Policies and Forms

Please take a moment to review the following policies and forms before your initial session. These do not need to be printed, as we will go over them together during your first appointment.

Forms

Please complete the required intake forms below before your first appointment. You may email the completed forms using our secure, HIPAA-compliant email system, or mail them to our office. If you haven’t received the forms by email, please call 646-369-2110 and I’ll be happy to send them to you. Completing the forms typically takes about 20 minutes.

Legal Involvement Disclosure

If you are currently involved in any legal matters, such as custody disputes, domestic violence cases, or visitation conflicts, please disclose this before starting therapy. This practice does not participate in legal proceedings and does not offer court testimony. If litigation is anticipated, I will refer you to another therapist who can provide this support.

Email and Text Communication Policy

Some clients prefer to communicate via email or text. Please note:

These methods are not secure and may pose privacy risks.
There is a possibility that emails or texts could be intercepted or misdirected.
Any communication via email or text may become part of your clinical record, at the discretion of the provider.
Do not use email or text for urgent or emergency matters. Please call 911 or go to your nearest emergency room.

Good Faith Estimate

Under federal law, you have the right to receive a Good Faith Estimate of the expected cost of your mental health care if you are uninsured or choose not to use insurance. Upon request, we are happy to offer an estimate before your first appointment.

The current fee for a 45-minute psychotherapy session is $200, payable at the time of service.
The length and frequency of therapy will vary based on your needs, concerns, and treatment goals. Typically, therapy can last from a few months to several years, depending on your individual situation.

Notice of Privacy Policy

To protect the privacy of your health information, this notice describes how psychotherapy and medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.

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

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

PHI refers to information in your health record that could identify you.
Treatment refers to the provision, coordination or management of your health care and other services related to your health care. For example, a consultation with another health care provider, such as your family physician or another psychologist/social worker.
Payment is reimbursement I obtain for my services related to your healthcare. An example of payment is my disclosure of your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
Health Care Operations are activities related to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
Use applies only to activities within my office or practice, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
Disclosure applies to activities outside of my office or practice, such as releasing, transferring, or providing access to information about you to other parties. II. Uses and Disclosures Requiring Authorization I may use or disclose PHI for purposes outside of treatment, payment, and healthcare operations when your appropriate authorization is obtained.
Authorization is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment, and healthcare operations, I will obtain authorization from you before releasing this information. I will also 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 that 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.

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 I have reasonable cause to believe that a child has been subject to abuse, I must report this immediately to the New Jersey Division of Youth and Family Services.
Adult and Domestic Abuse - If I reasonably believe that a vulnerable adult is subject of abuse, neglect, or exploitation, I may report the information to the county adult protective services provider.
Health Oversight - If the New Jersey State Board of Social Work Examiners issues a subpoena, I may be compelled to testify before the Board and produce your relevant records and papers.
Judicial or administrative proceedings - If you are involved in a court proceeding and a request is made for information about the professional services that I have provided you and/or the records thereof, such information is privileged under state law, and I must not release this information without written authorization from you or your legally appointed representative, or a court order.

This privilege does not apply when you are being evaluated by a third party or where the evaluation is court-ordered. I will inform you in advance if this is the case.
Serious Threat to Health or Safety - If you communicate to me a threat of imminent serious physical violence against a readily identifiable victim or yourself or the public and I believe you intend to carry out that treat, I must take steps to warn and protect. I also must take such steps if I believe you intend to carry out such violence, even if you have not made a specific verbal threat. The steps I take to warn and protect may include arranging for you to be admitted to a psychiatric unit of a hospital or other health care facility, advising the police of your threat and the identity of the intended victim, warning the intended victim or his or her parents if the intended victim is under 18, ad warning your parents if you are under 18.
Worker’s Compensation - If you file a worker’s compensation claim, I may be required to release relevant information from your mental health records to a participant in the worker’s compensation case, a reinsurer, the health care provider, medical and non-medical experts in connection with the case, the Division of Worker’s Compensation, or the Compensation Rating and Inspection Bureau.

Patient’s Rights and Social Worker’s Duties

Patient’s Rights

Right 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 the 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 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 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 circumstances, but in some cases, you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process.
Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. At your request, I will discuss with you the details of the amendment process.
Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization At your request, I will discuss with you the details of the accounting 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.

Social Worker’s 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 present you with a revised notice.

Questions and Complaints

If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, you may discuss it with me. If you believe that your privacy rights have been violated and wish to file a complaint, you may send your written complaint to me. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.

Effective Date, Restrictions, and Changes to Privacy Policy

This notice will go into effect on February 2, 2022. I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. I will provide you with a revised notice at that time.

Form 1

Authorization for Release or Exchange of Confidential Information

I hereby authorize the following provider to release or exchange confidential information pertaining to my Bio-psycho-social, social work, medical, psychological, and/or psychiatric history. This information is being requested for the purpose of completing patient assessment and treatment.

Provider Name: _______________________________

Address:_____________________________________

____________________________________________

City: ____________________

State: ___________________

Zip: _____________________

Phone: ___________________

I understand that I may revoke this consent at any time by informing the above parties in writing. However, my revocation will not be effective to the extent that action has been taken in reliance on the authorization. I understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient of your information and no longer protected by the HIPPA Privacy Rule.

Name of Patient Signature of Patient Date

________________________________/____________

Signature of Parent/Guardian Date

_______________________________/_____________

Witness Signature Date

_______________________________/______________

Form 2

Tele-Mental Health Informed Consent

I, _____________________________________, hereby consent to participate in tele-mental health with, _____________________________________________, as part of my psychotherapy. I understand that tele-mental health is the practice of delivering clinical health care services via technology-assisted media or other electronic means between a practitioner and a client who are located in two different locations.

I understand the following with respect to tele-mental health:

1) I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.

2) I understand that there are risks, benefits, and consequences associated with tele-mental health, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.

3) I understand that there will be no recording of any online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.

4) I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to tele-mental health unless an exception to confidentiality applies (i.e., mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).

5) I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that tele-mental health services are not appropriate, and a higher level of care is required.

6) I understand that during a tele-mental health session, we could encounter technical difficulties resulting in service interruptions. If this occurs, we will end and restart the session. If we are unable to reconnect within ten minutes, I will call my therapist at 646.369.2110 to discuss, as we may need to re-schedule.

7) I understand that my therapist may need to contact my emergency contact and/or appropriate authorities in case of an emergency.

Emergency Protocols

As your therapist, I need to know your location in case of an emergency. You agree to inform me of your location address at the beginning of each session. I also need a contact person who I may contact on your behalf in a life-threatening emergency only. This person will only be contacted in the event of an emergency, to go to your location or take you to the hospital.

In case of an emergency, my location is: ______________________________________________

and my emergency contact person’s name, address, phone:

______________________________________________

I have read the information provided above and discussed it with my therapist. I understand the information contained in this form and all of my questions have been answered to my satisfaction.

Signature of client/parent/legal guardian Date

________________________________/_______________

Signature of therapist Date

________________________________/_______________

Please contact me with any questions that you may have. I look forward to hearing from you!

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