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HIPPA &

Privacy Practices

Notice of Privacy Practices

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THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL 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

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

“PHI” refers to information in your health record that could identify you.

“Treatment, Payment, and Health Care Operations” § Treatment is when I provide, coordinate, or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another psychologist. § Payment is when I obtain reimbursement for your health care. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage. § Health Care Operations are activities that relate 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, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

“Disclosure” applies to activities outside of my office, such as releasing, transferring, or providing access to information about you to other parties. After you have read this notice you will be asked to sign a form indicating receipt of this notice as well as a separate Consent form to allow me to use and share your PHI. In almost all cases I intend to use your PHI here in my office or share your PHI with other people or organizations to provide treatment to you, arrange for payment for my services, or health care operations.

Uses and Disclosures Requiring Authorization

I may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An “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, or health care operations, I will obtain an authorization from you before releasing this information. I will also need to 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.

Use or disclosure of your protected health information for marketing purposes.

You may revoke all such authorization (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, 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, in the ordinary course of my profession, have reasonable cause to suspect or believe that any child under the age of eighteen years (1) has been abused or neglected, (2) has had nonaccidental physical injury, or injury which is at variance with the history given of such injury, inflicted upon such child, or (3) is placed at imminent risk of serious harm, then I must report this suspicion or belief to the appropriate authority.

Adult and Domestic Abuse – If I know or in good faith suspect that an elderly individual or an individual who is disabled or incompetent has been abused, I may disclose the appropriate information

Health Oversight Activities – If a government agency is investigation my practice, I must disclose some information.

Judicial and Administrative proceedings – There are some federal, state, or local laws which require me to disclose PHI. If you are involved in a lawsuit or legal proceeding and I receive a subpoena, discovery request, or other lawful process I may have to release some of your PHI. I will only do so after trying to inform you of the request, consulting your lawyer, or trying to obtain a court order to protect the requested information. 

If you bring a lawsuit against me and disclosure is necessary or relevant to a defense, I may disclose the appropriate information.

Serious Threat to Health or Safety – If I believe in good faith that there is risk of imminent personal injury to yourself or to other individuals or risk of imminent injury to the property of other individuals, I may disclose the appropriate information. I may also disclose PHI if it is necessary for you to be hospitalized for psychiatric care.

Worker’s Compensation – I may disclose PHI regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.

 

Patient’s Rights and Therapist’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 a 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 mental 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. On 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 (as described above in this Notice). On 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.

• Right to Restrict Disclosures When You Have Paid for Your Care Out-of-Pocket. You have the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket in full for my services.

• Right to Be Notified if There is a Breach of Your Unsecured PHI. You have the right to be notified if: (a) there is a breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted to government standards; and (c) my risk assessment fails to determine that there is a low probability that your PHI has been compromised.

 

Therapist’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 notify you in person, via mail, or via another method agreed upon in advance

 

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 contact Elevate Life Solutions 617-888-7787 for additional information. If you believe that your privacy rights have been violated and wish to file a complaint with me, you may send your written complaint to elevatelifesolution@gmail.com.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. Our office can provide you with the appropriate address upon request. You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.

 

Other Uses of PHI in Healthcare

• Business Associates – There are some jobs I hire other businesses to do for you. In the law, they are called Business Associates. Examples may include a copy service to make copies of your health records or a billing service to print, mail, and follow-up on my insurance claims for reimbursement, to mail patient bills, and/or to contact your insurance company regarding benefits, eligibility, and authorization. These business associates need to receive some of your contract to safeguard your information.

Thanks for submitting!

Informed Consent for Therapy Agreement

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Please read through the following informed consent agreement. What follows is a basic understanding

between client and therapist. In general, what are listed below are the responsibilities and obligations of your therapist, and some expectations of you as the client. This document also contains important information about our professional services and business policies. Do not sign the informed consent unless you completely understand and agree to all aspects. If you have any questions, please bring this form back to your next session, so you and your therapist can go through this document in as much detail as is needed. When you sign this document, it will represent an agreement between us.

 

Psychotherapy

• Voluntary Participation: All clients voluntarily agree to treatment, and accordingly may terminate any time without penalty. Therapy involves a large commitment of time, money, and energy, so you should be thoughtful about the therapist you select. In the first couple of sessions, you should be deciding whether your therapist is right for you. If you feel it is not a good match, then your therapist will be happy to assist you in finding a new therapist.

