hospital 305-585-6487
• Contact Miami Children’s Hospital Dept. of Psychiatry at 305-666-6511

If I will be unavailable for an extended time, I will provide you with the name of a colleague for you to contact, if necessary.

Text Message Communication: Whenever possible, our communication should occur through face-to-face meetings, by phone or email. I will accept text messages as a brief form of communication to arrange appointment times, coordinate logistics, ask a simple, non-consequential question or in case of an emergency when you need to reach me immediately. I will not discuss recommendations, provide therapeutic feedback or otherwise engage in substantive exchanges via text message. I ask that you please reach out to me by phone or email whenever possible rather than via text message. Please understand that text messaging is not an acceptable form of communication when it comes to therapeutic issues or situations that involve complex advice or consultation. Also, please be aware that if you send me a text message, I may not get back to you right away if I am in session, it is after hours or on the weekend or I am otherwise occupied.

Limits on Confidentiality

The law protects the privacy of all communication between a patient and a psychotherapist. In most situations, I can only release information about your treatment to others if you sign a written authorization form. Authorization must meet certain legal requirements as imposed by HIPAA. There are other situations that require only that you provide written, advance consent.

There are some situations in which I am legally obligated to disclose information about you in the event that I feel someone is in danger and I must take action to protect them from harm. These situations are unusual in my practice however I must inform you of their possibility:

• If I know, or have reason to suspect that a child under 18 is abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child’s welfare, the law requires that I file a report with the Department of Children and Family Services. Once such a report is filed, I may be required to provide additional information.
• If I know or have reasonable cause to suspect that a vulnerable adult has been is being abused, neglected, or exploited, the law requires that I file a report with the central abuse hotline. Once such a report is filed I may be required to provide additional information.
• If I believe that there is a clear and immediate probability of physical harm to the patient, to other individuals, or to society, I may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or the appropriate family member, and/or the police or seeking hospitalization of the patient.

If such situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to only what is necessary.

Patient Rights

The laws and standards for my profession require that I keep Protected Health Information about you in your Clinical Record. HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that I amend your record, requesting restrictions on what information from your Clinical Records are 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 my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, and my privacy policies and procedures. I am happy to discuss any of these rights with you.

Minor Patients

Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. Children between the ages of 13 and 17 may independently consent to (and control access to the records of) diagnosis and treatment in a crisis situation. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, and parent involvement is also essential, it is usually my policy to request an agreement with minors over 14 years of age and their parents about access to information. This agreement provides that during treatment, I will provide parents only with general information about the progress of the treatment, and the patient’s attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless I feel the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. There may be cases such as when substance abuse or other high-risk behavior is involved where I may not agree to work with a minor if he/she does not provide consent for me to communicate freely with parents or other legal guardian.

Billing and Insurance

You will be expected to pay for each session at the time it is held, unless we agree otherwise. I do not accept insurance however I will provide invoices with the appropriate CPT codes and diagnostic codes to assist you in processing claims with your insurance company. If your account has not been paid for more than 60 days and arrangements for payment have not been made, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim.

YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU UNDERTSNAD THE HIPAA INFORMATION DESCRIBED ABOVE.

R&A Therapeutic Partners
5901 SW 74 Street, Suite 201
South Miami, Florida 33143
Phone 786-452-7352

CONSENT FOR TELEHEALTH CONSULTATION

• I understand that my health care provider wishes me to engage in a telehealth consultation.
• My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.
• I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
• I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
• I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

CONSENT TO USE THE TELEHEALTH

Zoom is the technology service we will use to conduct telehealth video conferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:

• Zoom is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
• To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

By signing this form, I certify:

• That I have read or had this form read and/or had this form explained to me.
• That I fully understand its contents including the risks and benefits of the procedure(s).
• That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

BY SIGNING BELOW, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.