Five Valleys Therapy
Glenn Blumenson, LCSW PLLC
111 N. Higgins Ave, Suite 409
Missoula, MT 59802
Phone: 406-823-0108
Email: [email protected]
Informed Consent for Counseling Services
Services:
Welcome to my counseling practice! I’m excited to get the chance to work with you. Before we get started, please read through this document as it contains important information about my business policies and the services I offer. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights regarding the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Despite the document’s length, please read through these pages carefully as it is very important that you understand them. When you sign this document, it will represent an agreement between us. I am happy to discuss any questions you may have when signing them or at any time in the future. Our initial sessions will involve gathering a full picture of your history, your presenting concerns, and your goals for therapy. Based on these goals, we will develop a plan to support your growth and work together to achieve your desired outcome.
*Counseling and therapy are used interchangeably throughout this document.
Benefits and Risks:
While many empirical studies show the benefits of therapy, I am unable to guarantee the results or effectiveness of this treatment. Therapy will involve discussing issues that may feel uncomfortable or increase distress in the short term. Keeping consistent appointments, openness, and providing feedback about my approach are all important ways to ensure you get the most from therapy. My job is to help you identify and interrupt unhealthy patterns that may be keeping you stuck. This can feel frustrating and like a slow process at times, but through insight and action, I’m hopeful you will be able to achieve the growth and healing you are seeking.
Privacy & Confidentiality:
All information disclosed within sessions and the written records pertaining to those
sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law. If a situation arises in which I must disclose your personal information without your permission, I will only disclose the minimum necessary to satisfy the obligation. For detailed information regarding your right to confidentiality and privacy, please review the attached forms “Notice of Privacy” and “HIPAA Information”.
In addition, disclosure of confidential information may be required by your health insurance carrier to process claims. Once claims have been sent to insurance companies, I cannot control what they do with that information. I provide the minimum amount of information necessary.
Records and Release of Information:
I am required by law to keep treatment records for at least 7 years. If you have
concerns regarding your treatment records, please discuss them with me. As a client, you
have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when I assess that releasing such information might be harmful in any way. I can release your records to other mental health or medical professionals only with your authorization, and your signing of a Release of Information form.
Client Responsibilities:
Payment and Fees: Under the No Surprises Act, you are entitled to a “good faith estimate” which informs you of the cost of therapy. I offer a sliding scale payment option to clients who do not have or do not wish to use insurance when paying for our sessions. My direct/private pay rate ranges from $125 - $185 for a 60-minute therapy session, depending on your income. Once you inform me of your decision to pay privately, we will determine the cost of your sessions together(no less than $125 and no more than $185 per 60-minute session).
My rates are subject to change and you will be notified of any future changes in rates, in writing. Please speak with me if these rates become a barrier to continuing services.
Session fees are payable at the time of our session(cash, check, or credit), unless I am billing your insurance, in which case you must pay your copayment and/or deductible at the session.
Billing in Network:
I am an in-network provider with several insurance companies that are common in the region. If I am a provider with your plan, my billing company (Med-Write) will submit claims for you, but at our session, you must pay any portion not covered by your plan. To submit claims to insurance, I am required to provide a mental health diagnosis and treatment plan substantiating our work together. You may inform me if you have insurance-related questions or concerns. You are responsible for understanding and keeping track of your insurance benefits, including your copay and deductible. I ask that you inform me of any changes in either your plan or your benefits, which can change yearly. If you are not aware of your insurance benefits at our first session, I will charge you the full rate of the session and apply any extra charges as a credit toward future sessions. I require a credit card to be kept on file for session payments and cancellation fees; please let me know if you would prefer a different method of payment and we can discuss the options. Health Savings Accounts (HSA) are appropriate for session payments, however, they are not able to be applied to cancellation fees. Payment is due at the time of service and you are financially responsible for all charges whether or not paid by your insurance, including therapeutic phone calls or crisis intervention support, which are typically not covered by insurance and would be prorated in 15-minute increments.
Cancellation Policy:
If you are unable to make your scheduled appointment, please notify me as soon as possible. I have a 24-hour cancellation policy, therefore there will be a missed or late cancellation appointment fee of $100 for missed sessions and cancellations with less than 24 hours notice, except in medical emergencies. Insurance will not pay for missed sessions or late cancellations. You may be charged a fee if you are more than 15 minutes late for a scheduled appointment, as insurance cannot be billed for that time.