 

• Client Involvement: All clients are expected to show up to appointments on time, prepared to focus on and discuss therapy goals and issues, and will not attend while under the influence of mood-altering chemicals. All clients are expected to be open and honest so your therapist can assist you with your goals. Therapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. For therapy to be most successful, you are encouraged to work on things we talk about both during our sessions and at home. Inconsistent attendance can negatively affect your therapy progress.

 

• Therapist Involvement: Your therapist will be prepared at the designated time, (barring emergencies), and will be attentive and supportive in meeting the therapy goals and do everything possible to assist you in achieving a greater sense of self-awareness and work toward helping you resolve problem areas.

 

• Guarantees: Although many people do get better in therapy, some do get worse. Accordingly, your

therapist makes no guarantee of results. It is not possible to guarantee results such as: becoming happier, saving marriages, becoming less depressed, and so forth.

 

• Risks of Therapy: Just as medications sometimes causes unexpected side effects, therapy can stimulate painful memories, unanticipated changes in your life, and uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. In some cases, client’s symptoms can become worse during the course of therapy, occasionally necessitating hospitalization. Another risk of therapy is that throughout the process of therapeutic change it is not uncommon for clients to reach a point of change where they may feel they are different and no longer able to be the same person they were upon entering therapy. At times these feelings can be unsettling.

 

• Benefits of Therapy: The benefits of therapy can include: a higher level of functional coping, solutions to specific problems, new insights into self, more effective means of communicating in relationships, symptomatic relief, and improved self-esteem.

 

• Alternatives to Traditional Therapy: can include life coaching, stress management, peer self-help groups, and support groups.

 

• Credentials and Qualifications: Therapists at Elevate Life Solutions hold a variety of degrees in the field of social work and or psychology such as: Master’s in psychology, Licensed Marriage and Family Therapist, or Licensed Independent Clinical Social Worker. In each case your therapist is licensed by the state of Massachusetts to provide psychotherapy.

 

• Therapy Approach & Theory: Your therapist generally uses a therapy approach that includes a Cognitive Behavioral, Solution Focused, Acceptance and Commitment therapy and Motivational Interviewing.  Your therapist focuses largely upon client responsibility in therapy, building a relationship with clients, creating a nurturing environment conducive to change and problem solving, exploration of past events and how they continue to affect you today, analysis of underlying belief systems and their relation to inadequate functioning or hindrance to change, and implementation of specific emotional, cognitive, and behavioral techniques designed to aid in change toward specified goals.

 

• Colleague Consultation: In keeping with standards of practice, your therapist may consult with other mental health professionals regarding care and management of cases. The purpose of this consultation is to ensure quality of care. Your therapist will maintain complete confidentiality and protect your identity by not using real names or any identifying information.

 

• Meetings and Length of Therapy: Once we have agreed to work together, we will usually schedule one appointment every week at a time we can agree upon. Session length is 50 minutes. Because our meetings are your time, you are expected to come to each session with a sense of what it is you would like to discuss or work on during that particular session. Length of therapy is quite variable based on client motivation, number and severity of issues to resolve, and work efforts outside of therapy sessions. On average, many people feel they have obtained what they were looking for in 10-25 sessions. For some it is fewer and for others it may go longer.

 

• Confidentiality and Privilege: The information and content shared in therapy will remain confidential, except as noted in the next section: Exceptions to Confidentiality and Privilege. Your information will not be shared with anyone without your written consent. Your information is also privileged, which means that your therapist is free from the duty to speak in court about your counseling unless you waive that right, or a judge orders it.

 

• Exceptions to Confidentiality and Privilege: As a mandated reporter in the state of Massachusetts your therapist is legally obligated to violate confidentiality under the following circumstances:

When the therapist has reason to suspect that the client has been, or is currently, involved in the

abuse or neglect of child, When the therapist has reason to suspect that the client has been, or is currently, involved, in the abuse or neglect of vulnerable disabled or elderly adults, if a client is pregnant and taking street drugs, If the client reports sexual misconduct by another therapist, if a client is a serious danger to themselves, i.e., if suicidal, If a client is a serious danger to someone else, i.e., if homicidal, and If the courts order copies of records

 

• Ethical Guidelines: Your therapist follows the National Association of social Workers (NASW) ethical guidelines

 

• Medical Records: The laws and standards of our profession require that we keep treatment records. You are entitled to receive a copy of the records unless we believe that seeing them would be emotionally damaging, in which case we will send them to a mental health professional of your choosing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. We recommend you review them in your therapist’s presence so we can discuss the contents. All client records include: an intake sheet filled out prior to therapy, a chronological listing of appointments and fees, a copy of signed releases, copies of any correspondence regarding your case, a copy of the signed informed consent packet materials, and a copy of all therapist notes. All

records will be maintained by your therapist in a secured area for a period of seven years from the time-of-service termination. As a client you have a right to access your records. You also have a right to contest material in your records and it will be noted in your record. You do not have a right to alter your records or dictate information be removed. You have the right to access and view your record, but you do not own the records, they are property of Elevate Life Solutions.

