WELCOME

Welcome to my practice! As you consider working with me, it is important that we have a shared understanding of what we can expect from each other. This document contains important information about my professional services and business policies. Please read it carefully and discuss with me any questions you may have at our first meeting. When you sign this document, it will represent an agreement between us, which you may revoke in writing at any time. If you have any questions or concerns while completing the forms, please call the office and one of our helpful staff members will be happy to assist you. I am looking forward to meeting you and your family.

PSYCHOLOGICAL SERVICES AGREEMENT

This document (the Agreement) contains important information about the professional services and business policies of Dr. Allison Solomon, Psy.D., PC. and The Virtual Center for Anxiety & OCD. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA).  HIPAA is a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations.  HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that Dr. Solomon obtain your signature acknowledging that she has provided you with this information prior to the end of your session.

Although these documents are long and sometimes complex, it is very important that you read them carefully. We can discuss questions you have about the procedures at any time. When you sign the Psychological Services Consent Form, it will also represent an agreement between us. You may revoke your consent in writing at any time.  That revocation will be binding unless we have taken action in reliance on it or if you have not satisfied any financial obligations you have incurred.

PSYCHOLOGICAL SERVICES

Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychotherapist and patient, and the particular problems you are experiencing. There are many different methods Dr. Solomon may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things discussed both during therapy sessions and at home. Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. Psychotherapy has also shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience.  In addition, therapy may be experiential at times.  Therefore, you may be requested to participate physically.  Please notify Dr. Solomon of any physical limitations and know that you have the right to refuse. The first few sessions will involve an evaluation of your needs. By the end of the evaluation process, Dr. Solomon will be able to offer you some first impressions of what treatment will include and a treatment plan with recommendations to follow if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with Dr. Solomon. 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 our procedures, you should discuss them whenever they arise. If your doubts persist, you are encouraged to set up a meeting with another mental health professional for a second opinion.

Dr. Solomon does not provide any court evaluations, instead focusing her practice solely on the clinical treatment of patients. For any court-related matters, we can refer you to a forensic psychologist or specialist. Please be mindful that should Dr. Solomon be required to prepare and submit letters, records, or testimony for any court-related matters, her legal rate of $650 per hour will apply. Fees for services under 1 hour will be charged in 15 minute increments. As indicated on the patient-psychologist agreement and consent for treatment document, if certain circumstances arise during the course of treatment that require.

PATIENT RESPONSIBILITIES

Each patient is responsible for providing accurate contact information as well as billing information. If telephone numbers and/or addresses change, patients must inform Dr. Solomon's business office. Furthermore, the patient understands that the evaluation and treatment provided by Dr. Solomon is limited to outpatient psychology services. This does not necessarily constitute total or definitive psychological care. Further evaluation and treatment may be required in some cases. It is the patient's responsibility to obtain follow up medical care for general health as needed, or when advised to do so by Dr. Solomon.

MEETINGS/SCHEDULING

The initial evaluation period may last from 1 to 4 sessions. During this time, you and Dr. Solomon can decide if she is the best person to provide the services that you need in order to meet your treatment goals. A "therapy hour" is defined as a 45-50 minute session. 

Once an appointment is scheduled, you will be responsible to pay for that session unless you provide 24 hours' advance notice of cancellation (unless we both agree that you were unable to attend due to circumstances beyond your control). Please inform us if you do not want us to leave a message at any of the phone numbers you provided. We do not accept cancellation or change notices received via email. You must speak to Dr. Solomon or use the secure patient portal to make, change, or cancel appointments.

If you need to cancel or change an appointment, please use the secure patient portal. Please remember that you will be charged when you do not show for a scheduled appointment.

CONTACTING DR. SOLOMON

You may call and leave a confidential message with our office voicemail at any time. Dr. Solomon does not return calls on evenings, weekends, and holidays. During business hours, she is often not immediately available by telephone. Messages are checked several times a day and your call will be returned within 48 hours unless it is a weekend or holiday, in which case Dr. Solomon will return your call on the first business day thereafter.  If you are unable to reach Dr. Solomon and feel that you can't wait for her to return your call, contact your family physician or the nearest emergency room and ask for the psychologist [psychiatrist] on call. If your call has not been returned within a reasonable time period, please call again because it is likely that something went wrong and your message was not received. If you are requesting correspondence over phone that requires more than 10 minutes of Dr. Solomon's time, you may be informed that charges may apply before this service is provided.