Medicaid Clients:
Please note that the fees described in this policy cannot be applied to clients with Medicaid insurance. Clients with Medicaid insurance who miss a session, cancel without 24-hour notice, or are late to appointments may be referred out to another practice. Because these fees do not apply to clients with Medicaid, if you late cancel or do not show up, I will lose money and the opportunity to schedule another client waiting for an appointment. If any of these situations occur, I will make a point to have a conversation with you regarding any potential barriers and we may decide to reduce the frequency of your sessions, or possibly take a break from or end therapy.
Contact and Relationship:
I am not a crisis service. I only take calls and respond to texts and emails during
normal business hours. I will do my best to return communications within 48 business hours. Please keep the content of written texts and emails pertaining only to scheduling and not therapeutic content, as the confidentiality of those forms of communication cannot be guaranteed. In case of emergencies or crises, please contact 911 or call the MT Suicide Prevention and Mental Health Crisis Line at 988.
Since we live in a smaller community, we might see each other or enter
into a dual relationship. If we do run into one another, I will not verbally acknowledge or approach you first to protect your confidentiality. You are welcome to either ignore or acknowledge me and I will not take offense either way and will follow your lead. I will not disclose how I know you in these situations, nor will I enter into a dual relationship that may interfere with our therapeutic progress. As a means of preserving client confidentiality, I do not accept friend requests on any social media platforms.
Telehealth:
You have the option of using teletherapy for our sessions if you choose.
Teletherapy can often be a useful adjunct or alternative to in-person therapy, as it provides more flexibility in the event of extenuating circumstances, such as adverse weather, mild illness, or transportation obstacles. I provide teletherapy services via HIPAA-compliant platforms such as Doxy and PsychologyToday’s Sessions. When engaging in a teletherapy session, you must be in a safe and private area to ensure the confidentiality of the session.
Legal Issues:
I am not formally trained in matters that involve the legal system and do not
voluntarily become involved in these matters. If you feel you need such assistance, I will try to refer you to a provider who has more experience with the legal system. If I am deposed, issued a subpoena, or otherwise compelled to give testimony, you understand that my fee will be $250 per hour plus travel and other related expenses. This fee will be paid by you, the client, and will be subject to a 30-day cancellation policy.
End of Counseling:
If at any point during therapy, I assess that I am not effective in helping you reach
your goals, we will discuss your options, including ending the counseling relationship and providing referrals to another professional. You have the right to end therapy and
communication at any time. Terminating therapy is best when done collaboratively and with the opportunity for closure.
Glenn Blumenson, LCSW PLLC
111 N. Higgins Ave, Suite 409
Missoula, MT 59802
Phone: 406-823-0108
Email: [email protected]
Informed Consent for Counseling Services
Services:
Welcome to my counseling practice! I’m excited to get the chance to work with you. Before we get started, please read through this document as it contains important information about my business policies and the services I offer. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights regarding the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Despite the document’s length, please read through these pages carefully as it is very important that you understand them. When you sign this document, it will represent an agreement between us. I am happy to discuss any questions you may have when signing them or at any time in the future. Our initial sessions will involve gathering a full picture of your history, your presenting concerns, and your goals for therapy. Based on these goals, we will develop a plan to support your growth and work together to achieve your desired outcome.
*Counseling and therapy are used interchangeably throughout this document.
Benefits and Risks:
While many empirical studies show the benefits of therapy, I am unable to guarantee the results or effectiveness of this treatment. Therapy will involve discussing issues that may feel uncomfortable or increase distress in the short term. Keeping consistent appointments, openness, and providing feedback about my approach are all important ways to ensure you get the most from therapy. My job is to help you identify and interrupt unhealthy patterns that may be keeping you stuck. This can feel frustrating and like a slow process at times, but through insight and action, I’m hopeful you will be able to achieve the growth and healing you are seeking.
Privacy & Confidentiality:
All information disclosed within sessions and the written records pertaining to those
sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law. If a situation arises in which I must disclose your personal information without your permission, I will only disclose the minimum necessary to satisfy the obligation. For detailed information regarding your right to confidentiality and privacy, please review the attached forms “Notice of Privacy” and “HIPAA Information”.
In addition, disclosure of confidential information may be required by your health insurance carrier to process claims. Once claims have been sent to insurance companies, I cannot control what they do with that information. I provide the minimum amount of information necessary.
Records and Release of Information:
I am required by law to keep treatment records for at least 7 years. If you have
concerns regarding your treatment records, please discuss them with me. As a client, you
have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when I assess that releasing such information might be harmful in any way. I can release your records to other mental health or medical professionals only with your authorization, and your signing of a Release of Information form.
