By Repose LLC and By Repose Psychotherapy (owned and operated by Mary Breen LCSW PLLC) Practice Policies & Treatment Agreement for Therapeutic Services
The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for therapist and client to reach a clear understanding about how their relationship will work, and what each of you can expect. This consent will provide a clear framework for your work with your therapist. Feel free to discuss any of this with your therapist. By clicking on the checkbox, you are agreeing that you have reviewed this information and agree to the items contained in this document.
THE THERAPEUTIC PROCESS
You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. Your therapist cannot promise that your behavior or circumstance will change. They can promise to support you and do their very best to understand you and your repeating patterns, as well as to help you clarify what it is that you want for yourself.
The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:
If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.
If a client threatens grave bodily harm or death to another person.
If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
Suspected neglect of the parties named in items #3 and # 4.
If a court of law issues a legitimate subpoena for information stated on the subpoena.
If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.
The laws and standards of our profession require that your therapist keep Protected Health Information (PHI) about you in your clinical record. Your clinical record may contain information such as a diagnosis, intake information, consent to treatment, treatment plan, phone and electronic contact, and treatment notes. Treatment notes are brief summaries of our individual sessions outlining important issues, facts, or any treatment recommendations discussed. Except in unusual circumstances that involve danger to yourself and/or others or where information has been supplied to your therapist confidentially by others, you may request in writing to examine and/or receive a copy of your clinical record. These are professional records that can be misinterpreted and/or upsetting to untrained readers. For this reason, it is strongly recommended that you review them in your therapist's presence or upon your written consent, have them sent to another mental health professional to review with you.
Occasionally your therapist may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.
ENCOUNTERS OUTSIDE OF THERAPY
If you see each other accidentally outside of the therapy office, your therapist will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance, and your therapist does not wish to jeopardize your privacy. If you choose to acknowledge your therapist first, they will be more than happy to speak briefly with you; however, your therapist feels it is most appropriate to not engage in any lengthy discussions in public or outside of the therapy office.
MARY BREEN LCSW, PLLC does not provide crisis response services. If you are experiencing a psychiatric emergency, call 911 or use this free and confidential crisis resource.
CANCELLATION POLICY (Individual Therapy Sessions and Group Therapy Workshops)
Consistency is an essential part of the therapeutic process. When you make an appointment, this time is reserved specifically for you and is not available to other clients. If you are unable to keep a scheduled appointment, a minimum of 48 hour advance notice from the start of your scheduled appointment time is mandatory. If you do not provide 48 hour advance notice, you will be required to pay the full amount of the session you are missing. Late cancellations and no-shows impact your therapist's schedule and their ability to help other clients who would have benefited from that session time. Out of respect both your time, the therapist's time and valuing the services provided, the cancellation policy is strictly enforced. For this reason, you are required to keep a credit card on file. In the event that you do not provide 48 hours advance notice before canceling or no showing, your card will be charged for the full amount of the missed session. Please be advised that most insurance companies do not reimburse for missed sessions.
When 48 hours advance notice has been given and if your therapist’s or instructor’s schedule permits, you may be offered a make-up session prior to your next regularly scheduled appointment. If a pattern emerges of you being frequently unable to keep weekly appointments, your therapist or instructor will evaluate whether you are able to commit at this time and reserve the option of suspending or discontinuing treatment with you.
In the rare occurrence that an emergency situation forces your therapist or instructor to cancel your scheduled appointment, they will make every effort to provide you with as much advance notice as possible. Schedule permitting, they will reschedule your session.
All experiential sessions are scheduled in advance by appointment. They are generally 60 minutes long and typically occur on a weekly basis at an agreed upon time. Some sessions may be longer or more frequent depending on your needs. Requests to change the session length must be discussed in advance with your therapist in order for the time to be scheduled. Sessions typically begin and end on time for the purpose of establishing healthy therapeutic boundaries and to accommodate other clients who have scheduled appointments before or after you. If you are late for a session, you will lose some of that session time. In the event that you are out of town, sick or need additional support, phone or video chat sessions are available.
Cancellations and re-scheduled sessions must be received a minimum of 48 hours in advance of your session start time. This is necessary because a time commitment has been made to you and the session time is held exclusively for you. You will be responsible for the entire session fee if your cancellation or reschedule request is less than 48 hours from your appointment start time. Note that most insurance companies do not reimburse for missed sessions. Client requests related to scheduling, rescheduling, and cancellations will be overseen by the client coordinator and your therapist.