EMERGENCIES

Dr. Solomon does not provide 24-hour or emergency therapy services. Although she will make every effort to be available to you if crises arise, you cannot depend on her to be available in emergency situations. If Dr. Solomon is out of town or unavailable for an extended period of time, she will provide you with contact information for a colleague so that you may have interim support, if necessary. If you anticipate needing more than very occasional crisis contact with Dr. Solomon outside of our sessions, please talk with her about this prior to beginning treatment. In the event that you have an urgent need and cannot reach Dr. Solomon, please go to the nearest emergency room or call 911. You may also call the National Crisis Hotline at 1-800-273-TALK or the Crisis Text Line by texting HOME to 741741 or by visiting www.crisistextline.org.

MINORS & PARENTS

For patients under 18 years of age, their parents must review and sign the Consent for the Provision of Psychological Services to a Minor form.  Consent from both parents, regardless of the custodial arrangement, is the preferred practice of this office. Dr. Solomon prefers to see parents and children together as much as possible, as she believes in taking a collaborative approach to therapy. As children enter the teenage years, Dr. Solomon tends to spend more time with them individually in therapy. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, Dr. Solomon strongly encourages teenage children to share treatment information directly with their parents. She will also provide you with general information about treatment status.  Dr. Solomon will not share specific details without his/her assent, however, if she believes that your child is at serious risk of harming him/herself or another, you will be informed.  Examples of serious risk would include a plan to harm self or suicidal ideation which is intensifying.

If you are in a divorce or custody litigation, or involved in the court system in any other manner, you need to understand that Dr. Solomon's role as a therapist is not to make recommendations for the court concerning custody or parenting issues or to testify in court concerning opinions on issues involved in the litigation.  By signing this disclosure statement, you agree not to call Dr. Solomon as a witness in any such litigation.  Experience has shown that testimony by therapists in domestic cases causes damage to the clinical relationship between a therapist and a patient.  Only court-appointed experts, investigators, or evaluators can make recommendations to the court on disputed issues concerning parental responsibilities and parenting plans. Dr. Solomon is happy to write letters to jurisdictions regarding a person's attendance in psychotherapy when requested by the patient.

BILLING AND PAYMENTS

Dr. Solomon is a fee-for-service provider. The office does not file insurance claims for you, however, we will provide you with all of the information that you should need to make a claim in the form of a "super bill" invoice. You may receive reimbursement from your insurance provider if you have "out of network" benefits. This has been successful for a number of patients. Of course, plans vary, particularly with regard to mental health coverage, and you will need to discuss reimbursement with your insurance provider if you would like to pursue this option. Payment is due at the time of your visit and then your insurance company may reimburse you directly after you submit your claim.  Also, if you plan on billing your insurance for reimbursement of your visit, you may need to obtain a prescription from your physician prior to your first appointment (depending on the type of insurance plan you have). If you do not plan on billing insurance, you do not need a prescription. You will be expected to pay for each session at the time it is held at the beginning of your session.  When therapy is provided over the telephone or video conferencing, you will be responsible for paying for these therapy services prior to the session. You may choose to have a credit card number kept on file for these appointments if this would be more convenient.

You should also be aware that most insurance companies require you to authorize us to provide them with a clinical diagnosis. Sometimes we have to 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 will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, we have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. We will provide you with a copy of any report we submit, if you request it.

CONFIDENTIALITY POLICIES

The law protects the privacy of all communications between a client and a psychologist.  In most situations, Dr. Solomon can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows:

Dr. Solomon is professionally and ethically required to consult with other psychologists regularly. Such consultations are bound by the same confidentiality as are individual sessions. Should she decide to consult about your case, she will omit identifying information from such consultations to protect your privacy. If you object to Dr. Solomon's consulting with colleagues about your situation, please inform her so that she can understand your concerns. Dr. Solomon will note all consultations in your file to further protect the privacy of your information.  If you use health insurance to pay for any portion of your treatment, Dr. Solomon may be required to release some treatment details to your insurance company.

