Office hours are 9 a.m. to 4 p.m., Monday through Friday. Voice mail is available 24 hours a day. Phone calls and email are generally for administrative matters, such as scheduling appointments. Therapeutic matters are to be reserved for therapy sessions. There is no charge for brief (≤ 10 minutes), administrative phone calls.

            Fees-- initial sessions are $200 for 50-60 minutes; individual therapy is $150 per 45-50 minutes; couples/family therapy is $175 per 45-50 minutes.  Longer sessions can be arranged, for which the fees are pro-rated. Full fees are to be paid at time of service. For your convenience, you may pay by cash, check, or credit card. Current patients will always be given substantial notice of any intended fee increase.

            Full charge is made for any sessions missed or canceled with less than 24 hours (business day) notice.

            This means, for example, that a 2:30 Tuesday appointment must be cancelled by 2:30 on Monday.  Monday appointments must be cancelled by Friday, since weekends are not business hours.  Similarly, appointments following holidays must be cancelled by the preceding business day.

            Cancellations must be made in person or by phone/voicemail. Email is not adequate unless it is well in advance AND you have received a confirmation email from me.

            Voice mail-- (410)544-9564-- is available at all times and automatically records the date and time of incoming calls.

            In the event of inclement weather, there will be an outgoing message on the voicemail by approximately 7 a.m. to tell you if the office is closed. Please call to confirm the status of your appointment. Regardless of whether the office is open, there is no penalty if you cannot make it to your appointment because of the weather.

            I maintain no relationships with insurance companies and do not either bill them or accept payment from them. If you request it, at the end of each month an itemized invoice (“Superbill”) will be provided to you that you can submit to your insurance company for reimbursement.  If treatment plans are required and you wish to submit one, we will complete it together during your session time and you can submit it. It is your responsibility to keep track of when an authorization expires and when a summary is due.

The person accepting financial responsibility for professional services will be responsible for any costs involved in the event that a court, your attorney, or other legal entity with whose orders I must comply requires my services or my records. The financially responsible party will be expected to pay for all of my professional time, including preparation and transportation costs, even if my participation is compelled by another party. I charge $300 per hour for preparation and/or attendance at any legal proceeding.  Payment will be required in advance.

If letters or reports are requested or required for any reason, the financially responsible party will be billed for the time involved, at the usual hourly rate, with a minimum half-hour charge.

            If a minimum negotiated payment is not made for two months on overdue balances, your overdue balance will be applied in full to a credit card (below). Alternately, the account may be turned over for collection or to Small Claims Court, and the person accepting financial responsibility for professional services will be responsible for any expenses incurred to collect overdue balances.

            Regardless of how you intend to pay for sessions, please provide a current credit card number.  It will only be used at your request or if you default on payment of your account.

__________________________               ________                      ____________________

            Card #                                                  Expires                                  Name on card

____________

3 digit verification code on back of card, on signature strip

            I have read and I understand the conditions of this agreement and agree to abide by these conditions.

___________________________ _______________

signature                                              date

(3/11)

Form #3
Informed Consent
Benna Z. Sherman, Ph.D.

Licensed Psychologist

Informed Consent to Psychotherapy

Risks and Alternatives 

The primary risk of therapy, albeit small, is that it can lead to unpredicted personal changes and temporary destabilizations.  Career paths can change, relationships can be terminated, memories can resurface, etc. There is no sure way to guarantee results or the qualitative nature of the process.  However, patient welfare is always the guiding principle.  You will always be actively involved in making decisions about therapeutic goals and methods.

Please be aware that there are many different therapies and therapists available.  If this therapy does not meet your needs, you are encouraged to consider alternatives.

Emergencies

            This practice is NOT an emergency service.  I am not predictably accessible outside my normal business hours, although voicemail is available 24 hours a day, 7 days a week.  I will make every effort to return phone messages in a timely way.  However, if you have an emergency and I am not available, please go to the nearest emergency room.

Confidentiality

            Please read the provided “Policies and Procedures” concerning federal HIPAA regulations pertaining to handling of patients’ Protected Health Information.

In general, the confidentiality of all communications between a patient and a psychologist is protected by law, as well as by the American Psychological Association Code of Ethics.  In general, I can only release information about our work with your written permission.  There are a few exceptions, however, and you should be aware of them from the outset.

            In most judicial proceedings you have the right to prevent me from testifying.  However, in child custody proceedings, adoption proceedings, and proceedings in which your emotional condition is an important element, a judge may require my testimony if it is determined that resolution of the issues before the court requires it.  If you are involved in litigation, or are anticipating litigation, and you choose to include your mental or emotional state as part of the litigation, I may have to reveal part of all of your treatment or evaluation records.

            If you are called as a witness in criminal proceedings, opposing counsel may have some limited access to your treatment records.  Testimony may also be ordered in a) legal proceedings relating to psychiatric hospitalization; b) malpractice and disciplinary proceedings brought against a psychologist; c) court-ordered psychological evaluations; and d) certain legal cases where the client has died.

            In addition, there are some circumstances in which I am required to breach confidentiality without a patient’s permission.  This occurs if I suspect the neglect or abuse of a minor, in which case I must file a report with the appropriate state agency.  In addition, if, in my professional judgment, I believe that a patient is threatening serious harm to self or another, I am required to take protective action, which may include notifying the police, warning the intended victim, or seeking the client’s hospitalization.  The intent of these requirements is that a psychologist has both a legal and ethical responsibility to protect endangered individuals from harm when professional judgment indicates that such danger exists. 

            I may occasionally find it helpful or necessary to consult about a case with another professional. In these consultations, I make every effort to avoid revealing the identity of the client.  The consultant is, of course, also legally bound to maintain confidentiality.

            I am required to maintain complete treatment records.  Patients are entitled to receive a copy of these records, unless I believe that the information would be emotionally damaging and, in such cases, the records must be made available to the patient’s designee.  Patients will be charged an appropriate fee for records preparation.

            If you submit claims to an insurance company or other third party, you will need to provide the payor with a clinical diagnosis, record of treatment dates and services, and, sometimes, a treatment plan or summary.  This obviously compromises confidentiality as well.  You must understand that once this kind of information leaves my hands I cannot warrant its continued confidentiality.

            If you are under 18 years of age, please be aware that your parents or guardians have a right to receive general information on the progress of the treatment and may have the right to access your chart in its entirety.

            Under current Maryland law, in group, family, and marital therapy, all participants are required to consent to the release of information before any information can be released. One marital partner may not waive privilege for another.  In cases of marital therapy, therefore, the record may be released only if both parties waive privilege or if release of the record is court ordered.

            The law governing these issues is complex.  If you need more specific advice, formal legal consultation may be advisable.

            Note:  email is not a secure method of communication.  Please be aware that I cannot guarantee the confidentiality of email communication.

Parents/Guardians

            If you are consenting to treatment for a minor, by signing the consent for services the parent/guardian is affirming that there is no other parent/guardian that has the legal right to override your consent or deny such services.

            I have read the above and understand and consent to it.

I have received and had an opportunity to ask questions about the Maryland Notice Form, which details HIPAA Policies and Procedures to Protect the Privacy of Patient’s Health Information as implemented by Dr. Sherman.

            _____________________________                    _______________

                        Signature                                                                      Date

            ______________________________                  ________________

                        Signature                                                                      Date

IF THIS IS CONJOINT THERAPY (involving more than one person, such as in marriage counseling) ALL NON-MINOR PARTIES TO THE THERAPY MUST SIGN THIS FORM                         

(9/09)