Psychotherapy Bilingual Solutions, LLC
GENERAL POLICY AGREEMENT
CONSENT: In signing this policy form, I consent to
Psychotherapy Bilingual Solutions, LLC and Betty Carvajal, PhD, LMHC.
CONFIDENTIALITY: No information is given out to anyone about you
unless you have signed a release. In the
case of a minor child, information will be shared with the parent(s) as it
applies to helping the child outside of treatment. In general, if there is concern that a
patient is going to harm him/herself or someone else, or in cases of child
abuse, severe substance abuse or possibly a court order, confidentiality as
described above does not apply.
PHONE: If you need to be in touch in between
sessions: please call 904-392-5434. I
will get back with you as soon as possible.
EMAIL: Please note that email/text messaging are not
considered formal, confidential, or
an emergency form of communication. Concerns and in depth conversation needs to
be done in your therapy session. Emails
can be utilized for communication regarding your session schedule only. Please initial here _______ if you consent to the limited use of
email/internet communication as part of your therapy process understanding that
although your emails and info will be kept confidential by Psychotherapy
Bilingual Solutions, LLC/Betty Carvajal, PhD, LMHC, the internet is not a
secure and confidential environment as described under the law.
TEXTING: TEXT MESSAGING ONLY TO MAKE OR CANCEL APPOINTMENTS
In a state of emergency please dial 911, or leave me a voicemail if
you need to change appointments.
under co-pays) and CANCELLATION POLICY: While we are empathic to reasons (i.e. job
related problems, minor illness, or schedule mix-ups or conflict) it is
required that everyone give at least a 24 business hour notice to cancel a
session; if less than a 24 hour notice is given, or if a session is a no-show,
your credit card will be charged a penalty for such cancelled sessions at the
full session rate of $120.00. If you are
more than 15 minutes late for your appointment you will be charged and need to
You will not be charged for a cancelled
session if it is an emergency. In this
context, an emergency is: 1) a death in the family, or in your
spouse’s/significant other’s family; 2) a serious illness (i.e. you, or a
family member are hospitalized, you have the flu, or pneumonia); or 3) severe
weather. In these cases, if you request,
every attempt will be made to reschedule a session. Multiple emergencies per year may become an
issue with treatment and will be discussed as well; discharges are subject to
the discretion of Betty Carvajal, PhD, LMHC.
- : The fee for your initial assessment is $120.00. Thereafter, most session fees are $120.00 per
50 minute hour and $150.00 for 75 minute (or 1.5 sessions). Fees are due at the time of your
session. Psychotherapy Bilingual
Solutions, LLC accepts insurance as a form of payment only if authorized. An ABN, (Advance Beneficiary Notice) will be
signed in case your insurance denies payment, then you will be responsible for
full payment upon denial. If out of
network we will provide you with a Receipt that you can submit yourself to your
insurance company. Many insurance
companies will reimburse a portion of the session fees depending upon your out
of network coverage plan. Please initial
here if you allow Psychotherapy Bilingual Solutions, LLC to release diagnostic
information related to your treatment to your insurance company on a Superbill.
Payments can be made in the form of cash,
check or credit card. A copy of your
card will be placed in your confidential file to be used in the event of
cancellations and for convenience.
GENERAL POLICY and AGREEMENT - Continued
- : Since I
am bound by law to keep your confidentiality in public, it will be up to you
whether or not you want to acknowledge me should you see me in a store or
elsewhere out and about. If you do so I
will happily say “hello” and keep quiet about any specifics related to your
- : is an important piece of
treatment. If you are taking prescribed medications, it is
important that I am able to speak with your prescriber regularly. I will have you sign a specific release that
will enable me to do so.
- : If you arrive to the office under the
influence of alcohol and or any other drugs, you will be asked to leave by: taxi,
another driver, or ambulance and at your expense.
- It may be necessary for me to speak with your Primary Care Physician,
and any other Prescriber involved in your care, to coordinate services and
ensure that you are medically cleared by those professionals to receive the
private practice level of psychotherapy care.
- It may be necessary for you to see a Nutritionist, Registered
Dietician or Holistic Practitioner who specializes in Eating Disorders.
I agree and consent to treatment with Betty
Carvajal, PhD, LMHC, Psychotherapy Bilingual Solutions, LLC under the
guidelines outlined above and I have also read, and understand, the HIPAA
policy laws and guidelines, outlining the policies and practices that protect
the privacy of my health information.
__________________________________________ Date: ________________
Betty Carvajal, PhD, LMHC:
$120.00 Session: ______