Welcome to my Practice!

This document will provide you important details about the services I offer. Please read through it carefully and make notes of any questions you have so that we can further discuss them when we meet. I appreciate your efforts to read through this information in its entirety.

Psychotherapy Services

I provide psychotherapy services to children from ages 3-18, women, and families. The services I offer include individual and family therapy, parent consultation, and some case management. In order to provide comprehensive services I often collaborate with a variety of other health and educational professionals.

My therapeutic approach primarily stems from cognitive-behavioral therapy (CBT), which emphasizes how thoughts, feelings, and behaviors influence each other. In addition to CBT, I use a variety of other approaches including play therapy, art therapy, strengths based and solution-focused approaches. With your engagement and effort, we hope to achieve the positive changes you would like to work toward. CBT and other therapies have the best outcomes with consistent participation and continued work outside of the therapy office. From time to time, I may prescribe “homework” although not required it is highly recommended.

When working with children and families, there are times when you may want to include other people join a session. It is important that we discuss those individuals ahead of time before scheduling them to participate in a session. Inclusion of any additional parties must be approve by all parents/guardians with legal custody of a minor client.

Intake Process

Effective psychotherapy requires a good fit between client and therapist. During the intake process, which can typically last between 1 – 4 sessions, I will answer any questions you have about my practice, gather background information about you and/or your family, and discuss concerns and goals. The intake phase will help us determine whether or not I am a good match for your needs. If we decide that this is not a good match, I will refer you to another therapist who can better meet your needs.

Professional Fees

My fee is $120 for a 60-minute session and extended family sessions will range from $145 (75 minutes) to $165 (90 minutes). I will as needed and only with your written consent provide consultation or recommendations to schools. This will be charged at a rate of $50 per hour.

Billing and Payment

Payment is due at the time of services and may be paid using a major credit card, cash, or check (made out to Women and Children’s Renewal Center, LLC). Credit Card payments are made through a secure client portal. Many clients prefer that I keep their credit card on file so that I can automatically bill for services at the time they are received.

You must cancel appointments at least 24 hours in advance to avoid being charged for the session. The late cancelation charge may be waived if we are able to reschedule your missed session for another time within the same week, but I cannot guarantee my availability. You will not be charged for late cancellations related to personal emergencies, unexpected illness, or inclement weather.

If a check of yours is returned by the bank for insufficient funds, you will be responsible for reimbursing any bank fees charge to my account for your returned check. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of hiring a collection agency or an attorney to secure the payment. If such legal action should become necessary, its cost would be included in the claim. In addition, this process would require me to disclose otherwise confidential information. In most collection situations, the only information I release is the client’s name the nature of services provided, and the amount due.

Insurance

I am considered an out-of-network provider for insurance purposes. If you would like to submit to your insurance company, I will provide you with a “superbill” containing all of the required information to submit for reimbursement. You can submit this bill to your insurance company and receive directly any reimbursements for which you might qualify. However, a superbill is not a guarantee of reimbursement. By signing this agreement, you are indicating that (1) you agree to pay for all services at the time they are rendered, (2) you understand that you may or may not be eligible to receive insurance reimbursement, (3) I have no knowledge regarding your reimbursement eligibility, and (4) any attempt to seek reimbursement is solely your responsibility.

Please be aware that if you choose to provide this superbill receipt for services to your insurance company, it must include a psychiatric diagnosis. In that event, I will inform you about the diagnosis that I plan to render before it is given. Any diagnosis that is made will become part of your permanent insurance records. Note that even if you do not pursue reimbursement through your insurance company, a superbill may be useful for tax purposes or for utilizing funds set aside in an employer-based health savings account.

You should be also aware that your contract with your health insurance company requires that I provide them with information relevant to the services that I provide to you if you submit claims. Maryland permits me to send some information without your consent in order to file appropriate claims. I am required to provide them with a clinical diagnosis and treatment information typically limited to the Uniform Treatment Plan. I will provide you with a copy of any report I am required to submit, if you request it. By signing this agreement, you agree that I can provide requested information to your insurance carrier.