FEES & BILLING
The current fee-for-service for experiential sessions ranges from $100-$700 depending on the instructor you are working with, session and package type, and services requested. Full payment of the agreed upon fee-for-service during the time of your consultation or copayment is expected at the beginning of each scheduled appointment or in advance if you are purchasing a session package. By Repose Psychotherapy and By Repose LLC accepts payment by credit card only and credit cards are kept securely on file and auto-charged for all services, late cancellations, and unpaid balances. Note that a $15.00 service charge will be charged for any disputed fees that were found to be legitimately charged. By Repose Psychotherapy and By Repose LLC fees are reevaluated annually and generally increases by a nominal amount. The studio will provide you with advance notice of any increases in fees. In addition to weekly appointments, the practice charges $250 per hour for any other professional services you may need, though will prorate the hourly cost by quarter-hours if work is for periods of less than one hour. Other services include the writing of reports, letters and affidavits, telephone conferences and other calls made on your behalf, consultations with other professionals with your permission, preparation of treatment records or summaries, and the time spent performing any other service you may request of the practice.
If you become involved in legal proceedings that require the practice’s participation, you will be expected to pay in advance for all professional time, including preparation, transportation costs and travel time, as well as the cost of any legal representation the practice may incur, even if your therapist or the practice owner is called to testify by another party. Due to the complexity of legal involvement, the current fee is $400 per hour for preparation and attendance at any legal proceeding.
If your account has not been paid for more than 30 days and arrangements for payment have not been agreed upon, the practice has the option of suspending or discontinuing treatment with you and using legal means to secure payment. This may involve employing the services of a collection agency or utilizing small claims court which will require disclosure of otherwise confidential information. In most collection situations, the only information released regarding a patient's treatment is her/his/their name, the nature of the services provided, and the amount due, including any costs incurred in the process. By signing this document, you agree to bear all financial responsibility for all attorney and court costs associated with collecting an unpaid debt.
If you have a charge from us on your card that you don’t understand, please let us know immediately by contacting us at email@example.com and we will review the charge to ensure it is legitimate and respond to you accordingly. When you have questions about a charge from us on your card, we strongly recommend that you do not formally dispute the charge through your credit card company without first bringing it to our billing team’s attention with your inquiry. Once you dispute the charge through your card issuer bank, your confidentiality is compromised and your patient privacy rights are forfeited since Repose will provide all evidence necessary to demonstrate the charge was legitimate and accurate. This may include your signed cancellation policy contract and other signed practice agreements, secure message exchanges, emails, voicemails, any relevant psychotherapy notes completed by your therapist, or other therapists interactions with any of our team members. Additionally, we will pause treatment until this is resolved. We reserve the right to discontinue providing services due to violating practice policy by failing to pay for services rendered nor abiding by our treatment agreement guidelines. In summary, when you have a billing question or concern, it is best to come to us first. We will do our very best to explain all charges and if the error is on our end, we will fix it as soon as possible. Our billing office is available to help you Monday through Friday 9-5pm and may be reached at firstname.lastname@example.org.
By checking the box and submitting this form, you are agreeing to pay for each scheduled therapy session for your co-payment amount or the fee established with By Repose Psychotherapy and By Repose LLC.. You understand that you are financially responsible for paying for all scheduled sessions and you are aware that insurance often does not provide reimbursement for missed appointments. You agree to provide updated credit card information to be kept on file to cover the cost of scheduled sessions that you did not show up for or that you did not cancel with at least 48 hours advance notice. you accept that any missed appointments or late cancellations will result in your credit card being charged the regular fee amount for individual psychotherapy as outlined in the Treatment Agreement Terms and Conditions. Clients who have unpaid balances of more than one session or have their credit card on file expire will be subject to paused services until updated card information is provided and the balance is paid in full.
By Repose Psychotherapy (owned and operated by Mary Breen LCSW PLLC) is a preferred provider with Wellfleet (formerly known as Consolidated Health Plans) insurance serving the New York University, Sarah Lawrence College, and School of Visual Arts student bodies. We are also in-network with Aetna Student Health serving Columbia University, FIT, and Pratt Institute students. Clients are responsible for paying the co-pays associated with this insurance plan at the beginning of each session paid by credit card. Per the cancellation policy and in the event that you do not provide 48 hours advance notice before canceling or no-showing to an appointment, your credit card on file will be charged the full amount of the session reimbursement amount. As previously stated in this document, most insurance companies do not reimburse for missed sessions. By signing this document, you are agreeing to full payment of any canceled or missed sessions without at least 48 hours advance notice of your appointment start time. Additionally, you are responsible for the full payment if your insurance provider denies any claim submissions.
