For more information:

(603) 247-4191 / drrobin@insightsgroup.net

1245 Washington Road

Rye, New Hampshire 03870

For more information:

(603) 247-4191 / drrobin@insightsgroup.net

1245 Washington Road

Rye, New Hampshire 03870

NEW CLIENT INFORMATION AND CONSENT TO TREATMENT AGREEMENT

Welcome to our practice. This agreement contains important information about the professional services and business policies at Insights Group. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and client rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that clinicians provide you with a Notice of Privacy Practices for use and disclosure of PHI for the above purposes. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail.

Please read these documents carefully, ask your therapist any questions you may have, and sign the last page of this document. The law requires that we obtain your signature acknowledging that we have provided you with this information. Once signed, this document constitutes a binding agreement between us. You may revoke this Agreement in writing at any time after all financial obligations are met. These include obligations imposed by your health insurer in order to process or substantiate claims made under your policy; or you have not satisfied any financial obligations you have incurred.

Therapeutic Services

Therapy (including individual, couple, or family) is not easily described in general statements. These vary depending on the particular reasons you are seeking therapy. There are many different methods that may be used to deal with the challenges that you hope to address. Therapy is not like a medical doctor visit; instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.

Therapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy, specifically cognitive behavioral therapy, has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress.

The first few sessions will incorporate a determination of your needs. By the end of the initial period, your therapist will be able to offer you some first impressions of what the psychotherapy work will include. You should evaluate this information along with your own opinions of whether you feel comfortable working with your therapist. If you have questions about any procedures, feel free to discuss these whenever they arise. If your doubts persist, please discuss these further with your therapist, including any alternative methods for resolving them.

Limits on Confidentiality

The law protects the privacy of all communications between a client and a therapist. In most situations, we can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this agreement provides consent for those activities, as follows:

  • We maintain ongoing professional supervision for all our therapists. It is helpful to consult other health and mental health professionals about cases to maintain the best treatment options for those in our care. During a consultation, every effort is made to avoid revealing the identity of a client. The other professionals are also legally bound to keep the information confidential. All consultations will be noted in your Clinical
  • Insights Group contracts with Theresa Chenevert for insurance billing services. Protected information, such as name, diagnosis, and session date, needs to be provided to Mrs. Chenevert for billing purposes. As required by HIPAA, we have a formal business associate contract with her, in which she promises to maintain the confidentiality of this data except as required for insurance billing and processing specifically allowed in the contract or otherwise required by law. Insights Group also contracts with Peak Consultants (https://peakconsultantsllc.com) for bookkeeping services. Protected information is not provided to any employees of Peak
  • Disclosures required by health insurers or required to collect overdue fees are discussed elsewhere in this
  • If a client threatens to harm himself/herself, your therapist may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection

There are some situations where a therapist is permitted or required to disclose information without either your consent or authorization:

  • If you are involved in a court proceeding and a request is made for information concerning the professional services provided to you and/or the records thereof, such information is protected by the therapist-client privilege law. This information cannot be provided without your written authorization or a court order. If involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order the disclosure of such information.
  • If a government agency is requesting the information for health oversight activities, your therapist may be required to provide it.
  • If a client files a complaint or lawsuit against a therapist, then relevant information regarding that client and the treatment may be disclosed for legal defense
  • If a therapist has reason to suspect that a child has been abused or neglected, the law requires that she/he file a report with the Bureau of Child and Family Services. Once such a report is filed, additional information may be required as well. You will be informed of such
  • If a therapist suspects or has a good faith reason to believe that any incapacitated adult has been subjected to abuse, neglect, self-neglect, or exploitation, or is living in hazardous conditions, the law requires the filing of a report with the appropriate governmental agency, usually the Department of Health and Human Services. Once such a report is filed, additional information may be required as well. You will be informed of such
  • If a client communicates a serious threat of physical violence against a clearly identified or reasonably identifiable victim or victims, or a serious threat of substantial damage to real property, protective actions may be required. These actions may include notifying the potential victim, contacting the police, or seeking involuntary hospitalization for the

If such a situation arises, every effort will be made to fully discuss it with you before taking any action, and any disclosure will be limited to what is necessary. While this written summary of exceptions to confidentiality will prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future.

