Psychotherapy Agreement

Welcome to my psychotherapy practice...I CHOOSE TO THRIVE, INC.  It is my goal to offer you the best possible services to facilitate your healing, growth, and thriving. This document details my professional practice and business policies.  Please review and note any questions that I may answer for you during our first or next meeting.

**CONTACTING ME:  The best possible way to contact me is through your portal.

SESSIONS

Our standard sessions last 45 minutes ("The therapy hour").  This is 45 minutes of talk time.  

Our session must end on time (whether or not you are on time) so I may use the time immediately following our session to complete notes for this session and plan for our next session; my service to you extends beyond the talk time.  Please note, I make every effort to begin sessions on time.  The occasional exception is when there is an emergency/crisis that will need my immediate attention and cause me to run a few moments late for your appointment.  

I am currently 100% virtual.  We have the options of video meetings through DOXY (https://doxy.me/kristiabritt), telephone sessions, or online video through this portal. 

                                                                               Professional Fees, Billing and Payments  

Session fees will be charged on the day of your appointment.  You must keep an active card on file in order to be serviced.

Here are the session fees: 

$175.00 - 45 minutes (talk time)

$250.00 - 90 minutes (talk time)

$  30.00 -10 minutes talk time extension (You may opt to extend the 'talk time' by 10 minutes/ session for an additional $30.00 if time permits.)  Please note, insurance will not cover the extended sessions.

$225.00 - 45 minutes (intake / initial bio-psychosocial assessment)

$275.00 - 90 minutes (extended intake)

Other Fees:

$1.00 - Declined Card

$5.00 - Late Fee (if requested to collect payment at a later date for sessions/late cancellations/no show charges.)

***A reduced rate is available to 'self pay' clients who can show a proof of income.  I will be happy to do this for you.

***If you are currently receiving a reduced rate, you may maintain your current fee by submitting/updating your proof of income.

                                                                                                Credit Cards

An active/current credit card must be (and will be kept safely) on file at all times to receive services to ensure accountability and responsibility for payment of fees that accrue on your account.  These fees include:  session fees, late cancellation fees, no show fees, paperwork/document fees, etc.  Make sure you keep your cards updated.  If you have multiple cards on file, as a default, I usually charge the card that had been most recently added.  If you rather a different card be charged, you may make the payment yourself prior to our session or request me to charge by giving me the last 4 digits in order to identify.  Once your card is entered, I do not have access to the full number but only the last 4 digits.  

If the card on file is declined at the time of charges, there is a $1.00 fee.  You will be notified and a payment can be made on the same day to avoid a late fee of $5.00.  

                                                                                              Insurance 

If I am "Out-of-Network" for your insurance, fees are paid at the time of the session.  You will then be provided a billing statement to submit to your insurance company for your reimbursement.  If I am contracted with your insurance company as an "In-Network" provider, then I will submit claims on your behalf.  You will only be responsible for your portion (deductibles, copays, and/or coinsurances).  Your claims will be submitted in a timely manner.  If after 60 days, and your claims are not paid by your insurance company, you will be responsible for the bill at the insurance contracted rate (which is usually less than my full fees).  It is your responsibility to update me with any changes with insurance coverage prior to the session(s) when the changes take effect, (otherwise you will be charged the full fee).

For other professional/admin/case management services on your behalf, outside of psychotherapy, it is my practice to charge $100/hour on a prorated basis.  Such services include letter writing, preparation of records or treatment summaries that have been requested, other professional consultation, disability paperwork, and consultations with other professionals for which you authorized.  As a courtesy, I will coordinate services with your medical professional (PCP or Psychiatrist), at no charge to you.  Please note I will not complete disability/FMLA paperwork without a full assessment and 3 sessions. EAP benefits cannot be used while out on disability/FMLA (per the policies of the EAP companies).

                                                                                     Missed Appointment Policy

Your scheduled appointment time is reserved exclusively for you.  If you are unable to attend your scheduled appointment, please notify me as soon as possible (so this slot could be offered to a current client, a client on the waiting list, or a client with a clinical emergency).  Cancelling your appointments prior to the 24 hours window of time is the preferred way (and no missed appointment charge).  Please do not cancel your appointments via telephone, text, or email but instead, message me through this portal to ensure I receive the message timely and I can offer your slot to someone else if needed.  If you cancel within the 24 hours before your appointment window, there will be a charge.