There are some situations where Dr. Solomon is permitted or required to disclose information without either your consent or authorization:

Generally, if you are involved in a court proceeding, Dr. Solomon cannot disclose any information about you without your written consent or a court order. In the event that she is court ordered to disclose your information, Dr. Solomon is legally obligated to do so. If a government agency requests information for health oversight activities, Dr. Solomon may be required to comply.If a client files a complaint or lawsuit against her, Dr. Solomon may disclose relevant information regarding that client in order to respond to the complaint.If a client files a worker's compensation claim, Dr. Solomon may be required to comply with legal requests. This may include disclosure of your record to parties involved in the claim.

Certain Federal and State laws require that Dr. Solomon take action that she believes is necessary to attempt to protect others from harm. These situations include:

If Dr. Solomon has cause to suspect that you or someone you know is or may be abusing or neglecting a child, an elderly person, or an otherwise impaired or disabled person, she is required by law to report this to the proper authorities.If Dr. Solomon believes that you present an imminent danger to the health and safety of yourself or someone else, she may be required to disclose information in order to take protective actions, including initiating hospitalization, warning the potential victim, if identifiable, and/or calling the police.

If such a situation arises, Dr. Solomon will make every effort to fully discuss it with you before taking any action and will limit her disclosure to only what is necessary.

OFFICE POLICIES

Welcome! Please keep a copy of this sheet as a helpful reference. All payments are due on the date of service. Your credit card is required in order to schedule appointments. Your card may be charged the morning of the date of service. We accept all debit and credit cards. You will be provided with an invoice, which can be sent to your insurance company for possible reimbursement. We do not participate with any insurance plans or policies. If you or your child are being treated for Anxiety, OCD, Emetophobia, Trichotillomania, or Dermatillomania (skin-picking), please ask Dr. Solomon for instructions for petitioning your insurance for reimbursement) or find the "Fight for Your Rights" document on www.drallisonsolomon.org.

As with all medical practices, we have a 24-hour cancellation policy for all appointments. Each appointment is a designated time for your care. Proper cancellation notice allows our office to schedule other patients who are waiting to be seen as soon as possible. If you are unable to make your appointment, we respectfully request at least 24-hours' notice, otherwise you will be charged the full session fee. You will be responsible for keeping track of your own appointments in order to avoid the full appointment fee for those missed appointments which are cancelled or rescheduled less than 24 hours prior to the appointment. Please specify the best phone number to reach you on.

The initial consultation is an evaluation regarding diagnosis and treatment recommendations. Dr. Solomon reserves the right to determine if treatment should continue here or be referred out to clinical specialists who would better serve the diagnosis at hand. Dr. Solomon also reserves the right to terminate treatment of any patient who does not meet compliance with office policies, willfully disregards treatment recommendations, and protocols, or is disrespectful or threatening toward office staff.

Ongoing therapy session time is traditionally 45 minutes. Appointments may be booked for longer periods (60 minutes, 90 minutes, 120 minutes). If you are interested in more intensive treatment, you and Dr. Solomon can discuss a personalized program with extended session times as well as multiple sessions per week. At times, due to unforeseeable circumstances, Dr. Solomon may run late while in session with a prior appointment. Please understand that you will still receive your entire session time.

For minors, parent-only appointments may be scheduled at any time - either by Dr. Solomon's suggestion, or your own request. Phone sessions can be scheduled as well. There is no charge for brief, routine letters needed throughout your treatment. However, a more complex letter, such as those stating diagnoses, treatment recommendations, and school 504/IEP letters will be billed at Dr. Solomon's hourly rate in 15 minute increments. The same rate applies to any forms that need to be completed as well.

"Updates": Important events often happen between sessions. Please send "updates" prior to an appointment through the secure patient portal. By sending updates ahead of time, Dr. Solomon can make the best use of your session time. Email communication with Dr. Solomon should not be the primary means of communication. If you do not receive a response to email within 1-2 business days, please call the office, as this is the preferred method of contact for important messages.

Your signature below indicates that you have read and understand the information detailed in Dr. Solomon's Psychological Services Agreement, agree to abide by its terms, and consent to participate in treatment.