Welcome to Nurtured Healing and Wellness! This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. 

Although these documents are long and sometimes complex, it is very important that you understand them. Signing this document represents an agreement between us. We can discuss any questions you have when you sign or at any point in the future.

I. THE THERAPEUTIC PROCESS

Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each party. As a client in therapy, you have certain rights and responsibilities. There are also legal limitations to those rights you should be aware of. As your therapist, I have responsibilities to you, as well. These rights and responsibilities are described in the following sections.

Therapy is a service provided by a qualified and licensed clinician. Although each session and individual’s perception of therapy may be unique, you can expect a few things to be consistent: a nonjudgmental and empathetic environment to openly discuss challenges, fears, hopes, and goals, and appropriate and qualified analysis of the relationship and individual wellness. Psychotherapy requires the active participation of both the client and the clinician. In order to receive the greatest benefit from treatment, it is recommended that you take time to reflect on the topics and suggestions given during sessions.

You have taken a very positive step by deciding to seek treatment. Therapy is not always easy; you may find yourself having to discuss very personal information. You could find those conversations difficult, embarrassing, and vulnerable. You may be anxious, distressed, and uncomfortable during and after such conversations. Therapy is intended to alleviate problems, but sometimes, especially at first and as you get to the root of things, may result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings and behaviors attached to those events can bring on strong feelings of anger, depression, anxiety, etc. I may suggest that you do some things that might, initially, make you feel awkward or uncomfortable. Sometimes therapy requires trying new ways of doing things. You will always be free to move at your own pace. I may challenge you and your old ways of thinking and doing things, but I cannot make any promise about the results you will experience.

II. APPOINTMENTS

Appointments will ordinarily be 53 minutes in duration, once per week at a mutually agreed upon time, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. 

Every client has a different situation, which makes it challenging to provide a timeframe for the duration of therapy. Sessions may last from a few weeks to several months or years as you explore various areas of your life and well-being. The course of therapy depends on the presenting concerns, your commitment to change, and may be impacted by the number of sessions covered by insurance. In general, I consider my job to be to “work myself out of a job.” I will be in ongoing dialogue about your needs, progress, and recommended duration of therapy. You are invited at any time to ask questions about my methods or the direction of your therapy.

III. CANCELLATION POLICY

If you need to cancel or reschedule your appointments, please provide a minimum of 24 hours notice. Failure to notify me 24 hours in advance of your scheduled appointment time will result in a late cancellation fee being charged. The late cancellation fee is $100 and no show fee is $150. Please note that these fees are your sole responsibility as the client and insurance cannot be billed for these fees. If you are late by 15 minutes or more and have not contacted me, I will assume you are not coming. Missing an appointment will result in you being charged the late cancellation or no-show fee, as appropriate. These fees must be paid in full at or before your next session. 

I appreciate your understanding and adherence to this policy.

IV. PROFESSIONAL FEES

The standard fee for the initial session (diagnostic assessments) is $250 and each subsequent session is $200. If you are not using insurance and are unable to afford these fees, you may be eligible for a sliding scale fee for services. 

You are responsible for paying at the time of your session unless prior arrangements were made. 

There is a $25 service charge for personal checks returned for any reason. Payment plans may be made at my discretion pending individual circumstances. To schedule an initial appointment, I require a valid credit card to be on file. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment.

In addition to weekly appointments, it is our practice to charge this amount on a prorated basis (break down the hourly cost) for other professional services that you may require such as report writing, telephone conversations that last longer than 15 minutes, attendance at meetings or consultations which you have requested, or the time required to perform any other service which you may request. 

If you anticipate I recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required even if another party compels me to testify.

Please note that these fees are reviewed annually and you will be notified in writing of any changes to our fees.

V. INSURANCE

To set realistic treatment goals and priorities, it is important to evaluate your resources available to pay for your treatment. If you have a health insurance policy, it may provide some coverage for mental health treatment. With your permission, Nurtured Healing and Wellness will assist you to the extent possible in filing claims and ascertaining information about your coverage, but you are responsible for knowing your coverage and for letting me know if/when your coverage changes.

Due to the rising costs of healthcare, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. Managed Health Care plans such as HMOs and PPOs often require advance authorization, without which they may refuse to provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your wellness journey and therapy services.