Client Responsibilities:
Payment and Fees: Under the No Surprises Act, you are entitled to a “good faith estimate” which informs you of the cost of therapy. I offer a sliding scale payment option to clients who do not have or do not wish to use insurance when paying for our sessions. My direct/private pay rate ranges from $125 - $185 for a 60-minute therapy session, depending on your income. Once you inform me of your decision to pay privately, we will determine the cost of your sessions together(no less than $125 and no more than $185 per 60-minute session).
My rates are subject to change and you will be notified of any future changes in rates, in writing. Please speak with me if these rates become a barrier to continuing services.
Session fees are payable at the time of our session(cash, check, or credit), unless I am billing your insurance, in which case you must pay your copayment and/or deductible at the session.
Billing in Network:
I am an in-network provider with several insurance companies that are common in the region. If I am a provider with your plan, my billing company (Med-Write) will submit claims for you, but at our session, you must pay any portion not covered by your plan. To submit claims to insurance, I am required to provide a mental health diagnosis and treatment plan substantiating our work together. You may inform me if you have insurance-related questions or concerns. You are responsible for understanding and keeping track of your insurance benefits, including your copay and deductible. I ask that you inform me of any changes in either your plan or your benefits, which can change yearly. If you are not aware of your insurance benefits at our first session, I will charge you the full rate of the session and apply any extra charges as a credit toward future sessions. I require a credit card to be kept on file for session payments and cancellation fees; please let me know if you would prefer a different method of payment and we can discuss the options. Health Savings Accounts (HSA) are appropriate for session payments, however, they are not able to be applied to cancellation fees. Payment is due at the time of service and you are financially responsible for all charges whether or not paid by your insurance, including therapeutic phone calls or crisis intervention support, which are typically not covered by insurance and would be prorated in 15-minute increments.
Cancellation Policy:
If you are unable to make your scheduled appointment, please notify me as soon as possible. I have a 24-hour cancellation policy, therefore there will be a missed or late cancellation appointment fee of $100 for missed sessions and cancellations with less than 24 hours notice, except in medical emergencies. Insurance will not pay for missed sessions or late cancellations. You may be charged a fee if you are more than 15 minutes late for a scheduled appointment, as insurance cannot be billed for that time.
Medicaid Clients:
Please note that the fees described in this policy cannot be applied to clients with Medicaid insurance. Clients with Medicaid insurance who miss a session, cancel without 24-hour notice, or are late to appointments may be referred out to another practice. Because these fees do not apply to clients with Medicaid, if you late cancel or do not show up, I will lose money and the opportunity to schedule another client waiting for an appointment. If any of these situations occur, I will make a point to have a conversation with you regarding any potential barriers and we may decide to reduce the frequency of your sessions, or possibly take a break from or end therapy.
Contact and Relationship:
I am not a crisis service. I only take calls and respond to texts and emails during
normal business hours. I will do my best to return communications within 48 business hours. Please keep the content of written texts and emails pertaining only to scheduling and not therapeutic content, as the confidentiality of those forms of communication cannot be guaranteed. In case of emergencies or crises, please contact 911 or call the MT Suicide Prevention and Mental Health Crisis Line at 988.
Since we live in a smaller community, we might see each other or enter
into a dual relationship. If we do run into one another, I will not verbally acknowledge or approach you first to protect your confidentiality. You are welcome to either ignore or acknowledge me and I will not take offense either way and will follow your lead. I will not disclose how I know you in these situations, nor will I enter into a dual relationship that may interfere with our therapeutic progress. As a means of preserving client confidentiality, I do not accept friend requests on any social media platforms.
Telehealth:
You have the option of using teletherapy for our sessions if you choose.
Teletherapy can often be a useful adjunct or alternative to in-person therapy, as it provides more flexibility in the event of extenuating circumstances, such as adverse weather, mild illness, or transportation obstacles. I provide teletherapy services via HIPAA-compliant platforms such as Doxy and PsychologyToday’s Sessions. When engaging in a teletherapy session, you must be in a safe and private area to ensure the confidentiality of the session.
Legal Issues:
I am not formally trained in matters that involve the legal system and do not
voluntarily become involved in these matters. If you feel you need such assistance, I will try to refer you to a provider who has more experience with the legal system. If I am deposed, issued a subpoena, or otherwise compelled to give testimony, you understand that my fee will be $250 per hour plus travel and other related expenses. This fee will be paid by you, the client, and will be subject to a 30-day cancellation policy.
End of Counseling:
If at any point during therapy, I assess that I am not effective in helping you reach
your goals, we will discuss your options, including ending the counseling relationship and providing referrals to another professional. You have the right to end therapy and
communication at any time. Terminating therapy is best when done collaboratively and with the opportunity for closure.