 

• Disputes and Complaints: Any disputes or complaints that cannot be resolved between the client, therapist, and Elevate Life Solutions can be directed to the Board of Social Work.

 

• Professional Fees: All clinicians will perform an initial diagnostic session which is more expensive. Follow up therapy sessions are less expensive.

 

• Health Insurance: We are not in network with any health insurance provider.  You may seek reimbursement directly with your insurance provider.

 

• Phone Availability: We are often not immediately available by phone. Because of other obligations, we are currently only returning phone calls in the early morning and evening. We will also not answer the phone when we are with a client. When we are unavailable, you are able to leave us a voice message and we will make every effort to return your call the same day you have called, with the exception of weekends and holidays. If you are difficult to reach, we encourage you to leave us times when you will be available. We also encourage the use of 911 or 988 for emergencies.

 

• Emergency & Interruption of Therapy: In the event of any mental health or substance abuse emergency, we encourage you to call 911 or 988. When we are on vacation or plan to be unavailable for a brief period of time, we will provide you with the name and number of another therapist you can contact with questions or come in to see as needed. In the event of a longer interruption of therapy we will make appropriate referrals as needed.

 

• Termination: Either the client or the therapist may end therapy at any time. Your voluntary involvement allows you to discontinue at any time. If your therapist feels you are no longer benefiting from therapy or your therapist feels there is a conflict in values they may discuss termination. If you desire additional therapy your therapist will provide you with a referral competent to address your issues.

 

• Billing and Payments: You will be expected to pay for each session at the beginning of our meetings, unless we have agreed on other arrangements. Keep in mind that it is you that is responsible for full payment of fees. My signature below indicates that I understand and agree to pay the full amount for therapy sessions 24 hours prior to each scheduled session.

 

• Cancellation, No Show or Late Arrival: In general, all clients must provide the therapist a minimum of 24 hours notice in the event of a cancellation, which does not include weekends. This means if you have an appointment at 1:00 pm on Monday, you will need to have cancelled by 1:00 pm on the Friday prior. Clients will be charged for appointments that are not canceled at least 24 hours in advance and for all no shows. Insurance companies do not pay for missed appointments; therefore, you will be responsible for the full amount charged. Clients arriving late will not be provided an extension of time beyond what they were scheduled so as not to disrupt another client appointments. No reduction in fees will result from shortened sessions due to a client’s late arrival. Additionally, if a client misses two appointments, your therapist has the option to terminate services and refer you to another agency for services.

 

• Account Balance Maximum: Whenever a client’s account reaches an outstanding balance of $500 and no payments have been made or received toward the account, additional services will be suspended.

Services will remain suspended until client begins making payment toward their account. If no payments are made, services will remain suspended and/or clients may be referred to alternate providers for services.

 

• Collections: If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we have the option of using legal means to secure payment. This may involve hiring a collection agency or going through small claims court. In most collection situations, the only information released regarding a client’s treatment is his/her name, the nature of the services provided, and the amount due. Accounts turned over to collections may be subject to future requirements such as providing a retainer for future services.

 

Elevate Life Solutions: Informed Consent Agreement

 

As the client, my signature below indicates that I have been provided a copy of the Informed Consent for Therapy Agreement. My signature below confirms my understanding of all the rules and responsibilities of both the client and the therapist, in addition to understanding the financial terms and agreements. My signature constitutes my agreement and compliance to this document. I, as well as my clinician, will abide by the stipulations listed herein.

Thanks for submitting!

Authorization to Release Information

                                                                                         Name of Client                                                              Date of Birth:

 

 

 

 

 

 

I authorize Elevate Life Solutions (hereinafter “Provider”) to disclose mental health treatment information and records obtained in the course of psychotherapy treatment, including, but not limited to therapist’s diagnosis, of the client listed above to:

                                                                                      Name of Individual or Organization

Address

Phone/Fax:

 

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I authorize Elevate Life Solutions to send the following information: (Type in all that apply)

 

(Full Treatment, Specific Record Dates of Treatment 

Initial Treatment Plan, Psychiatric diagnosis(es), Treatment Summary or Other:

 

 

 

 

 

 

 

 

The above information will be used for the following purposes:

 

 

                                                                                                                                    

 

 

 

I understand that I have a right to receive a copy of this authorization. I understand that any cancellation or modification of this authorization must be in writing. I understand that I have the right to revoke this authorization at any time unless Provider has taken action in reliance upon it. And, I also understand that such revocation must be in writing and received by Provider to be effective. I understand that this authorization will automatically expire after 1 year.