You should also be aware that most insurance companies require your authorization to provide a clinical diagnosis. Diagnoses are technical terms that describe the nature of your problems and whether they are short-term or long-term problems. Sometimes I must provide additional clinical information such as treatment plans or summaries or copies of the entire record (in rare cases). This information will become part of the insurance company files, and, in all probability, some of it will be computerized. Though all insurance companies claim to keep such information confidential, Nurtured Healing and Wellness has no control over what they do with it once it is in their hands. By signing this Agreement, you agree that I can provide the requested information to your insurance carrier if they request this information, if you plan to pay with insurance. It is important to remember that you always have the right to pay for services directly and avoid the reporting and complexities associated with insurance coverage. 

If you plan to use your insurance, authorization from the insurance company may be required before they will cover therapy fees. If you did not obtain authorization and it is required, you may be responsible for full payment of the fee. 

Many policies leave a percentage of the fee (co-insurance) or a flat dollar amount (co-payment) to be covered by the patient. Either amount is to be paid at the time of the visit by credit card or check. Some insurance companies may also have a deductible, which is an out-of-pocket amount that must be paid by the patient before the insurance companies are willing to begin paying any amount for services. This will typically mean that you will be responsible to pay for sessions until your deductible has been met; the deductible amount may also need to be met at the start of each calendar year. 

Once we have all of the information about your insurance coverage, I will discuss what we can reasonably expect to accomplish with the benefits available and what will happen if coverage ends before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above, unless prohibited by my provider contract.

If you are using insurance coverage for your services at Nurtured Healing and Wellness, we will be happy to submit claims to receive payment directly from them if we are an in-network provider with an active contract with your insurance or third-party payer. In that case, Nurtured Healing and Wellness will submit claims according to the contract terms with your insurer. Your clinician will also provide you with receipts and any other information you may need so that you may submit your own insurance claims and be reimbursed by your carrier. Your copay is due at the time of your visit. If there is a problem collecting payment from your insurance or managed care company for the balance, you remain responsible for payment of the fee(s). if we have not received payment from your insurance or third-party payer within eight weeks of any therapy session, we may bill you directly for past and ongoing visits. If your carrier does not pay you, you will be responsible and failure to pay may necessitate termination of services and a referral to another provider. I do not submit claims to insurance companies that I am not in network with, nor do I submit to secondary insurance payers. I will be happy to provide a superbill in these instances to aid in your own submission for reimbursement.

It is in your best interest to verify the details of your health insurance policy and share that information with Nurtured Healing and Wellness staff. Your clinician may assist you in verifying your coverage and submitting your claims to the insurance company, however, you remain responsible for knowing your insurance benefits. You also remain personally responsible for deductibles, co-payments, co-insurance, non-covered, ineligible, or unauthorized services. It is recommended that you verify your coverage 24 hours prior to the first appointment to be sure that I am a covered provider, and these services will be covered.

If you experience any changes in your insurance coverage, it is your responsibility to notify me prior to your session. In the event that the insurance information you have provided is incorrect, resulting in the denial of a claim, you will be subject to a $25 insurance resubmission fee. An example of this is if your coverage has ceased or changed and you fail to notify us before your session.

If I am not a participating provider for your insurance plan, I will provide you with a receipt of payment for services, which you can submit to your insurance company for reimbursement. Please note that not all insurance companies reimburse for out-of-network providers.  If you prefer to use a participating provider, I will do my best to refer you to a colleague.

VI. PROFESSIONAL RECORDS

Therapists are required to keep appropriate records of the psychological services provided. Your records are maintained securely within the TherapyAppointment software. I keep brief records noting that you were here, your reasons for seeking therapy, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records received from other providers, copies of records sent to others, and your billing records.

Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them with me or have them forwarded to another mental health professional to discuss the contents. 

If I refuse your request for access to your records, you have the right to have the decision reviewed by another mental health professional. We can discuss this further upon your request. You also have the right to request that a copy of your file be made available to other health care providers. 

In addition to therapy sessions, it is our practice to charge for other professional services that you may require, such as report writing, telephone conversations that last longer than 15 minutes, attendance at meetings or consultations which you have requested, or the time required to perform any other service which you may request, such as appearing in court. If you have a request for your clinician to engage in these professional services, you may be charged a prorated fee of our clinical rate for every 15 minutes required to complete the request. I will make reasonable efforts to limit this information to the minimum necessary to accomplish the intended purpose of the request. I reserve the right to decline these requests. It is my practice not to become involved in any custody, visitation, or legal disputes. It is important that you seek appropriate and qualified legal advice regarding divorce or custody agreements.

If you or another provider on your behalf (including attorneys) request your records, an administrative fee of $25 will be required to release your records.

