Prior to beginning treatment, it is important for you to understand Whole Life Wellness’s approach to psychotherapy with adolescents, and adults. It is also important that we agree to some rules about confidentiality during the course of treatment.

Psychotherapy Benefits and Risks

Psychotherapy can have benefits and risks. Since psychotherapy can involve discussing unpleasant aspects of your and/or your teenager’s life, you or your teen may experience uncomfortable feelings. Psychotherapy can, however, help to solve problems, improve symptoms and functioning, and reduce feelings of distress. But there are no guarantees or assurances of what you or your teenager will experience.

Confidentiality

With the exception of certain specific exceptions (described below), everything you and/or your teenager tell your therapist is confidential. This means that nothing will be revealed without your consent. If we need to talk with or write to your/or your teen’s school or with other professionals who work with you and/or your teen, we will ask you to sign a consent to release and exchange information.

Pertaining to work with your adolescent, it is possible that he/she will reveal sensitive information regarding sexual contact, alcohol and drug use, or other potentially problematic behaviors. Sometimes these behaviors are within the range of normal adolescent experimentation, but at other times they may require parental intervention. If we ever believe that your child is at serious risk of harming him/herself or another, we will inform you.

There are some exceptions to confidentiality. If you plan to pay for all or part of treatment with insurance, the insurance carrier has a right to know certain basic information, such as a diagnosis and the dates of your sessions. Some managed care companies require more information on an ongoing basis in order to conduct utilization review. Other exceptions to confidentiality are child abuse and neglect, dangerous behavior directed toward other people and potential suicide. Please see the Notice of Policies and Practices to Protect the

 Privacy of Your Health Information (provided to you) for more information about the exceptions to confidentiality.

HIPPA Communication Requirements

Due to HIPPA regulations and standards, it is vital that we make every effort to protect your health information, and with email and text this cannot be ensured. In moving forward email and text will be limited to scheduling updates and exchanging password-protected documentation. Session content will be communicated either face to face or over the phone during a scheduled conversation.

Psychotherapy Sessions

Each psychotherapy session lasts for 50-100 minutes, beginning on the hour and ending 10 minutes before the next hour. We make every effort to start and end sessions on time.

Fee and Payments

The fee is $200 per 50 min session. Off site sessions including school observations, IEP meetings, and in-home appointments can be provided. The fee for these sessions is $225 per hour. You are financially responsible for the bill. We require a credit card be kept on file so that you can be billed at each session. We do not participate in any managed care networks, or discounted “capitation” plans. You may wish to contact your insurance to clarify coverage for an “out of network provider”. You will be provided with invoices that include all information needed to file for insurance reimbursement and income tax purposes.

Phone Consultation Policy

Due to the often complex nature of both familial and social systems, we understand that some between session problem-solving will be indicated from time to time. In an effort to maintain high quality services offered both in and out of session we are now offering 15- minute phone-based appointments. These 15-minute sessions can be scheduled simply by calling or emailing Whole Life Wellness at: 312-519-3187 and [email protected] These phone sessions will be billed at a rate of $25 per appointment. When 15 minutes simply is not enough, a face-to-face session can be scheduled in an effort to meet your unique needs.

Outside Provider Consultation

At Whole Life Wellness, we are happy to collaborate with outside service providers given a signed release of information form has been obtained. Phone-based consultation will be billed at a rate of $25 per 15 minutes.

Legal Involvement

The therapist’s role with you and/or your teen is limited to providing treatment. In this role, we will not provide recommendations concerning custody or custody arrangements (e.g., visitation) and will not become involved in any legal dispute. If, for any reason, a therapist is required to appear as a witness, the party responsible for their participation agrees to reimburse them at the rate of $375 per hour for time spent traveling, preparing reports, testifying, being in attendance, and any other case-related costs.

Missed Sessions

If you need to cancel a session for a reason other than illness or emergency, we ask that you give at least 24 hours notice. If a session is missed or canceled without 24-hour notice, you are responsible for paying for the missed session.

Availability and Emergencies

We may not be immediately available by telephone. In the case of an emergency, always call 911 and/or proceed to your nearest emergency room. You are welcome to leave a voicemail and we will return your call as soon as we are able. If your therapist is unavailable for an extended period of time, we will have someone else cover; we will let you know who that person is and how you can reach them.

Professional Records

The laws and standards of our profession require that we keep treatment records. You and your child (if age 12 years or older) have the right to inspect and copy your records. Please see the Notice of Policies and Practices to Protect the Privacy of Your Health Information (provided to you) for more information about my professional records.

Termination

Both client and therapist have the right to terminate services at any point during treatment. Your signature below indicates that you have read this agreement and agree to its terms.