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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 ONLY.

In a state of emergency please dial 911, or leave me a voicemail if you need to change appointments.

 

SCHEDULING: (see 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 reschedule.

 

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.

 

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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 care.
  • :  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.

 

Patient Signature: __________________________________________ Date:  ________________

 

Betty Carvajal, PhD, LMHC: __________________________________ Date:  _________________

$120.00 Session:  ______

$150.00 Couple Session: _______

Insurance: _______