HIPPA

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that mandates privacy requirements and client rights pertaining to the use and disclosure of your Protected Health Information (PHI) in connection with treatment, payment and health care operations. HIPAA requires me to provide you with a Notice of Privacy Practices (the Notice), which is attached to this agreement and explains HIPAA and its application to your personal health information in detail. The law requires that at the end of the first session I obtain your signature acknowledging that I have provided you with this information. Although these documents are long and sometimes complex, they contain important information about your rights and I ask that you review them carefully. We can discuss any questions you have about the procedures. When you sign this document, it will represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have taken action in reliance on it; or unless there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; or unless you have not satisfied any financial obligations you have incurred.

CLIENT RIGHTS INCLUDING CONFIDENTIALITY

At any time you may ask questions about the process and the course of therapy and/or refuse therapeutic or diagnostic procedures or methods. I expect that questions about the methods, effectiveness, and duration of therapy will be raised by both of us at regular intervals during the course of treatment in order to evaluate progress, make adjustments, and decide when to end your therapy. You are encouraged to discuss these topics and are reminded that you may end treatment at any time. You may also seek a second opinion if you wish to do so.

I treat the information you share with me with the greatest respect. The confidentiality of our conversations and my records are protected by standards for professional practice established in the NASW Code of Ethics.

In most situations, I can only release information about your treatment to others if you sign a written Authorization form. However, there are some circumstances in which no authorization is required. Federal Law (HIPAA) specifies these circumstances. As you will see below, the Federal requirements are aimed at protecting the rights of clients and clinical social workers, and in some cases, the community at large. Most of them reflect the legal and ethical responsibility of a clinical social worker to take action to protect endangered individuals from harm when such a danger exists. Fortunately, such situations are rare. If a crisis of this sort should occur, it is my policy to discuss these matters fully with you before taking any action, unless in my professional judgment there are compelling reasons not to do so. Confidentiality will be respected in all cases, except as noted below:

• I may occasionally find it helpful to consult other health and mental health professionals. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep the information confidential. Unless you object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all formal consultations in your Clinical Record.
• If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected. I cannot provide any information without your written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information.
• If a government agency is requesting the information for health oversight activities, I may be required to provide it for them.
• If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself.
• If health insurers require disclosures or it is necessary to collect overdue fees, I may disclose relevant information as specified elsewhere in this Agreement.

There are some situations in which I am legally obligated to take actions that I believe are necessary to attempt to protect others from harm. In such situations, it may be necessary to reveal some information about a client’s treatment. Again, these situations are unusual in my practice.

• If I have reason to believe that a child or vulnerable adult has been subjected to abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, the law requires that I file a report with the appropriate government agency, usually the local office of the Department of Social Services. Once a report is filed, I may be required to provide additional information.

• If I know that a client has a propensity for violence and the client indicates that s/he has the intention to inflict imminent physical injury upon a specified victim(s), I may be required to take protective actions. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate the possibility that the client will carry out the threat such as seeking hospitalization of the client and/or informing the potential victim or the police about the threat.

• If I believe that there is an imminent risk that a client will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the client’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalization and/or notifying family members or others who can protect the client.

If such a situation arises, I will make every effort to discuss it with you before taking any action and I will limit my disclosure to what is necessary. With the exception of situations in which I am legally required to breach confidentiality, you agree that I may use my professional judgment to determine what is and what is not shared with parents of child/minor clients. This allows minors (particularly adolescents) to participate in therapy without feeling at risk of having their personal information shared with parents. This creates a private, therapeutic environment, and offers a respectful attitude toward my minor clients. I welcome any questions or concerns about this aspect of my practice.

While this written summary of exceptions to confidentiality should help to inform you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex; in situations where specific advice is required, formal legal advice may be needed

PROFESSIONAL RECORDS

You should be aware that, pursuant to HIPAA, I may keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your treatment issues impact your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances in which disclosure is reasonably likely to endanger the life or physical safety of you or another person, you may examine and/or receive a copy of your Clinical Record if you request it in writing. However, because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so that you can discuss the contents with that professional. In most circumstances, I am allowed to charge a copying fee (and certain other expenses). If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request. In addition, I may keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary, they may include sensitive information that is not required to be included in your Clinical Record, such as the content of our conversations, the analysis of those conversations, and how they impact your therapy. These Psychotherapy Notes are kept separate from your Clinical Record. While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes without your signed, written Authorization. Insurance companies cannot require your Authorization as a condition of coverage nor penalize you in any way for your refusal. Clients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. While privacy in psychotherapy is very important, particularly with teenagers, parental involvement is often essential to successful treatment. You agree that I may use my professional judgment to determine what is and what is not shared with parents of child/minor clients. I will provide parents with a summary of their child’s treatment if requested. If I feel that the child is in danger or is a danger to someone else, I will notify the parents of my concerns. Before giving parents any information, I will attempt to discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.

