Dear Potential New Client,
Welcome to my practice. The following information will be helpful to you as we proceed. Please read the policies and procedures carefully, and if you have no questions or concerns, please sign below. If you do have questions, please let me know before signing, and I will be happy to answer any questions and discuss any concerns you may have.
Appointment Times: I schedule appointments directly with you. Sessions are 60 minutes in duration. Five minutes of every appointment are devoted to scheduling and payment. Standing times are often available, if preferred.
Appointment location/platform: All appointments are held via confidential videoconference on a secure HIPPA-compliant telehealth platform called Doxy.me, or telephone, if preferred. To videoconference, you will need a computer or smart-phone with a good internet connection and webcam. You will click on the following link https://doxy.me/drvirts prior to every appointment, which you may consider doing a few minutes before to test your video and audio quality. Please save this link in your email Contacts or anywhere you prefer to have easy access to it for your appointments. This link will take you to my secure online virtual waiting room, where you will be prompted to enter your name to confidentially sign-in. Once I see that you are there, I will be able to give you access to the platform for confidential videoconferencing.
Appointment Frequency: At the beginning of treatment, weekly psychotherapy appointments are generally recommended, depending on the initial assessment. Sometimes more frequent appointments are recommended, if a person is experiencing severe distress, instability, and/or time urgency. Scheduling sessions more than two weeks apart during initial phases of treatment tends to interfere with a client’s progress toward their goals. Once treatment goals are reached and coping and functioning are stable, usually less frequent appointments are scheduled to maintain and reinforce progress/coping, and the therapist and client mutually decide on a termination schedule and date.
Appointment Cancellations: Please provide 24-hour notice by phone to cancel a scheduled appointment. Sessions canceled or missed without 24-hour notice are charged at full-rate. Insurance companies do not pay for missed appointments. Occasionally, you may experience an illness or crisis outside your control that may result in your cancelling less than 24 hours before your appointment; this is understandable and there is no charge for such occasions. If I cancel an appointment, I will provide you at least 24-hours’ notice. Upon rare occasion, when assisting another client experiencing a psychological emergency or confronting some other urgent situation outside my control, I may need to cancel our appointment and be unable to provide 24-hours’ notice. If so, I will contact you as soon as possible to reschedule your session.
Fees and Payments: The fee for the initial appointment is $190.00, and the fee for a 60-minute follow-up appointment is $150.00. You are responsible for payment of your bill; payment-in-full in the form of Venmo bank transfer, credit/debit/or HSA card, or check is collected at each appointment. There is a 3% processing fee for payment with credit card, and a $15.00 fee for returned checks. You will be provided a receipt for all payments.
***Please note: If you plan to seek reimbursement from your insurance company, please let me know. I will provide you a special receipt on a monthly basis (called a “Super-Bill”) that lists the necessary diagnostic and service codes needed to file with your insurance company. You should also call your behavioral health insurance office to notify them of your entering therapy with an out-of-network provider, and request any specific procedures you need to follow to obtain reimbursement. Some companies require a particular claim form to be completed, which they should provide you. I am happy to answer any questions you may have about insurance filing, as well as intervene on your behalf, should you experience any difficulties obtaining reimbursement.***
Telephone Calls: You may text or leave voice mail messages for me on my cell phone (615) 848-8214. I am the only person with access to my phone. I return calls as quickly as I can and within 24 hours. There is no charge for phone conversations 15 minutes or less in duration. If you are experiencing sustained emotional distress and are having difficulty calming or re-centering yourself between appointments, you are welcome to call or text, and I will return your call or text as soon as I am able. Such phone calls will be skills-focused - to help you implement skills for managing distress, particularly at the beginning of treatment while you may be developing coping skills. Calls longer than 15 minutes will be charged a prorated rate of $2.50 per minute after the first 15 minutes. If you are unable to wait for a return call or text from me, please call The Crisis Intervention Center available 24 hours/day at (615) 244-7444.
Potentially Life-Threatening Emergencies: If you experience a potentially life-threatening psychological emergency, such as having sustained (i.e., more than fleeting or passive) thoughts of hurting yourself or others, and need urgent assistance to help reduce the risk of a potentially life threatening event, you should call 911, go to the nearest emergency room, or call The Crisis Intervention Center available 24 hours/day at (615) 244-7444, as well as leave a message on or text my cell phone. You should also notify someone from your support system.
Miscellaneous Service Fees: Tasks outside routine record keeping and scheduling that arise between office visits and require sustained attention/effort longer than 15 minutes (e.g., completing forms, emails, reviewing records, consulting other treatment providers, or writing letters or standard reports on your behalf, etc.) will also be charged a prorated rate of $2.50 per minute after the first 15 minutes. The fee for medical records is $20.00 for records 5 pages or less in length and $0.50 per page for each page copied after the first 5 pages, per Tennessee Code Annotated.
Legal, Disability, Worker’s Compensation, or Other Similar Proceedings: Due to the potential negative effects on a client’s psychotherapy, it is my policy to not participate in any court or legal proceedings, depositions, Disability or worker’s compensation claims, or other mental health evaluations you may be involved in. If you are currently or planning to be involved in a lawsuit, legal proceeding, Disability or worker’s compensation claim, or need a statement or report from a mental health provider in relation to such a proceeding, please let me know. I will be happy to refer you to a forensic or other appropriate psychologist that will be better able to assist you with this process. I do not provide treatment records, treatment summaries, or disability/functional capacity/worker’s compensation/or other mental health reports for such purposes.
Treatment Termination: I will never terminate your treatment without considerable time and mutual discussion in advance. Please provide similar consideration and let me know if you are ever uncomfortable or dissatisfied with any aspect of your treatment before stopping therapy without notice. I will treat your concerns with utmost respect and care.
Treatment Limitations/Risks: Psychological care, like other things in life, offers no absolute guarantee of success, and there are limitations to any form of care. Please be advised that when a person confronts long-standing psychological, behavioral, and/or emotional issues, they may experience more distress before they feel and cope better, particularly in the beginning phases of therapy. Temporarily increased distress is also a part of the normal healing process with some psychological interventions. I aim and take therapeutic precautions to limit distress and coping difficulties related to psychotherapy interventions. However, there may be times when distress and coping problems cannot be reasonably predicted or prevented. I request that clients call my cell phone to let me know if they are experiencing and need help managing sustained distress or difficulties coping. (Please follow separate instructions above for managing Potentially Life-Threatening Psychological Emergencies.)
Your Informed Consent to Care: I have supplied this information so you understand some of the parameters of care you will receive from me. We will discuss, typically in the first several sessions, ways and recommendations for approaching your particular struggles and devise a treatment plan together that targets your needs and goals.
Please ask me any questions or share with me any concerns you may have about any of the above information. By signing below, you acknowledge having read, understood, and agreed to the policies, procedures, and information provided in this form. Your signature acknowledges your informed consent for care.
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