Professional Records

The laws and standards of our profession require that Protected Health Information about you be kept in an individual Clinical Record. You may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them in the presence of your therapist, or have them forwarded to another mental health professional so you can discuss the contents. In the event you request the release of a copy of your Clinical Record, there is a charge for copying fee of $15.00 for the first 30 pages or 50 cents per page, whichever is greater.

Electronic Communications

Increasingly, insurance companies require that we send billing and other information (e.g., treatment plans) electronically. Such communications may be through e-mail, facsimile, and/or a web site. We can not guarantee the confidentiality of such communications. If you do not consent to electronic communications, please inform your therapist immediately so that other arrangements can be made.

Telehealth

Insights Group offers the option of therapy services and psychological, psychoeducational and career evaluation through the use of Telehealth and related technologies to facilitate the delivery of healthcare services. Telehealth involves the use of electronic communications (specifically, TheraLink or Zoom platforms) to enable health care providers and patients at different locations to share patient information for the purpose of improving patient care. The information may be used for diagnosis, therapy, follow-up and/or education, and may, but not necessarily, include any of the following: instant messaging, chat, telephone and/or email conversations, live two-way audio and video, and output data from medical devices and sound and video files. As an option, Telehealth allows for improved access to medical care by enabling a patient to remain at a remote site while but still working with the practitioner at distant/other sites.

By consenting to Telehealth, you understand the following:

  1. You have the right to withhold or withdraw your consent to the use of Telehealth in the course of your care at any time, without affecting your right to future care or
  2. Your practitioner must clearly disclose his/her identity, including information such as the practitioner’s name, address, contact information, and medical licensing credentials.
  3. Insights Group and its representatives will not allow any other people to observe or participate in the Telehealth encounter without your knowledge or advance
  4. Insights Group and its representatives will not make recordings of any video or telephone encounters about you without your advance consent.
  5. You have been informed about when online communication should not take the place of a face-to-face interaction with a practitioner.
  6. You have the right to be provided meaningful opportunities to give feedback about any concerns you may have about your care.
  7. You agree to hold harmless your practitioner for delays in evaluation or for information lost due to such technical failures.
  8. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional

Client Rights

HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include the ability to request an amendment of your record; to request restrictions on what information from your Clinical Records is disclosed to others; to request an accounting of most disclosures of protected health information that you have neither consented to nor authorized; to a determination of the location to which protected information disclosures are sent; to having any complaints you make about our policies and procedures recorded in your records; and to a paper copy of this Agreement, the attached Notice form, and our privacy policies and procedures. Please feel free to discuss any of these rights with your therapist.

NH Board of Mental Health Regulations

The New Hampshire Board of Mental Health Practice regulations require all licensed mental health professionals to provide clients with certain basic information, including the Mental Health

Bill of Rights and information on each professional’s qualifications, scope of practice, and code of ethics. A copy of the Mental Health Bill of Rights is included with this form and posted in our waiting room.

Treatment of Minors

Clients under 18 years of age who are not emancipated and their parents should be aware that the law allows parents to

examine their child’s treatment records unless the therapist decides that such access is likely to injure the child, or we agree otherwise. If the treatment is for drug dependency, parents may examine the records of children under age 12. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes our policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree to this, the therapist will only provide them with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. Any other communication will require the child’s authorization, unless the therapist believes that the child is in danger or is a danger to someone else, in which case, she/he will notify the parents of this concern. Before giving parents any information, the therapist will discuss the matter with the child, if possible, and do her/his best to handle any objections the child may have.

Office Hours

Our office hours are Monday through Thursday from 9:00 am to 8:00 pm, Friday 9:00 am to 4:00 pm, and Saturdays from 8:00 am to 12:00 pm. Exceptions include holidays and scheduled vacations, of which you will be informed in advance.

Telephone Messages

You will typically reach your therapist’s voice mail system when you call. Please leave your message and we will return your call as soon as possible. If you are difficult to reach, please inform your therapist of times when you will be available.