COMMUNICATION AND EMERGENCIES
I can be reached by phone at 240-200-5757 or by e-mail suzannedellorfano@gmail.com. When using email, the privacy of e-mails to that address cannot be guaranteed.

• E-mail can be used to discuss scheduling, to give brief reports about your progress, or to ask simple questions that can be answered concisely. However, I am unable to provide any form of treatment or therapeutic advice via e-mail.
• Phone calls are answered by voicemail if I am not available. Please leave a message and I will call you back at my earliest convenience, typically within 24 hours.
• If you are having an urgent crisis and need immediate assistance, please call 911 or go to your nearest emergency room.

CONSENT TO TREAT
I consent to my/my child’s participation in psychotherapy services with Suzanne Dell’Orfano, MSW, LICSW and I agree to the policies of her practice as detailed in the above paragraphs. I understand that services will be rendered in a professional manner, consistent with accepted ethical standards. I am aware that if psychotherapy services are not rendered in a professional and ethical manner, I may file a complaint with the Maryland State Board of Examiners of Social Workers.

I have read this agreement and agree to its terms and I have been provided a copy of this agreement and the Notice of Policies and Practices to Protect the Privacy of Your Health Information. The contents of these documents have been satisfactorily explained to me, and I have had the opportunity to ask questions and clarify my understanding of these policies.

Whenever possible, I prefer to have both parents’ signatures in the case of minor clients.
Both parents must sign their consent to treatment of a minor if parents are in the process of separating, or are separated/divorced and have joint legal custody.

Uses and Disclosures for Treatment, Payment, and Health Care Operations:

I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

“PHI” refers to information in your health record that could identify you.

“Treatment, Payment, and Health Care Operations”

· Treatment is when I provide, coordinate, or manage your health care and other services related to your health care.

· Payment is when I obtain reimbursement for your healthcare. An example is when I disclose your PHI to your health care insurer for reimbursement or determine your eligibility for coverage.

· Health Care Operations are activities that relate to the performance and operation of my practice. Examples include, case management, care coordination, quality assessment, and business activities.



II. Uses and Disclosures Requiring your Consent:

I may use or disclose PHI for purposes of outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances, I will obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.


III.Uses and Disclosures with Neither Consent nor Authorization

I may use or disclose PHI without your consent or authorization in the following circumstances:

· Child Abuse: If there is a child abuse investigation, I may be compelled to turn over your relevant records.

· Adult and Domestic Abuse: If there is an elder abuse or domestic violence investigation, I may be compelled to turn over your relevant records.

· Health Oversight: The Maryland Social Work Board of Examiners may subpoena relevant records from me should I be the subject of a complaint

· Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your evaluation, diagnosis, and treatment and the records thereof, such information is privileged under state law, and I must nor release your information without written authorization by you or your personal or legally appointed representative, or a court order. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

· Serious Threat to Health Or Safety: I may disclose confidential information when I judge that disclosure is necessary to protect against a clear and substantial risk of imminent serious harm being inflicted by you on yourself or another person. I must limit the disclosure of the otherwise confidential information to only those persons and only that content which would be consistent with the standards of the profession in addressing such problems.

· Workers Compensation: If you file a worker’s compensation claim, this constitutes authorization for me to release your relevant mental health records to involved parties and officials. This would include a past history of complaints or treatment of a condition similar to the complaint.

IV. Patient’s Rights and Psychotherapist/Clinical Social Worker’s Duties:

Patients Rights:

· Rights to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request.

· Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your written request, I will send your bills to another address)

· Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstance, but in some cases, you may have this decision reviewed. On your request, I will discuss with you the details of the request and the denial process.

· Right to a Paper Copy – You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.

Psychotherapist Duties:

· I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.

· I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect

· If I revise my policies and procedures, I will notify you by written document which will be mailed to you at the address designated as your billing address.

V. Complaints

· If you are concerned that I have violated your privacy rights, or you disagree with the decision I made about access to your records, you may contact the Maryland Social Work Board of Examiners for further information.

· You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services.

This notice will go into effect on April 10, 2003.