Trenton J. Peterson, MA, LMFT
403 Jackson St., #308
Anoka, MN 55303
Office: (763) 712-1903
Fax: 763) 712-191
Outpatient Services Contract
Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully and jot down any questions that you might have so that we can discuss them at our next meeting. Once you sign this, it will constitute a binding agreement between us.
Psychological Services
Psychotherapy is not easily described in general statements. It varies depending on the personality of both the therapist and the client and the particular problems that affect the client’s life. There are a number of different approaches that can be utilized to manage problems that you hope to address. It is not like visiting a medical doctor, in that it requires a very active effort on your part. In order to be most successful, you will need to work both during our sessions and at home.
I see patients/clients as individuals, couples, and as families. My therapeutic orientation is primarily Narrative, which means that, I see the problem as the problem, not the person as the problem. Therapy is conducted through the use of identifying how problems might be affecting ones life, and identifying ways that have been helpful to eliminate the problem’s affects on that persons life. This perspective tends to be very empowering to the people that I work with. Those people whom I consult with about their lives, are viewed as experts on not only their lives, but how the problems have worked in their lives, and even how they are going to eliminate its affects on their lives.
Psychotherapy has both benefits and risks. Risks sometimes include experiencing uncomfortable levels of feelings like sadness, anxiety, anger, and frustration, loneliness and helplessness. Psychotherapy often requires recalling unpleasant aspects of your history. Psychotherapy has also been shown to have benefits for people who undertake it. It often leads to a significant reduction of feelings of distress, and better relationships and resolutions of specific problems. But there are no guarantees about what will happen.
By the end of the evaluation, which may include a diagnostic assessment, if your health insurance requires it, I will be able to offer to you some initial impressions of what our work will include and an initial treatment plan. You should evaluate this information along with your own assessment about whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you to secure an appropriate consultation with another mental health professional.
Meetings
My normal practice is to conduct an initial interview, which may result in a diagnostic assessment, again based upon insurance needs, which may last 1-3 sessions. During this time, we can both decide whether I am the best person to provide the services that you need in order to meet your treatment objectives. If psychotherapy is initiated, I will usually schedule one forty-five minute (one appointment hour of forty-five minute duration) at a mutually agreed upon time and frequency. If a client is late, the session is shortened accordingly; if the therapist is late the client will receive the full forty-five minutes or will be charged a prorated fee.
Missed Appointments
Once an appointment hour is scheduled, you will be expected to pay for it unless you provide at least 24 hours advance notice of cancellation. (For Monday appointments, cancellation should be by noon Friday). My fee for a cancellation or missed appointment is $120, which must be paid before another session will be scheduled. If you miss three appointments without twenty-four hour notice, we will have to discuss referrals to appropriate resources for you to use.
Professional Fees
My fee for the initial diagnostic assessment is $180.00. My hourly fee for individual, couples, and family therapy is $120.00. This fee includes the Minnesota Care Program health provider 2% tax. In addition to appointments, it is my practice to charge the therapy rate on a prorated basis for other professional services you may require such as report writing, telephone conversations which last longer than 10 minutes, preparation of records or treatment summaries or the time required to perform any other service which you may request of me. In unusual circumstances, you may become involved in a litigation, which may require my participation. You will be expected to pay for the professional time required even if I am compelled to testify by another party. Because of the complexity and difficulty of legal involvement, I charge$250.00 per hour for preparation and attendance at any legal proceeding.
Billing and Payments
You will be expected to pay for each session at the time it is held, unless we agree otherwise or you have insurance coverage, which requires another arrangement. For example, if you have insurance with a co-payment, then please pay the co-payment at the time the session is held and your insurance company will be billed for its share of the fees. If you have an insurance that reimburses via check to you, full payment is due prior to services rendered. Payment schedules for other professional services will be agreed to at the time these services are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or installment payment plan.
If your account is more than 60 days in arrears and suitable arrangements for payment have not been agreed to, I have the option of using legal means to secure payment, including collections agencies or small claims court. In most cases, the only information that I release about a client’s treatment would be the client’s name, the nature of the services provided, and the amount due.
Insurance Reimbursement
In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources are available to pay for your treatment. If you have a health benefits policy, it will usually provide some coverage for mental health treatment. I will provide you with whatever assistance I can in facilitating your receipt of the benefits to which you are entitled including filling out forms as appropriate. However, you, and not your insurance company, are responsible for full payment of which we have agreed to. Therefore, it is very important that you find out exactly what mental health services your insurance policy covers.
You should carefully read the sections in your insurance coverage booklet that describes mental health services. If you have questions, please call your plan and inquire. Of course, I will provide you with whatever information I can based on my experience and will be happy to try to assist you in deciphering the information you receive from your carrier.
