1) Confidentiality
All information that clients communicate to us is kept strictly confidential except in the following circumstances:
- The client or clients’ guardian signs a release of information stating that
the clinician can communicate with a particular person or entity
- A client presents as a danger to self or others
- There is evidence that there is or has been abuse or neglect of a child or
vulnerable adult
For the purpose of providing the highest quality of care, we may consult about clinical matters with other licensed mental health professionals, who are bound to keep the details confidential.
2) Evaluation and Methods of Treatment
At the beginning of treatment, we will conduct an evaluation and determine a mental health diagnosis or diagnoses, as indicated. We will then develop a treatment plan together with you that may include individual, family, couples, and/or group psychotherapy. We may discuss options for other mental health treatment or recommend additional treatments or services (EG, psychiatric, educational, medical).
3) Policy regarding missed appointments
Clients are responsible for paying for their scheduled time unless they cancel more than 24 hours in advance.
4) Policy regarding legal/custody disputes
We do not allow any records of treatment to be used in custody disputes, either during treatment or subsequent to treatment. We do not testify in Court, provide depositions, or otherwise provide legal testimony regarding custody matters.
5) Charges for professional services
In certain circumstances we charge for professional services (such as phone
consultations, meetings, or report-writing) ancillary to in-person therapy.
6) Payment Policies
Payment is due at the time of service. We accept payment by check, cash,
bank/debit cards, and credit cards. We charge a small processing fee for credit
cards, and we charge a fee for returned checks. When applicable, we provide a
monthly invoice that may be used to obtain reimbursement. In the limited cases that we may bill insurances or other entities directly, we may need to provide clinical information.
7) Emergency Availability
While clinicians may communicate with clients outside of sessions in various forms (EG, email, phone), such communication does not imply that the clinician is available to respond promptly/adequately in emergency situations. Clients who are experiencing a mental health emergency and/or are in need of immediate assistance should call 911, go to the nearest emergency room, or contact an appropriate Crisis Center (Montgomery County Crisis Center phone number: 240‐777‐4000).
Informed Consent for Psychotherapy
I have read and discussed the information provided by Jonah Green and Associates, LLC covering the various aspects of therapy for my child, my family, or myself. These include the methods of evaluation and treatment, and alternatives to treatment. I have also discussed scheduling, fee policies regarding missed appointments, and matters related to insurance.
I have also read the information provided on confidentiality and have had any questions answered. I understand that there are limits to confidentiality in this relationship.
Notice of Privacy Practices
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal program that requires that medical records and other individually identifiable health information are kept properly confidential. It gives health providers permission to use and disclose your medical information only for the purposes of treatment, payment, and healthcare operations. You have the right to request restrictions on certain uses and disclosures of protected health information. You also have the right to receive confidential communications of your health information, to inspect and copy your health information, to amend your health information, to receive an accounting of disclosures of health information, and to obtain a paper copy of this notice upon request.
You have the right to file a complaint with the U.S. Department of Health and Human Services if you feel your rights have been violated. The contact information is: The US Department of Health and Human Services, Office of Civil Rights, 200 Independence Avenue, S.W., Washington, DC 20201. Phone numbers: (202) 619-0257 or 1-877-696-6775.
I have read and understand both the Informed Consent and the Notice of Privacy Practices.