DISCLOSURE OF CLINICAL PSYCHOLOGY PRACTICE POLICIES AND PROCEDURES


SSC Neuropsychological Therapy Group PLLC
100 N HOWARD ST STE W, SPOKANE, WA, 99201-0508, UNITED STATES

 

The State of Washington requires that all Psychologists, Therapist, Counselors, and Clinicians provide a complete disclosure statement of their practice, office policies, and payment guidelines. The following statement is detailed and meets the requirements of the State. It will also help you to clearly understand the process of receiving psychological services and what should be read carefully. Thank You.

Overview of Practice

As a licensed Clinician, I provide therapy to adults, children, and adolescents. I provide individualized sessions, couple’s sessions, and, from time to time, groups. I provide consultation to teachers, physicians, vocational rehabilitation counselors and other allied professionals regarding test results and/or treatment results only with written consent of the patient. I am an independent practitioner and am solely responsible for the services and treatment that I provide to clients.

My approach is called "Cognitive-Behavioral Therapy" (CBT). This means that I look at patterns of thinking and behaving that contribute to emotional distress, life difficulties or block the attainment of goals. I believe that it is usually more important to learn how to cope with the present than to relive the past. Thus, therapy is focused on the problems of today, although stumbling blocks and thinking patterns learned over time may be addressed as well. Biological concerns may also play a role, and in some cases referral to a physician or consultation with your own physician(s) for a medical evaluation or for pharmacological treatment may be suggested. In therapy we may discuss current problems, as well as family history, and memories of past events (as they relate to present distress). I may ask many questions to try to understand what thoughts, feelings, our behaviors are negatively influencing you, and to help make sense of how you came to think and act as you do based on early history. My therapeutic style tends to be active/directive, which means that I may point out many behavior or thinking patterns that appear to hinder your emotional growth. I believe the individuals and couples with whom I work should be actively involved in therapy and that our relationship is one of collaboration, a joint working partnership. Your therapy experience will tend to progress more rapidly if you have specific goals for what you would like to achieve.

However, since many people enter therapy just wanting to feel better with a few specific goals, I can help you to develop a plan for therapy, clarify your goals, and to reach appoint of stability within treatment.

Education and Licensure

Nevada State University, Walden University, and Saint James School of Medicine MS, in science and psychology, and Ph.D. in Clinical psychology.
License as a Psychological associate & License Professional counselor associate.

Patients' Rights

1. You have a right to confidentiality. What we discuss in therapy is confidential information and privileged communication in the same manner as conversations between an attorney and client. There are times when the law may compel me to break confidentiality. These exceptions are:
A. If I become aware that a child under 18 is or has been abused, or a developmentally disabled person or a dependent/vulnerable adult is or has been abused, a report must be made to the appropriate authorities (RCW 26.49).
B. If a client threatens another person, I must protect the other person by warning the
person at risk and reporting the danger to the appropriate authorities (RCW 71.05).
C. If a client poses a danger to self or others or is unable to take care of basic needs, I will take appropriate action to protect the client's safety (RCW 71.05).
D. If a client discloses HIV infection, does not have a physician monitoring the
condition, and has IV drug-using or sexual partner(s) I may be obligated to report the
identity of the client and partner(s) to the local public health officials (WAC 248-100-
072). I will first consult with the health care officer without identifying the client, as there may be an exception to this ruling.
E. When ordered by a court of law to release information or when required to comply with an investigation by the State Board of Health, Department of Psychology Licensing.
F. I am required to report to any licensed healthcare provider (including myself) when I have actual knowledge that a final determination of unprofessional conduct has been made by some jurisdiction regarding that provider. I am likewise required to report any incidence of
unprofessional conduct by a healthcare provider that is determined to pose a threat to
patient health or safety. Finally, I am required to report a healthcare provider's mental or
physical condition determined to pose a threat to patient health or safety.