VII. CONFIDENTIALITY

In accordance with the standards set forth by the State of Illinois and the Health Insurance Portability and Accountability Act (HIPAA), the information you provide to Nurtured Healing and Wellness will be treated as strictly confidential, meaning that I will not share information you have provided with unauthorized individuals. However, there are exceptions, including those situations in which I am required by law to report, such as suspected abuse to a child and/or dependent adult, harm or threat to self, and harm or threat to others. While these situations are rare, you should be aware of the possible occurrence as well as the protective actions required of me as your therapist. These actions may include notifying the potential victim, notifying the police, seeking appropriate hospitalization for the client, and/or contacting family members or others who can help provide protection.

VIII. COUNSELING AND TREATMENT OF MINORS

While privacy in therapy is crucial to successful progress, parent/guardian involvement can also be essential. It is my policy not to provide treatment to a minor under age 12 unless they agree that I can share whatever information deemed necessary with a parent/guardian. 

For minors 12 and older, I request an agreement between the minor and parent/guardians to share general information about treatment progress and attendance, as well as a treatment summary upon completion of therapy. All other communication requires the minor's agreement, unless we determine that there is a safety concern (see also above section on Confidentiality for exceptions). In this case, I will make every effort to notify the minor of my intention to disclose information and handle any objections raised.  

Nurtured Healing and Wellness requires this Terms of Service and Policies document to be completed by both parents or legal guardians of a minor. A minor is identified as a client under the age of 18. If applicable, custody or guardianship documentation such as a parenting agreement must be provided to the practice prior to the initial appointment. 

Please note that at the age of 12, a minor has certain rights to their file that may affect what information can be communicated or released outside of treatment. If you are under 12 years of age, please be aware that the law may provide your parents/guardians the right to examine your treatment records. If you are between the ages of 12 and 18, the law may provide your parents/guardians the right to examine your treatment records if, after being informed of their request to examine your records, you do not object or your therapist does not find that there are compelling reasons for denying access to the records. Notwithstanding the aforementioned, your parents/guardians are always entitled to the following information: current physical and mental condition, diagnosis, treatment needs, services provided, and services needed. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any questions, concerns, or objectives you may have with what is prepared to discuss. You may speak with me if you have any concerns or questions about this.

IX. CONTACTING YOUR CLINICIAN

If you need emergency care and/or experiencing a mental health crisis, please call 911 or 988 or ask a support person to assist in transporting you to the nearest emergency room. For non-emergent needs, you may leave a message on my confidential voicemail or send  a message through your client portal. I am often not immediately available, however, will attempt to return your call within 48 business hours. Please refrain from discussing topics other than scheduling or billing information outside of our face-to-face interactions.

I cannot ensure the confidentiality of any form of communication through electronic media. If you choose to share any personal information via email or other electronic media, you acknowledge that this is a risk. While I do my best to respond in a timely manner, an immediate response is not guaranteed. You are always welcome to call the office at 630/354.0459 and leave a voicemail. 

If, for unforeseen reasons, you do not hear from me or I am unable to reach you, and you feel you cannot wait for a return call or feel unable to keep yourself safe, please go to your local hospital Emergency Room or call 911 and ask to speak to the mental health worker on call. I will make every attempt to inform you in advance of planned absences, and provide you with the name and phone number of the mental health professional covering my practice.

X. OTHER RIGHTS

You always have the right to voice your needs as a client. If for any reason you are dissatisfied with your  services, please let your therapist know so that she can address your concerns. Such comments will be taken seriously and handled with care and respect. You may also request a referral to another therapist and are free to end therapy at any time.  If we are unable to resolve your concerns, I will assist you in finding qualified help elsewhere.

You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of therapy and about my specific training and experience. You have the right to expect that I will not have social or sexual relationships with clients or former clients.

XI. SUSPENSION OR TERMINATION OF SERVICES

The decision to end therapy will be a conversation between you and your clinician, based on your progress, engagement in services, goals, and other relevant factors. Some situations may impact your time in therapy, such as insurance changes, life transitions, outstanding balances, excessive cancellations, and lack of scheduling follow-up sessions. Occasionally, I may elect to discontinue the treatment services provided. This may happen when no substantial progress is being made or other factors are interfering with my ability to help you. Additionally, if you do not keep a scheduled appointment and do not call within four weeks, I will assume you have chosen to terminate counseling at that time. Future considerations of re-engaging in services will need to be initiated by you. Failure to comply with the statements of this services contract may also lead to termination of services.

If your account shows a balance of $250 or more, services will be suspended until the balance is paid or a payment plan is established. If you are unable to afford services, I will make a referral to an outside agency for you to receive treatment. At Nurtured Healing and Wellness, I believe that it is in your best interest to discontinue services if they become a financial burden.