 

Provider shall not condition treatment upon my signing this authorization and I have the right to refuse to sign this form. I understand that information used or disclosed pursuant to this authorization may be subject to redisclose by the recipient and may no longer be protected by the HIPAA Privacy Rule, although applicable Massachusetts law may protect such information.                                                                                                 

Thanks for submitting!

Automatic Credit Card Payment Authorization

 

Elevate Life Solutions requires that a credit card be kept on file at all times.

 

Your name as it appears on the credit card:

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Credit Card Number:

Expiration Date (mm/yy): 

Security Code: 

Billing Zip Code: 

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I authorize Nancy Moniz, LICSW of Elevate Life Solutions to use automatic credit card billing for the balance of any outstanding accounts that are not settled within 60 days of service.

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Thanks for submitting!

Telemental Health Informed Consent

 

 

I, _____________________________________, hereby consent to participate in telemental health with, Elevate Life Solutions, as part of my psychotherapy. I understand that telemental 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 telemental 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 telemental 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 of the 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 telemental 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 telemental health services are not appropriate and a higher level of care is required.

6) I understand that during a telemental health session, we could encounter technical difficulties

resulting in service interruptions. If this occurs, end and restart the session. If we are unable to

reconnect within ten minutes, please call me 617-888-7787 to discuss since we may have 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

I need to know your location in case of an emergency. You agree to inform me of the address

where you are 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 to go to your

location or take you to the hospital in the event of an emergency.

 

In case of an emergency, my location is and my emergency contact person’s name, address, phone: 

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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.

Thanks for submitting!

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.  Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services. 

  

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.

  

Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.

  

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.

              

Make sure to save a copy or picture of your Good Faith Estimate.

 

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises

Thanks for submitting!

New Client Consent and Authorization

 

Consent to Treatment:                                                                                                                          

 

 

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I hereby consent to receive virtual therapy for mental health treatment from Nancy Moniz, LICSW.  I understand that my consent is voluntary. I also understand that I do not have to accept any treatment option Nancy Moniz, LICSW offers and that I may withdraw my consent at any time. I accept that working toward change may involve experiencing difficult and intense feelings, some of which may be painful, to reach therapy goals. I understand that the changes I make will have an impact on my partner and on others around me. I accept that such changes can have both positive and negative effects and agree to clarify and evaluate potential effects of changes before undertaking them. [This is especially true if dependent children are involved] On the other hand, therapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reduction in feelings of distress.

 

Treatment Sessions:                                                                                                                                   

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I understand that standard treatment sessions are 50 minutes in length, but that exceptions may occur. I also understand that there are circumstances in which individual therapy alone may not be the best treatment option. Such circumstances may include when there is active substance abuse, domestic violence or emotional abuse that are not stable and/or untreated. I further understand that Nancy Moniz, LICSW may choose at any time to discontinue services if any of these circumstances are present, and at such time all fees paid to Nancy Moniz, LICSW to date, regardless of duration of treatment, are nonrefundable. I understand that in such circumstances, Nancy Moniz, LICSW will make a good faith effort to provide me with alternative referrals for treatment, but that ultimately it is my responsibility to seek out and pursue treatment.

 

Confidentiality:                                                                                                                                           

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I understand that our communications are private and protected by law. Because of laws protecting confidentiality, in most situations my therapist cannot share information about our work without my permission. However, there are certain specific limits to confidentiality. I fully understand these limits below.

 

1. My therapist may share some of my protected information with staff for purposes such as scheduling and billing. All administrative staff are trained to protect my privacy and have agreed to be bound by the rules of confidentiality.

 

2. There may be times during our work when, in order to support progress toward my goals, my therapist will consult with a colleague or supervisor. My therapist will do this in a way that minimizes identifying information. All mental health professionals with whom my therapist consults are bound by the rules of confidentiality.

 

3. Generally, if I am involved in legal proceedings, my therapist cannot provide any information about our work without my permission. There are exceptions and, if I anticipate being involved in litigation, I should consult my attorney to determine whether a court could order my therapist to disclose information.

 

4. If I file a complaint or lawsuit against my therapist, my therapist may disclose relevant information pertaining to me to defend herself.