**Please note that many insurance companies now require that progress notes be sent
either to a medical director, primary care provider or, in some cases, to a claims clerk, the notes must be sensible and support continued therapy with a diagnosis and a treatment plan. Furthermore, insurance companies will have you sign a release for them to review my files for auditing purposes and may do so without further consent. The only way for you to be assured that your file is kept confidential is to choose not to use a third-party payer (insurance company) and to pay out of pocket for services. Although this will cause you to incur some expense, it will maintain your privacy in the long run, and you must decide if the potential loss of privacy to an insurance company is worth the reduction in cost. Whether or not the insurance company chooses to audit my files, they will require a psychiatric diagnosis on all claim forms. There are some situations where I am permitted or legally required to disclose information without either your consent or Authorization:
If I have reasonable suspicion that a child has suffered abuse or neglect, the law requires that I file a timely report with the appropriate government agency. If I have reason to believe that you or someone else is in imminent danger, I may be required to take protective actions, including notifying potential victims, contacting the police, seeking hospitalization for you, or contacting family members or others who can help provide for your protection.

As a result of regulations adopted by the Washington State Department of Health in 2008, I am required to report myself or another healthcare provider in in the event of a final determination of unprofessional conduct, a determination of risk to patient safety due to a mental or physical condition, or if I have actual knowledge of unprofessional conduct by another licensed healthcare provider.
Other, limited, circumstances in which confidentiality may be compromised are: if a government agency is requesting the information for health oversight activities (for example to look at Medicare billing compliance) If you file a complaint or lawsuit against me, I am permitted to disclose information as relevant for my defense. If you file a worker’s compensation claim, and your psychotherapy is relevant to the injury involved in your claim, if properly requested, I must provide a copy of your record to your employer and the Department of Labor and Industries. In any of the above situations, I will try to talk with you before acting and I will limit my disclosure to what is necessary.


Identification

Per rules provided by the Federal Trade Commission, designed to reduce healthcare identity fraud, I am required to request identification from new clients. The purpose of this regulation is to flag possible cases of identity theft or fraudulent use of health insurance coverage. On your first visit I will ask for and make a copy of your legal ID (government issued photo identification).

Records

I keep a record of the health care services I provide you. You may ask to see and copy that record. You may also ask me to correct that record. I will not disclose your record to others unless you direct me to do so or unless the law authorizes or compels me to do so (see # 1 above). You may see your record or get more information about it by asking me directly. It is also every client's right to have no session notes kept on file. If this is desired, a record, which includes date, time and type of service and diagnosis, must be kept, but clients can sign a waiver so that no other notes are kept on file. Please understand that without treatment records insurance companies may decide that all or further treatment is not "medically necessary" and may decide that they will not reimburse you for your treatment. Payment Policy - Because billing is complicated in the current healthcare market, and because the cost of services may rightfully cause anxiety for users of healthcare services, this section is quite detailed. I ask that you read it carefully and ask me any questions you have regarding these policies.

Fees:

Consultations and Intake session: $125.00
Psychotherapy (Individual or Couple): $125.00/Session
Case management $125.00/ Services
Therapy and Case management Services $200.00/Session
Canceled or Rescheduled therapy sessions $125.00
Group Therapy: $ 55.00/Person per session
Psychological Evaluation and Report: $150.00/Hour
Psychological Evaluation no Report: $115.00/Hour
In all cases either full payment or co-payments, if an insurance company is involved, are due at the time of service. Please have checks written prior to the beginning of your session. It is the patient's responsibility to be aware of their copayments, insurance company policies, and the need for any pre-authorization. Questions regarding bills, insurance, etc. can be forwarded to the MTG billing department by calling MTG (425)640-7009 Monday through Friday between the hours of 8 a.m. and 5 p.m. You may also route questions to me as they arise, to avert misunderstanding and possible compromise of your treatment. Whether or not an insurance claim is made, you are responsible for all charges incurred. Occasionally insurance claims are denied, even when an insurance company has approved a certain number of sessions. The patient must pay all fees even if the insurance company denies payment on a claim unless I have a specific contract with a Managed Care Company or PPO that states otherwise.


After my responsibility to only bill insurance companies for "medically necessary treatment", in the event that, in spite of my efforts and careful documentation, an insurance company decides after the fact that treatment was not medically necessary and bill me to recover their costs, I will require that you reimburse me for those costs unless expressly prohibited by my contract with a particular insurance company from doing so. If you are uncertain of the policy of your insurance company, I will gladly explain what you should expect regarding payment of denied claims. If you are in a unique situation and having financial difficulties and desire special arrangements, I can refer you to non-profit agencies that are subsidized by the government or other sources.

