NEW CLIENTS

New Clients:

 

I look forward to working with you.  If you’re returning, I’m glad to work with you again!

TO BECOME A CLIENT:

Before making an appointment for the first time, you must read the letter below and then fill out the New Client Information Form. As soon as I receive the form, I will send you an email letting you know that I received your information and provide you with information for scheduling an appointment, if I have openings. (If you don’t hear from me within 24 hours, please send me an email.)

VERY IMPORTANT: Please review the letter and contract (below the questionnaire.)   You can either print it out at home, sign it, and bring it with you to your first session, or I can supply a copy for you to sign when we meet.

PLEASE NOTE: You must answer every question in order for the form to be submitted. If you don’t want to or can’t answer a particular question, just put an X in the box.

VERY IMPORTANT: Please review the following letter and contract.  You can either print it out at home, sign it, and bring it with you to your first session, or I can supply a copy for you to sign when we meet.

Dear New Client:

Welcome. Your initial appointment will help me get a better understanding of your situation in order to determine how I might best help you. And it will give you a chance to determine whether my style suits you. You are the customer and you have the right to choose the best therapist for you. Don’t hesitate to ask questions.

Psychotherapy is a way of talking through your problems in order to begin resolving them. You will need to take an active part in psychotherapy by working on, and thinking about, the things you talk about. Counseling has been shown to have many benefits. However, there are no guaranteed results, and at times a session may leave you with unhappy feelings. When it is effective, counseling often leads to better relationships, solutions to specific problems, and feeling much less distressed.

MY BACKGROUND & EXPERIENCE:

I am a Licensed Clinical Mental Health Counselor and Board Certified Professional Counselor.  I have worked with individuals, families, couples and groups since 1992 when I received a Masters in Science from the University of Vermont. Prior to private practice, I worked for 8 years as an adolescent & family counselor in a non-profit community agency in Burlington, VT. In addition to private practice, I am an adjunct faculty professor in the Graduate Counseling Program at the University of Vermont and provide workshops & trainings to the general public and other professionals throughout the country.

MY ROLE IN WORKING WITH YOU:

As your counselor, I agree to provide you with a safe, thoughtful, emotionally supportive and respectful relationship where you can explore your beliefs about yourself and your world. My goal is to be genuine in my role as your counselor, to remain interested and curious in your work, to witness your feelings and experiences, to communicate understanding and to believe in your ability to think and experiment with acting in new ways. My theoretical orientation is based in cognitive behavioral and family systems theories. I work collaboratively with my clients to focus treatment goals, evaluate progress and to decide how often to meet, and when to end treatment.

THE BENEFITS & RISKS OF COUNSELING:

Counseling has been demonstrated to be of benefit for most people and in most situations. Some benefits include relief from feelings that can be debilitating, like depression or anxiety. Just the opportunity to talk things out completely and to be understood, can be beneficial. As a result of counseling, you may be better able to cope with social or family relationships or learn new ways to manage your feelings. Risks may include experiencing uncomfortable feelings or the possibility that some changes may lead to worsening of your problems. You decide how long to be in counseling and when and how you have met your goals. However, if I believe our working together will not benefit you, I will help you with referrals to other counselors or services.

HIPPA: The law, called HIPAA (Health Insurance Portability and Accountability Act) regulates the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. HIPAA requires that I give you a Notice of Privacy Practices. The Notice, attached to the clipboard in my office, explains HIPAA’s application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information, which I will collect from you at your first appointment. If you would like, I will give you a copy of the Notice.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please read and review it carefully.

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. For psychotherapists this requires little change from the practice of confidentiality that has been required of our profession prior to HIPAA. In general, the HIPAA Act gives you, the client or patient, significant new rights to understand and control how your health care information is used. HIPAA provides penalties for covered entities that misuse personal health information.

As required by HIPAA, I have prepared this explanation of how I am required to maintain the privacy of your health information and how I may use and disclose your health information. Please note that, for the practice of psychology, these HIPAA requirements compliment rather than add any significant change to our normal and usual practice as regards record keeping and confidentiality.

I may use and disclose your medical records only for each of the following purposes: treatment, payment and healthcare operations.

Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would be performing psychotherapy in this office, or making a referral to another health care provider for additional evaluation or treatment.

Payment means such activities as obtaining reimbursement services, confirming insurance coverage, billing or collection activities, and utilization review for managed care coverage and approval and/or at the request of a third party payer for your treatment (your insurance company). An example of this would be sending a bill for your psychotherapy visit to your insurance company, or telephonically, by mail, or by fax, sending the necessary clinical information for your insurance company to approve more sessions for coverage for you.

Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost management analysis, and customer service. An example would be an internal quality assessment review.

I may also create and distribute de-identified health information by removing all references to any and all individually identifiable information.

I may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that might be requested by or is of interest to you.

Any other uses and disclosures will be made only with your written authorization.

You may revoke such authorization in writing and I am required to honor and abide by that written request, except to the extent that I have already taken actions relying on your prior written authorization to take such actions.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer or to me.

The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. I am, however, not required to agree to a requested restriction if Vermont law or Federal law indicates that to do so would be a violation of Duty to Warn Statutes of person or property, violation of mandated reporting of known abuse of a minor or child, or violation of mandated reporting of known abuse of an elderly or incapacitated person. As a psychotherapy client you own the privilege of confidentiality, and no information, including your presence in therapy or the fact that you are a patient, will be disclosed without your specific written permission in a release of information request.

Psychotherapy has traditionally always been more restricted in its mandated legal and ethical protection of your protected health information. HIPAA regulations do not affect any previous safeguards to your privacy as a patient, except in certain cases to strengthen them.

The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternate locations.

1. The right to inspect and copy your protected health information.

2. The right to amend your protected health information.

3. The right to receive an accounting of disclosures of protected health information.

4. The right to obtain a paper copy of this notice from us upon request.

I am required by law to maintain the privacy of your protected heath information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

This notice is effective as of July 2006 and I am required to abide by the terms of the Notice of Privacy Practices currently in effect. I reserve the right to change the terms of my Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that I maintain. I will post and you may request a written copy of a revised

Notice of Privacy Practices from this office. You have recourse if you feel that your privacy protections have been violated. You have the right to file written complaint with our office, the Department of Health and Human Services, or the Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of my office. I will not retaliate against you in any fashion for filing a complaint.  Please speak with me or contact my office for more information. For more information about HIPAA or to file a complaint, please write to or contact:

The U.S. Department of Health and Human Services, Office of Civil Rights, 200 Independence Avenue, S.W. Washington, D.C. 20201

(202) 619-0257 or Toll Free: 1-877-696-6775

FEES, HEALTH INSURANCE, AND MANAGED CARE. The fee for the initial 50-70minute consultation is $175. After that, the fee for each 45-50-minute individual, couple, or family session is $130.  In some special circumstances, we may negotiate a lower fee, determined by your ability to pay.

If I am a provider for your insurance company and I have contracted with them to accept a lower fee, then your deductible and any noninsured portion of each session’s fee will be based on that contracted amount. If the insurance company decides to increase the fee that I am allowed to charge, your deductible and any noninsured portion of each session’s fee will be based on the increased amount. Also, sometimes managed care companies will authorize more sessions than your insurance benefits will pay for. If you see me for visits that are authorized but not paid for by your insurance benefits, by signing this form you agree to pay my fee, as listed above, for each authorized visit that is not covered by your insurance benefits. If your insurance company requires you to get authorization from them before seeing me and you do not do so, you are responsible for payment in full of the fees listed above.

Any telephone consultation or email which requires more than 10 minutes of my time, may be pro-rated at my standard hourly rate for professional services. Although health insurance may aid in payment, you alone are responsible for paying for your appointments.

PLEASE NOTE: If you cancel or do not keep an appointment without giving twenty-four hours’ advanced notice, you must pay for the time you have reserved. Insurance companies do not pay for missed appointments. Feel free to ask me any questions that you have concerning payment arrangements. Under a managed care plan, the insurance company periodically requires me to submit your diagnosis, progress, and treatment plan to their reviewer, who then determines if further treatment is medically necessary. I want you to know that if you have a managed care insurance plan, this information will be released to the reviewers. If you don’t want me to release this information, you can choose not to use your insurance coverage and pay for my services yourself at the time of each visit.

All accounts are payable in full within 30 days after billing. I reserve the right to collect any unpaid balance due to me. If you are not making regular monthly payments on the account balance, I may use a collection agency or take legal action to secure payment, as authorized by state or federal law, and the collections action will become a part of your credit record. You will be notified in writing before I take action to collect. I reserve the right to terminate treatment and refer you elsewhere for continued care if the unpaid balance exceeds $300.00.

IMPORTANT: By entering into a counseling agreement with Barbara Boutsikaris, you understand that Barbara Boutsikaris and/or her records/files will not be available for any court proceedings or hearings and you agree not subpoena Barbara Boutsikaris or her records/files.

Your Responsibilities:

1. You have the responsibility to provide me with complete and accurate information that will ensure the creation of a useful and individualized plan of care.

2. You have the responsibility to take an active part in your treatment process and to come to sessions without being under the influence of alcohol or any non-prescribed drugs.

3. You have the responsibility to pay any co-payment owed at the close of each session.  Payment for service is an important issue, in part because in counseling clarity of relationships and responsibilities is often a goal of treatment.

4. If you have health insurance, you are responsible for verifying your insurance coverage, deductibles, reimbursement rates, co-payments, and getting your initial authorization, if needed.

5. You have the responsibility to keep all scheduled appointments and to be no more than 15 minutes late. If you are not able to attend your appointment, you have the responsibility to call ahead no less than 24 hours and cancel your appointment and/or reschedule. An appointment is a commitment to our work and a contract between us to be present and on time. I will make our sessions a priority and ask you to do the same to keep missed sessions to a minimum. Rarely, and usually because of an emergency, I may not be able to start on time. For this I ask your understanding and assure you that you will receive the full time at the time of your session or at another time. Your session time is reserved for you and a canceled appointment is an interruption in your work. Therefore, unless there is an emergency or sickness, if you miss an appointment, are more than 15 minutes late, or cancel with less than 24 hours notice, you will be responsible for the full session fee, which can not be billed to your insurance.

Your Rights:

1. You have the right to services regardless of race, religion, sex, ethnic background, age sexual orientation, disability, ability to pay, HIV status, or any other non-clinical reason.

2. You have the right to be treated with courtesy, dignity, respect, and in a language you understand.

3. You have the right to receive confidential services. Your records are protected under the Federal Confidentiality Regulations and cannot be disclosed without your written consent unless otherwise provided for in the regulations. If you do give your written consent, you should know that you can revoke this consent at any time except to the extent that action has already been taken on it. By law, there are two situations in which I must tell others some of what you tell me: (1) When I believe you immediately intend to harm yourself or another person, or (2) when I believe a child, elder, or disabled adult has been, or will be, abused or neglected.

If you are under 18, your parent or guardians have a right to know, in general terms, about what happens in our sessions. Insurance companies receive only the dates of our appointments, my charges, and a diagnosis. On some occasions, insurance companies ask for more detailed information about your symptoms, diagnosis and my treatment methods. My policy is to provide the minimum information necessary to obtain payment and will inform you if this should occur.

4. You have the right to review your records, to make additions or corrections, and to obtain copies for other professionals or yourself. However, reading records, or having someone else read them, is a significant issue and I will want to explore this thoroughly before making the records available.

5. You have the right to receive information necessary to give informed consent prior to being involved in activities which include the use of audio or video tape recorders.

6. You have the right to clear professional and ethical boundaries within our therapeutic relationship. I cannot see you socially outside our sessions, or enter into a business or other relationship with you besides this therapeutic one. If we should run into each other outside of my office, I will follow your lead in order to protect your privacy and avoid confusion about the boundaries of our relationship.

7. You have the right to question any aspect of your treatment and to voice your opinions, recommendations or grievances without the fear of restraint, interference, coercion, discrimination or reprisal. If you are dissatisfied for any reason, please raise your concerns immediately. If you feel that you have been treated unfairly or unethically and cannot resolve this problem with me, you can contact the Vermont Office of the Secretary of State. Their number is 802-828-2363. For more information about this process, see a copy of the Client Grievance Procedures (on clipboard in the waiting room of my office).

8. You have the right to emergency services by calling either 911, Adult Crisis at 802-488-6425 or First Call for Children and Families at 802-864-7777. You can reach me in an emergency by calling my cell phone: 802-233-0162.

AGREEMENT: (This will be available for you to sign at your first appointment.)

I have read and understood the above agreement, and I agree to abide by its terms.  In addition, I understand that my signature below excludes me from using (or subpoenaing) Barbara Boutsikaris and/or relevant files in any court proceedings.

__________________________________       ___________________________

Signature of client (or parent)                                              Date

All clients using health insurance please sign below. A parent must sign if client is under 18. I hereby grant authorization to Barbara Boutsikaris to release any Protected Health Information (except Psychotherapy Notes) to my insurance company that is necessary for billing, or to process my claim for payment of services. I authorize my insurance company to send payment directly to Barbara Boutsikaris for all services provided. I agree that a photocopy of this authorization shall be as valid as the original.

I hereby consent for Barbara Boutsikaris, MS, LCMHC to provide treatment and evaluation to:

Print name of client:________________________________________________

Social Security #:________-_______-_______   Birthdate:_____/_____/_______

Signature of parent or guardian:_________________________________________

Date:____________________________________________________________