The practice is out-of-network for all other insurances and we can provide you with the necessary statements to receive reimbursement through your out-of-network benefits. Most insurance plans offer out-of-network benefits for mental health treatment, but it is necessary that you contact your insurance company to determine exactly what coverage you are entitled to through your specific insurance policy including information about your deductible. Be advised that you (not your insurance company) are directly responsible for the full amount of all fees associated with our services at the beginning of each session and you will later be reimbursed by the insurance company for any covered expenses. Additionally, you are responsible for the full payment if your insurance provider denies any claim submissions. By signing this document, you are acknowledging that you are responsible for the full payment of your agreed upon fee-for-service.
If you wish to receive reimbursement for psychotherapy services through your insurance company, the practice is required to provide information relevant to the services provided to you. The practice will make every effort to only release the minimum information about you that is necessary for the purposes requested. Please be aware that although insurance companies claim to keep your protected health information (PHI) confidential, the practice does not have control over how they will store or use your information. By checking the box and submitting this form, you are acknowledging a release of information that allows us to provide the required information to your insurance carrier.
CONTACT BETWEEN SESSIONS
To reach your therapist between sessions for any non-clinical issue (scheduling, billing, etc.), please contact the client coordinator or client concierge by emailing: email@example.com or by calling (212) 920-1976. If you need to reach your therapist for any clinical reasons, it is important for you to utilize the HIPAA compliant secure messaging through Simple Practice which is accessible via your secure client portal. Your therapist checks these messages every 24-48 hours with the exception of weekends, holidays, and scheduled time off. Unless your therapist determines that it is essential to respond, your message will be addressed during your next session together. In the instance your therapist will be unavailable for an extended period of time, they will provide you with a referral to another clinician within the practice in advance. Please be aware that By Repose Psychotherapy and By Repose LLC does not provide emergency services within this practice. In the event of a life or limb-threatening emergency, always call 911 or go to the nearest emergency room.
To make, reschedule, or cancel appointments, you may call the office at +1 (212) 920-1976 and leave a voicemail for the client coordinator who oversees all non-clinical client interactions. If you feel that it is necessary to contact your therapist between sessions regarding a clinical issue, you may send a message via the secure client portal. Your therapist will likely not be immediately available; however, they will attempt to check messages within 1-2 business days with the exception of weekends, holidays, and scheduled vacations. Unless they determine that it is essential to return your call, clinical issues will be addressed during your next session together. When your therapist will be unavailable for an extended period of time such as during a scheduled vacation, they will offer you contact information for another therapist within the practice who you may call if necessary. By Repose Psychotherapy and By Repose LLC (“Repose Studio”) does not provide emergency services within this practice. If a true emergency situation arises, call 911 or go immediately to the nearest emergency room.
Confidentiality cannot be ensured in any form of communication through electronic media, including text messages. If you prefer to communicate via email to: firstname.lastname@example.org for issues regarding scheduling or cancellations, this is acceptable and will be responded to by the client coordinator during weekday business hours.(Monday to Friday 9am-5pm EST) They will attempt to return messages in a timely manner, but immediate response is unlikely. For your own protection and security, do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies. As previously stated in this document, if you need to reach your therapist for any clinical reasons, please utilize safe and secure messaging through Simple Practice which is accessible via your secure client portal. Your therapist will check these messages every 24-48 hours with the exception of weekends, holidays, and scheduled time off. Unless they determine that it is essential to respond, your message will be addressed during your next session together. In the instance that your therapist will be unavailable for an extended period of time, they will provide you with a referral for another therapist within the practice in advance. By Repose Psychotherapy and By Repose LLC (“The Studio”) does not provide emergency services within this practice. If a true emergency situation arises, call 911 or go immediately to the nearest emergency room.
As a multidisciplinary practice, Repose is affiliated with both a wellness studio and clinical psychotherapy practice. From time to time, we send our clients email updates that may include helpful tips to support your mental health, new group and studio offerings, and practice updates. By checking the box, you acknowledging this and consenting to receive these optional emails with the email address you have provided us to keep on file. You may revoke your consent to opt into Repose emails at any time. With the exception of these practice emails being sent to you directly, under no circumstances will your protected health information (PHI) be used outside of your treatment at Repose nor disclosed without your explicit permission.
