Nassau Psychology Dynamic P.C. Child and Adult Neuropsychology 335 Central Ave. 2C Lawrence, NY 11559

SERVICES INFORMATION AND CONSENT FOR EVALUATION / TREATMENT

Welcome to our practice. This document contains important information about professional services and business policies. Please read it carefully and note any questions the client might have, which can be discussed at the beginning of the appointment. When the client signs this document, it will represent an agreement between the client and Nassau Psychology Dynamic P.C..

PSYCHOLOGICAL SERVICES

Psychotherapy, psychological testing, and neuropsychological testing are not easily described in general statements. The specifics vary depending on the personalities of the psychologist and client and the particular concerns the client brings forward. Several methods may be used to evaluate and treat the issues the client hopes to address. These services differ from a medical doctor visit in that they call for a very active effort on the client’s part. For these services to be successful, it will be necessary for the client (adult or child) to contribute during and sometimes outside of the sessions. The client understands there is no guaranteed, implied or predictable outcome for an evaluation or treatment. The client understands that the psychological services at Nassau Psychology Dynamic P.C. may be provided by a range of mental health professionals, some of whom are in training. All professionals-in-training are supervised by licensed staff. The client understands that while psychological/neuropsychological evaluations and/or psychotherapy may provide significant benefits, they may also pose risks. The evaluations and treatment may elicit uncomfortable thoughts and feelings and may lead to the recall of troubling memories or other emotional, behavioral, and physical reactions.

DEPOSITS

To reserve an evaluation slot, the client must submit a deposit (payment methods are usually specified in the welcome email). This deposit will hold the slot but should not be considered a guarantee of the appointment time, as extenuating circumstances sometimes make it difficult to accommodate the appointment. In such cases, the client will be contacted about rescheduling. Deposits are refundable up to a week before the evaluation. The deposit amount will go to the overall balance for the appointment.

MISSED SESSIONS/CANCELLATIONS

Once an appointment is scheduled, the client will be expected to pay for it unless the client provides 48 hours advance notice of cancellation. If it is possible, we will try to find another time to reschedule the appointment. The client can stop the evaluation or treatment at any time but will still owe the entire balance of the evaluation or treatment sessions.

BILLING AND PAYMENTS

The client is expected to pay half of the balance for evaluations and the entire balance for therapy and consultations before the session. This can be submitted by cash, check, Quickpay, Paypal, or Venmo at the beginning of a session. The entire balance for the evaluation is due before any feedback or report. Evaluations range in their fee structure and depend on individual case details. Hourly therapy and consultation rates are generally $250-$400 per session, but the rate may vary depending on the specific service. Phone calls longer than 5 minutes will be charged on a prorated basis.

INSURANCE REIMBURSEMENT

As our clinicians are licensed clinical psychologists in Florida and New York, clients can sometimes obtain partial reimbursement with out-of-network benefits in their insurance plan. Importantly, the client is responsible for determining if they have these benefits and for any necessary actions to access these benefits. Our clinicians will complete the forms needed for these benefits, within reason, but we do not contact insurance companies on behalf of our clients. The client (not the client’s insurance company) is responsible for the full payment of fees at the time of service. The client should carefully read the section in their insurance coverage booklet (or website) that describes mental health (aka “behavioral health”) services. If clients have questions about the coverage, they should contact their plan’s administrator. We will provide the client with whatever information we can based on our experience. We will be happy to help the client understand the information the client receives from the client’s insurance company. Still, we are not responsible for the accuracy of the information about insurance and coverage as this is not our focus.

CONTACTING US

Our neuropsychologists are often not immediately available by telephone. When unavailable, their telephones are answered by voicemail and are usually monitored frequently. We will make every effort to return calls as soon as possible during the workweek. If it is difficult to reach the client, please inform us of some times when the client will be available. If it is a simple matter such as scheduling that can be easily addressed, the client may also reach our office via email ([email protected]), and we will try to reply to the client by email on the same day except on weekends and holidays. If the client is unable to reach us and feels that they cannot wait, they should contact their family physician or go to the nearest emergency room and ask for the psychologist or psychiatrist on call. If, for any reason, we are unavailable for an extended time, we will try to provide the client with information about whom to contact if necessary.

TELEPSYCHOLOGICAL SERVICES

There are potential benefits and risks of video conferencing (e.g., limits to patient confidentiality) that differ from in-person sessions. Confidentiality still applies for telepsychology services in that nobody will record the session without permission from the other person(s). We generally use Zoom or Google Meet for these appointments, and the client agrees to the limited privacy afforded by those platforms. The client needs to use a webcam or smartphone during the session, and it is important to be in a quiet, private space that is free of distractions (including cell phones or other devices). Using a secure internet connection rather than public/free Wi-Fi is also important. Understandably, it may be determined that telepsychology is no longer appropriate due to certain circumstances, and treatment will be discussed.

RECORDINGS

It is sometimes necessary to record evaluations or therapy sessions to provide better psychological care. This will generally be discussed with the client, and they will be asked for verbal consent. These recordings are only used for evaluation and treatment purposes and will not be shared without explicit consent by the client. The client can object to being audio recorded or videotaped, and it will in no way jeopardize their relationship with our business.

ELECTRONIC COMMUNICATION

We are committed to protecting your personal health information (PHI) as defined in the Health Insurance Portability and Accountability Act (HIPAA) to the best of our ability. Still, we want you to understand the limitations of our power to do so when it comes to communication outside of individual sessions. Please read and acknowledge the following limits of confidentiality when using the phone, texting, or email. Cell phone calls, cellphone voicemails, texts, and email are not secure forms of communication. As a result, while we will attempt to protect the information shared by these methods (email inboxes, phones, and voicemail will be password protected), confidentiality can only be partially ensured when using these methods of communication. We cannot guarantee that any information sent via email or left in our voicemail box or text message database can be completely protected. By signing below, you allow us to communicate with you with PHI via email, phone, or text, even if these methods are not HIPAA compliant. If the client prefers, HIPAA-compliant communication platforms will be used.

PARENTS/ LEGAL GUARDIAN

If the client is a minor, the parent(s)/legal guardian signed below consents to the minor being evaluated and/or treated by the staff at Nassau Psychology Dynamic P.C.. By law, any child under 18 years old cannot be seen by a doctor without consent from a parent or legal guardian. If the minor arrives with someone other than a parent or legal guardian, we must have written permission from the parent or legal guardian that you have appointed this person to act on your behalf.

CONFIDENTIALITY

All information between evaluator/therapist and client is strictly confidential unless: