New Clients:

1) Please contact me via email to make sure that I am accepting new clients: familyworksvt@gmail.com

2) Once you receive the okay from me, just fill out the initial online registration form or click here.

3) Then you can schedule yourself into my calendar by clicking here.

4) Contact your insurance company to see if you need an initial authorization for mental health treatment.

5) 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:

I’m glad that you found me. 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.

Counseling 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 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 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 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.

HIPAA. 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.

FEES, HEALTH INSURANCE, AND MANAGED CARE. The fee for the initial 50-70minute consultation is $160. After that, the fee for each 45-50-minute individual, couple, or family session is $110. 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’ advance notice, you must pay for the time you have reserved. Insurance companies do not pay for missed appointments. If you are ill and call 24 hours in advance to cancel your appointment, there will be no charge. If your insurance company has contracted with me to accept a lower fee, 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. 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.

Feel free to ask me any questions that you have concerning payment arrangements. For problems involving payments and insurance, please call my billing person, Karolyn Micheels at Claims Connection in Plattsburgh, NY (1-800-775-1585) or email her at Claimsconnection@charter.net. Many insurance plans are managed care plans. 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.

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 for all co-payments at the close of each session. My fee is $110 per 45-50minute session. In some circumstances, we may negotiate a lower fee, determined by your ability to pay. 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, I will charge you the full session fee, which can not be billed to your insurance.

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. In an emergency, you have the right to reach me or another therapist. You can reach me or another therapist by calling my office at 658-7999 and following the instructions on the recorded message.

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.

Signature of client (or parent)                                 Date

All clients using health insurance please sign below; 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:____________________________________________________________