Sessions

Office hours are scheduled Monday - Friday, unless otherwise arranged due to unique and rare circumstances. Sessions run 45 minutes and may begin on the hour or the half hour. If you are late for a session, that session will last until the scheduled time, but you will be charged for the full 45 minutes. No therapy sessions are conducted over the telephone. If there is a need for a brief crisis intervention over the telephone, calls greater than 10 minutes in length are charged according to my regular fee schedule. Insurance companies do not reimburse for such calls, and the patient is responsible.

Cancellation Policy


I ask that you give me at least 12 hours’ notice of cancellation so that re-scheduling of appointments can be expedited. Cancellations received later or "no-shows" will be the subject. to billing at 100% of my regular fee and is therefore $125.00. Insurance companies will not be billed for charges associated with late cancellations or missed appointments. Such billings are illegal. Payment for missed sessions is due prior to or at the beginning of the next scheduled session.
Voicemail

When I am away from the office, a voice mail system will take your calls. This will also occur if I am in session when you call. Please leave the phone number where you can be reached whenever you leave a message. If you are calling in an emergency, please follow the urgent notification instructions at the end of my greeting and I will return your call at my first opportunity, 24 hours a day. If I am unable to return your call in a reasonable amount of time, do not hesitate to call the Crisis Clinic in Seattle at (206) 461-3222, or dial 911. 1 cannot guarantee that non-emergency calls will be returned within a 24-hour period. If I am scheduled to be out of town, I will let you know the dates in advance. I will provide you with the name of a colleague who can be contacted during my absence in case of an emergency.

Termination of Therapy

There is no set length of time for a person to be in therapy. Therapy will continue until goals are met, there is a mutual decision that the work of therapy is complete, or until the patient decides that they wish to stop. Periodic discussion of the progress that we are making will help to clarify goals and to evaluate your progress. Many insurance companies set limits on the number of sessions for which they will reimburse. This may vary from policy to policy, even with policies written by the same company. Individual policies, or policies written for small companies, may not cover outpatient mental health treatment. If you do not know the limits of your coverage, it is a good idea to call to find out that information. A treatment plan that considers your psychological needs, the limits of your insurance coverage, realistic goals that can be addressed in the given period and alternatives for what to do when and if your insurance no longer covers you for psychological services, will all be discussed with you.

(Please read the information sheet regarding "medical necessity" for further information about length of treatment and insurance reimbursement).

Dr. Shantay Coleman primarily uses a cognitive/behavioral approach during therapy sessions. This approach has been shown to be a valid treatment for depression, anxiety, and other psychological problems. This is a short-term therapy approach in which the therapist is active, assigns homework tasks, and keeps therapy goals directed and focused on the present, not the past. Dr. Shantay Coleman may utilize many psychological approaches or methodological approaches, which selection approach would be associated with an individual’s individualized signs and symptoms and current diagnosis.
My signature below indicates that I have read the disclosure statement provided during my initial session for psychological services by Dr. Shantay Coleman, and that all questions have been answered to my satisfaction. I understand that this is a legal document and that there are no other agreements, verbal or written, than those set forth in this document. I understand that I am responsible for payment at the rate listed in this disclosure statement unless other arrangements have been agreed upon and written below. I recognize that Dr. Coleman is an independent practitioner and that she is not a part of, or responsible for, a group. It is clear to me that Dr. Coleman is the only person with whom I am entering into an agreement with for psychological services and I can hold no other person, regardless of physical proximity to her, responsible for the services provided. Dr. Land may change his office policies and procedures at his discretion and will notify me in writing.

 

 

Special fee arrangement (if applicable):     

With the understanding that I am under no obligation to continue should I wish to cease therapy, I hereby give my consent for treatment and my signature indicates that I have agreed to the policies and procedures detailed in this document.
 
 Client  (if applicable) :      

Date :                             

Client 2 (or Guardian ):   

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Document name: DISCLOSURE OF CLINICAL PSYCHOLOGY PRACTICE POLICIES AND PROCEDURES
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