SOCIAL MEDIA POLICY
This office has an online social media presence for the purpose of sharing relevant information. There is no expectation that clients will follow us or read any blog/article that we may publish. If we happen to notice that you are following us, your therapist may bring it up during a session to discuss any impact that it may have on the therapeutic relationship. Due to the importance of your confidentiality and the importance of minimizing dual relationships, we do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, Instagram, etc). We believe that adding clients as friends or contacts on these sites can compromise your confidentiality and your respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when meeting with your therapist. If there is content you wish to share with your therapist from your online presence, you can explore it together during your session. Please note that Repose does not respond to direct messages via social media platforms. If you need to reach your therapist between sessions for any reason, please do so according to the procedure previously outlined in this document.
Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine by the State of California. Under the California Telemedicine Act of 1996, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist chose to use information technology for some or all of your treatment, you need to understand that: (1) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. (2) All existing confidentiality protections are equally applicable. (3) Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee. (4) Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent. (5) There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs. Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he/she/they would consider important information, that you may not recognize as significant to present verbally to the therapist.
TELEHEALTH EMERGENCIES AND CRISIS DISCLAIMER
By checking the box I hereby consent to participate in telehealth with Repose (owned and operated by Mary Breen LCSW PLLC), as part of my psychotherapy treatment. I understand that telemental health is the practice of delivering psychotherapeutic services via secure-technology assisted media or other electronic means between a practitioner and a client. I am acknowledging that I have read and understand the information provided below and all of my questions have been answered to my satisfaction.
By checking the box I understand and consent to the following related to telehealth emergencies and crisis disclaimer:
I understand that there are risks, benefits, and consequences associated with telemental health, including but not limited to, disruption of transmission by technology failures and/or limited ability to respond to emergencies
I understand that the privacy laws that protect the confidentiality of my protected health information (PHI) also apply to telehealth unless an exception to confidentiality applies (i.e. mandatory reporting of child, elder, or vulnerable adult abuse; being a danger to myself or others).
I understand that if my therapist deems that I am an active risk to fatally-harm myself or others, they reserve the right to breach confidentiality and contact necessary parties to coordinate care (clinical supervisor, emergency contact, EMS/ 911 if deemed clinically appropriate/Wellness Exchange/ Resident Life Services/ CPS, etc.).
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 telemental health services are not appropriate and a higher level of care is required. I understand that my therapist reserves the right to refer me to an appropriate referral source or higher level of care.
I understand that my therapist may not be available in the case of an emergency and I should not wait for communication back from my therapist. I will instead utilize one of the crisis resources provided to me in the Crisis and Emergency Resources document or will call 911 if my life or someone else’s life is in danger.
I understand that my assigned Repose therapist is not a crisis resource, and that in the case of an emergency I will need to utilize clinically appropriate resources outside of my therapist.
I understand that the Repose Psychotherapy Practice does not offer crisis resources and that in the case of an emergency I will need to utilize clinically appropriate resources outside of the Repose Psychotherapy Practice.
I understand that what I write in uploaded journal entries or documents does not constitute therapy and my clinician is not expected to read and respond to this material. Further, I understand that journaling and uploading documents does not constitute reaching out for support during a crisis and I will utilize clinically appropriate resources outside of Repose Psychotherapy Practice.
I understand that if I am non-responsive to my clinician in the case of an emergency after initiating contact via secure messaging, email, or phone, that they reserve the right to call and coordinate care with necessary crisis management parties. This may include, but is not limited to the following resources: 911, EMS, my emergency contact, Repose Clinician Supervisors, Child Protective Services, and if deemed clinically appropriate, the NYU Wellness Exchange, Columbia Student Health Crisis Support, and/or my university’s Residential Life Services.
I grant permission for my information to be released to my listed emergency contact and acknowledge that the extent of confidentiality is limited in such a circumstance.
CONSENT TO USE THE TELEHEALTH BY SIMPLE PRACTICE SERVICE
Telehealth by Simple Practice is another HIPAA-compliant security technology service we may use to conduct telehealth video conferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:
Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.
I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service.
To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.
By clicking the checkbox, I certify:
That I have read or had this form read and/or had this form explained to me.
That I fully understand its contents including the risks and benefits of the procedure(s).
That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.