 

5. If, in the course of our work, my therapist has reasonable cause to believe that any child under the age of 18 is being (or has been) physically or emotionally harmed in any way (either because of abuse—including sexual abuse—or neglect) the law REQUIRES my therapist to file a report with the Massachusetts Department of Children and Families. My therapist will inform me if she finds that she must file a report.

 

6. Similarly, if my therapist has reasonable cause to believe that an elderly person (age 59 or older) or a handicapped person of any age is (or has been) suffering from abuse, the law REQUIRES that my therapist file a report with the appropriate authorities.

 

7. Finally, if I let my therapist know that I intend to harm myself or intend to harm another person and my therapist believes the risk is real, my therapist may be REQUIRED to break confidentiality by contacting the police, alerting the intended victim, contacting a family member, and/or seeking my hospitalization without my consent.

 

Communication and Availability:     

                                                                                                 

 

Due to my therapist’s work schedule, my therapist is often not immediately available by telephone. When my therapist is unavailable, an automated voice mail answers her telephone. My therapist will make every effort to return my call on the same day I make it, except for weekends and holidays. If I will be difficult to reach, I will inform my therapist of certain times when I will be available. In a life-threatening emergency, I will call 911, 988 or go to the nearest Emergency Room. I understand that email is not a secure medium for communication and my therapist’s preference is that I contact her by phone. However, if I choose to contact my therapist using email, I am doing so with the full understanding that my therapist cannot guarantee the safety and security of that communication, despite Nancy Moniz, LICSW taking all possible action to protect my privacy. I also acknowledge that email occasionally disappears or is delayed and that my therapist may never receive an email that I send. For example, canceling a session via email is NOT an appropriate method of notification. My therapist recommends that to give adequate 24-hour notice of such cancellations, I do so by phone.

Thanks for submitting!

Cancellation and Attendance Policy

 

Cancellation Policy:                                                                                                                                     

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If I am unable to keep an appointment, I agree to notify Nancy Moniz, LICSW at least 24 hours in advance of my scheduled visit.

 

If an appointment is cancelled less than 24 hours in advance, I understand that I will be charged for the full session as an inconvenience fee.  This fee is not eligible for reimbursement by insurance.

 

I understand that my therapist will use a secure online credit card processing for all associated fees on my account including any inconvenience fee.

 

ACKNOWLEDGEMENT

My initials above and signature below acknowledge that I understand and accept the terms and conditions of this authorization and agreement.

Thanks for submitting!

New Client Intake

 

IDENTIFYING INFORMATION

Today’s Date: 

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Client’s Name:

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Partner(s) Name(s) if applicable

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Address:  

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Best Phone:

 

 

 

Email 

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Date of Birth:

 

 

 

 

Age:

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Gender Identity/Identifies:

Pronouns: 

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Spirituality/Religion:

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Relationship Status: 

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Sexuality Identity:

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Ethnic Identity:

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Other Social/Cultural/Racial Identities:

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Educational Background (School and   Degree):

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If you are currently a student where/for what: 

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If employed, what is your occupation:

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Years at current job: 

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Employer: 

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Children/Age(s): 

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Emergency Contact: 

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Relationship: 

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Phone: 

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Name of your primary medical provider:

 

 

 

 

 

Phone: 

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Who referred you? 

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PSYCHIATRIC HISTORY

(Medications, hospitalizations, and previous psychotherapy/counseling. Please provide as much information as possible, including names of treaters/facilities, dates, doses, etc.)

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FAMILY HISTORY

Please list first names, ages, occupations, and psychiatric histories for any immediate and meaningful family members including parents/guardians, significant others, siblings, children, etc.

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SOCIAL HISTORY

Is anyone currently harming you financially, verbally, physically, emotionally, or sexually? Yes No

Has anyone ever harmed you in these ways? Yes No

Please elaborate

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MEDICAL HISTORY

(Significant past or current physical illness, injuries, hospitalizations, medications. Please include dates.)

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SUBSTANCE USE

(Please describe any past or current use of alcohol and/or drugs including any recent

increase or decrease in use and why.)

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PRESENTING CONCERNS

(Main areas that you would like to address in therapy)

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Thanks for submitting!

Financial Obligation:                                                                                                                                   

I understand that I am responsible for full payment of all fees for services provided by Nancy Moniz, LICSW prior to the beginning of each session.                                                                   

I understand that my therapist will use a secure online credit card processing for all associated fees on my account including any inconvenience fee.                                                                                                                                                                                                                                                                                        ACKNOWLEDGEMENT

My initials and signature below acknowledge that I understand and accept the terms and conditions of this authorization and agreement. 

 

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Thanks for submitting!

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