Missed Appointment Charges ('MAC') are as follows:

1.  $75 Late Cancellation Fee:  Fees accrued from having less than 24 hours notice (on BUSINESS DAYS prior to appointment).

2.  No Show Fee (Your Full Session Amount): Full 'Self-Pay' Fee (or my contract provider rate if you have insurance) if cancellations are made ON THE DAY OF scheduled session.

***Your Card on file will be billed on the day of the Late Cancellation or No Show.

**** The exception to this charge will be in the event of an incapacitating emergency i.e., medical emergency or accident making it impossible to call to cancel. In which case, it the card had already been charged, you will receive a credit.

***AGAIN...PLEASE CANCEL YOUR APPOINTMENT THROUGH YOUR PORTAL ONLY.  This will ensure that your cancellation is received timely and you won't be charged.***  

                                                                                              Outstanding Balances

Although payments are made at the time of services, there are occasions where there is an accrued outstanding balance (i.e. declined cards, request to delay a payment for a few days).  

I will be happy to extend grace but please note the following:  

1.  Outstanding balances must be paid no later than 24 hours before the next scheduled appointment.  Reminders of balances will be sent no later than 48 hours prior to your appointment.  If a payment is not made by 24 hours prior to the appointment, you will be notified that the appointment will be cancelled and you may reschedule). 

2.  If not able to make a payment, you have up to 24 hours before the appointment may request a payment arrangement and we can proceed with your scheduled appointment. I am willing to work with you to make sure you get your care, just have timely communication with me.

 ***Remember if you need to cancel/reschedule your appointment, do so timely so your will not accrue an additional Missed Appointment Charge.

2.  $25.00 - Monthly Service Fee for outstanding balance not paid by the 25th of each month.  

CONSENT FOR TREATMENT

I, ______________________(sign below)_______________________, authorize and request that Kristia Britt- Orr, MA, LPC provide psychological examinations, treatment and/or diagnostic procedures which now or during the course of my care as a patient are advisable. The frequency and type of treatment will be decided between my therapist and me.

I understand that the purpose of these procedures will be explained to me and be subject to my verbal agreement.

I understand that there is an expectation that I will benefit from psychotherapy but there is no guarantee that this will occur.

I understand that maximum benefit will occur with consistent attendance and that at times I may feel conflicted about my therapy as the process can sometimes be uncomfortable. 

CONFIDENTIALITY

In general, the privacy of all communications between a patient and a therapist is protected by law, and I can only release information about our work to others with your written permission.  But there are a few exceptions:

In most legal proceedings, you have the right to prevent me from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determine that the issues demand it. 

There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a patient's treatment. For example, if I believe that a child, elderly person, or disabled person is being abused, I must file a report with the appropriate state agency. 

If I believe that a patient is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient.  

If the patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection.

 These situations have rarely occurred in my practice. If a similar situation occurs, I will make every effort to fully discuss it with you before taking any action.

CLIENT PORTAL:

As a client, you have automatic access to your own basic self-service portal that allows you to schedule, email me securely, see and print your invoices, and make payments).  You also can:

-Complete forms and paperwork.  

-Receive practice announcements and newsletters.  

-You also have access to your personal online journal.  (This is completely private, neither I nor anyone else, will have access to your personal entries.  You will, however, have the option to make any of your entries available for me to see--my clients find this to be helpful in preparation for sessions). 

SOCIAL MEDIA POLICY:

I do not accept friend request on my personal Facebook page from current or former clients because I believe that could compromise your confidentiality and our respective privacy.  Although I have YouTube videos, blogs, newsletters and business social media accounts that you are welcome follow or subscribe to; I have no expectation for you to follow.  I use these outlet to provide content to the general population.  Should you choose to follow or subscribe, please protect your identity as a client as so will I.  My primary concern is your privacy--these sources are not secure so please do not use them to contact me.

TERMINATION OF SERVICES:

Please understand that therapy is a time commitment for your personal betterment and it takes consistency to achieve this.  We understand there are many reasons why people may not attend or have consistent appointments.  Legally and ethically, we must terminate clients after a period of time with no contact.  It is our policy to terminate services if appointments are not scheduled within 6 weeks or if there is no contact in 2 months.  

If the therapeutic relationship is terminated pursuant to this policy, your case be reopened at any time you are ready to resume your sessions.  However, you may be placed on a waiting list.

Contact Information:

-If you or someone is requesting records/paperwork on your behalf, please use my HIPAA compliant email. I will give that address to you upon your request.

Kristia