The escalation of the cost of health care has resulted in an increasing level of complexity about insurance benefits that sometimes makes it difficult to determine exactly how much mental health coverage is available. “Managed Health Care Plans” such as HMO’s and PPO’s often require advance authorization before they will provide reimbursements for mental health services. These plans are often oriented towards a short-term treatment approach designed to resolve specific problems that are interfering with one’s usual level of functioning. It may be necessary to seek additional approval after a certain number of sessions. In my experience, while quite a lot can be accomplished in short-term therapy, many clients feel that more services are necessary after insurance benefits expire.
Once we have all the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if the insurance benefits run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for my services yourself and avoid the complexities that are described above.
You should also be aware that most insurance agreements require you to authorize me to provide a clinical diagnosis, and sometimes additional clinical information such as a treatment plan or summary, or in rare cases, a copy of the entire record. This information will become part of the insurance company files, and in all probability, some of it will be computerized. All insurance companies claim to keep such information confidential, but once it is in their hands, I have no control over what they do with it. In some cases, they may share the information with a national medical information data bank. If you request it, I will provide you with a copy of any report that I submit.
Contacting Me
The best place to reach me is to call at (763) 712-1903. I am usually not immediately available by telephone. I do not answer the phone when I am with a client. I do have voice mail that I monitor frequently. I will make every effort to return your call the same day, with the exception of weekends and holidays. If you are difficult to reach, please leave some times when you will be available. If you cannot reach me and you feel that you cannot wait for to return your call, you should call the psychologist or psychiatrist on call, crisis connection, or 911. Please let me know when you use other resources so that I may coordinate your care with these services. If I am unavailable for an extended time, I will provide you with the name of a trusted colleague whom you can contact if necessary.
Professional Records
Both the law and standards of my profession require that I keep appropriate treatment records. You are entitled to receive a copy of the records. Because these are professional records, they can be misinterpreted or can be upsetting, so I recommend that we review them together so that we can discuss their content. Clients will be charged an appropriate fee for any preparation time that is required to comply with an information request.
Minors
If you are under eighteen years of age, please be aware that the law may provide your parents with the right to examine you treatment records. It is my policy to request an agreement from parents that they consent to give up access to your records. If they agree, I will provide them only with general information on how your treatment is proceeding unless I fell that there is high risk that you will seriously harm yourself or another, in which case I will notify them of my concern. I will also provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you and will do the best I can to resolve any objections you may have about what I am prepared to discuss.
Confidentiality
You should feel free to refuse to give any information you do not feel comfortable disclosing. Withholding information may interfere with my work with you but it is your right to withhold information if you so choose. In general, law protects the confidentiality of all communication between a client and a therapist, and I can only release information about our work to others with your written permission. However, there are a number of exceptions.
In most judicial proceedings, you have the right to prevent me from providing any information about your treatment. However, in some circumstances such a child custody proceedings and proceedings in which your emotional condition is an important element, a judge may require my testimony is s/he determines that resolution of the issues before her/him demands it. If the proper legal authority subpoenas your records, I must comply.
There are some situations in which I am legally required to take action to protect others from harm, even though that requires revealing some information about a client’s treatment.
If I have reason to suspect that a child, an elderly person, or a disabled person is being abused, I must file a report with the appropriate state agency.
If I believe that a client is threatening serious bodily harm to another, I am required to take protective actions, which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization. If a client threatens to harm her/himself, I may be required to seek hospitalization for the client, or to contact family members or others who can help provide protection. If I learn that you have been abused or exploited by another professional person, I must report it.
These situations have rarely arisen in my practice. Should such a situation occur, I would make every effort to fully discuss with you before taking any action.
I may occasionally find it helpful to consult about a case with other professionals. In these consultantions, I make every effort to avoid revealing the identity of my client. The consultant is, of course, also legally bound to keep the information confidential. Unless you object, I will not inform you about these consultations unless I feel that it is important to our work together. When I need to reveal your identity (for example when I am working with one spouse and the therapist I am consulting with is working with the other spouse) I will obtain your written consent for release of specific information before consulting with the other professional.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have at our next meeting. As you might suspect, the laws governing these issues are quite complex and I am not an attorney. While I am happy to discuss these issues with you, should you need specific advice, formal legal consultation may be desirable. If you request, I will provide you with relevant provisions or summaries of the applicable state laws governing these issues.
Changes in Services or Fees
You have the right to receive reasonable notice of changes in services or fees. In my practice you will be notified 30 days in advance of such changes. Should events beyond my control result in an inability to give you proper notice of changes, I will make all efforts necessary to insure your continuity of care.
Emergencies:
In case of an emergency call 911, if it is non life threatening call my cell phone at (612)708-6631.
Other Resources
Information about mental health services that may be available to you can be obtained through your local community mental health center, First Call for Help, the community human services agency in your county, the State Department of Human Services – Mental Health Division- or your own health care plan. |