Emergency Coverage

Insights Group does not provide 24-hour crisis management. Therapists will return messages as quickly as possible but delay is to be expected as they support other clients and are not contracted to be “on-call” around the clock. Therapeutic phone contacts are billed at the following rates: 0-15 minutes, no-charge; 16-30 minutes $75; 31-60 minutes, $150. Other forms of communication are billed accordingly. Please address any questions with your therapist. If you are in crisis, call the number provided to you by your therapist for ongoing contact. (Please note that this is not covered by insurance.) In the event of a serious emergency in which time is critical, go directly to the nearest hospital emergency room or call 911.

Appointments

Counseling begins with an initial evaluation, which may last from 1 to 4 sessions. Sessions are typically 45-50 minutes long. Cancellations can disrupt the continuity of treatment and impede its progress. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation, unless we both agree that you were unable to attend due to circumstances beyond your control. It is important to note that insurance companies do not provide reimbursement for cancelled sessions.

Domestic Litigation

If you are involved in domestic litigation or become party to a divorce or custody action, you agree that you will not subpoena your therapist to court to testify. Courts appoint professionals who have had no prior contact with a family to conduct custody evaluations and to make recommendations to the Court. As clinicians, it is our primary role is to provide treatment, and not become encumbered in domestic matters. The professional relationship can be harmed when psychotherapists testify in divorce and custody cases.

Professional Fees and Payment Policies

If a therapist is paneled for insurance, and you choose to use insurance, Insights Group will bill your insurance company for you; however, it is important to realize that insurance companies require diagnostic information before making any payments. Please speak to your therapist if you have any concerns. If we have contracted with your insurance carrier, you will be expected to pay any deductibles and/or co-payments at the beginning of each session. For non-contracted policies, or non-insurance based patients, you will be responsible for payment in full at the time of the visit, unless otherwise arranged with your

therapist. Cash, Venmo, check and credit card payments are accepted. You can read more about the considerations when using insurance at https://insightsgroup.net/insuranceassurance/.

In addition to regular appointments, it is our practice to charge fees for other professional services you may need that extend beyond the standard therapy hour. Such services may include, but are not limited to, report writing, responding when texted, telephone conversations lasting longer than 15 minutes, professional consultations you have authorized, preparation of records, treatment plans and/or summaries. These services are not covered by your insurance company, and will be billed on a prorated basis consistent with our regular fees. If you become involved in legal proceedings that require your therapist’s participation, you will be expected to pay for all of her/his professional time, including preparation and transportation costs, even if she/he is called to testify by another party. Because of the complexity of legal involvement, the charge will be 200% of our regular fee for preparation and attendance at any legal proceeding.

If your account has not been paid for more than 90 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, which will require the disclosure of otherwise confidential information. In most collection situations, the only information that is released regarding a client’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs incurred will be included in the claim.

Insurance Reimbursement

In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment.

Your therapist will complete forms and provide you with whatever assistance needed to help you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of the fees. It is very important that you find out exactly what mental health services your insurance policy covers.

You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, your therapist will provide you with whatever information she/he can regarding your insurance coverage, but it is important to clarify any questions with your insurance company directly.

Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available.

“Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific

problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some clients feel that they need more services after insurance benefits end.

You should also be aware that your contract with your health insurance company requires that your therapist provide it with information relevant to the services that provided to you, and she/he is required to provide a clinical diagnosis. Furthermore, sometimes additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record, are required. In such situations, your therapist will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, we have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information database. You can read more about the considerations when using insurance at https://insightsgroup.net/insuranceassurance/.

By signing this agreement, you agree that your therapist can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for services yourself to avoid the limits of confidentiality with insurance carriers and other problems described.

YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS DOCUMENT WHICH INCLUDES THE CLIENT INFORMATION AND TREATMENT AGREEMENT FORM, AND TELEHEALTH APPROVAL, AND AGREE TO ITS TERMS. YOUR SIGNATURE ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA PRIVACY NOTICE FORM DESCRIBED WITHIN THAT DOCUMENT. If there is information you have questions about, please contact your practitioner prior to signing.

  • Date Format: MM slash DD slash YYYY
  • YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE ARRANGED FOR YOUR CHILD, TO BEGIN THERAPY SERVICES WITH INSIGHTS GROUP AND PROVIDE YOUR CONSENT FOR THIS TREATMENT.
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.
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