Clinic Policies, Procedures, Confidentiality, and Informed Consent for Psychological Services
The Process of Therapy/Evaluation and Scope of Practice. Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to produce lasting effects. During evaluation and therapy, remembering and talking about unpleasant events, feelings, or thoughts can bring up strong feelings of anger, sadness, worry, fear, etc., which may initially make you feel worse. The doctor may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. While research and professional experience support that for most people psychotherapy is highly effective in alleviating symptoms of emotional distress, there is no guarantee that psychotherapy will solve all your problems. During therapy, your doctor is likely to draw on various psychological approaches according to the problem that is being treated and her assessment of what will best benefit you. These approaches include, but are not limited to, behavioral, cognitive-behavioral, cognitive, psychodynamic, psychoanalytic, developmental, existential, humanistic, or psycho-educational. The psychologists at Introspection Beverly Hills do not provide medication or prescription recommendations, custody evaluations, or legal advice, as these activities do not fall within their scope of practice. It is important to note that if you are making the appointment to secure paperwork – NO PAPERWORK WILL BE COMPLETED DURING THE FIRST FIVE VISITS. People likely to benefit from their experience with our group are typically interested in establishing an ongoing relationship focused on improving their overall health and psychological wellness. If you are primarily interested in disability paperwork or a service animal letter our group is not an appropriate match.
The Difference Between a Psychiatrist, Psychologist, and Therapists.
Psychiatrists are licensed medical doctors who complete four years of residency training after medical school to specialize in mental health. They perform psychotherapy and prescribe medication. Because psychiatrists are physicians, they will first address any physical health issues that could be affecting mental health issues such as thyroid or vitamin deficiency. Meeting with a psychiatrist does not mean that you will receive a prescription for medication – there is not a pill for every issue. However, therapy is effective for everyone. Patients meet with a psychiatrist at least once and if regular care is recommended typically about once a month. Although psychiatrists are trained in medication management and psychotherapy, they are not qualified to interpret psychological tests.
Psychologists are specialized mental health doctors who complete 7-10 years of graduate studies in research and practice of Psychology. As Ph.D.s or Psy.D.s, psychologists are the only experts qualified to interpret psychological tests. Psychological testing adds a significantly higher level of precision to the diagnosis of mental health disorders and a qualitative understanding of the patient’s subjective stance. In addition to psychological testing, psychologists are experts in various modalities of psychotherapy. Psychologists typically meet with their patients weekly or in the case of psychodynamic and psychoanalytic treatments several times a week.
Licensed Marriage and Family Therapists (LMFT) and Licensed Clinical Social Workers (LCSW) are therapists who do talk therapy. They are not medical doctors and do not prescribe medication. They are not psychologists and do not interpret psychological testing. They typically meet with clients weekly or every other week.
Length of Therapy. The overall length of therapy varies depending on a few factors. At Introspection Beverly Hills we start patients out with a series of one-year weekly therapy sessions. Each therapy session is 50 minutes long. The purpose of these sessions is to check-in, discuss goals, develop insight and translate that insight into a plan for action. The initial one-year therapy series can be extended as needed. You may cancel any or all future appointments at any time and without any penalties by emailing scheduling@introspectionbeverlyhills.com or calling 424-421-4514 at least 24-hours in advance of your next weekly appointment.
Cancelation, Rescheduling, and No-Shows. Since scheduling an appointment involves reservation of time, a minimum of 24 hours (one business day) notice is required for rescheduling or canceling an appointment. Unless we reach a different agreement (for example, The Concierge Membership) the full $250 fee will be charged for sessions missed without such notification. Insurance companies do not reimburse for missed sessions; therefore, if you are an insurance patient, the full session fee of $250 will be charged to you if you late-cancel (less than 24-hour notice) or no-show for a scheduled appointment.
Termination. If at any point during psychotherapy your doctor either assesses that she is not effective in helping you reach the therapeutic goals or perceives you as non-compliant, she will discuss termination of treatment with you. If appropriate and/or necessary, she will recommend other qualified professionals to you. If you request and authorize it in writing, your doctor will talk to the provider of your choice to help with the transition. If at any time you wish to consult with another provider, you may do so. You have the right to terminate treatment at any time and without any penalties.
Payments and Insurance Reimbursement. Payments and co-payments are charged at the time of scheduling a session. Patients using their insurance for payments are responsible for their deductible payments, co-payments, and any payments denied by their insurance. Telephone conversations, site visits, writing and reading of reports, consultation with other professionals, release of information, reading
records, longer sessions, travel time, etc. are charged at the hourly rate of $250, unless indicated and agreed upon otherwise. Treatment rates increase over time, and you are recommended to refer to our website for the most up-to-date rates. Please notify our office if any
problems arise during therapy regarding your ability to make payments. Private pay patients who wish to obtain reimbursement from their insurance may request a Super Bill.
Records and Your Right to Review Them. Both the law and the standards of our profession require that we keep treatment records for at least 7 years. Please note that clinically relevant information from emails, texts, and e-faxes are part of the clinical records. Unless otherwise agreed to be necessary, Introspection Beverly Hills retains clinical records only as long as is mandated by California law. If you have concerns regarding the treatment records, please discuss them with your doctor. As a patient, you have the right to review or receive a
summary of your records at any time, except in limited legal or emergency circumstances or when your doctor assesses that releasing such information might be harmful in any way. In such a case, your doctor will provide the records to an appropriate and legitimate mental health professional of your choice.
Telephone and Emergency Procedures. If you need to contact your doctor in between sessions, please leave a message at 424-421-4514 and your call will be returned as soon as possible. Our messages are checked a few times during business days only. If you need to talk to someone right away please call Psychiatric Mobile Response Team (310) 482-3260, 24-hour Crisis Hotline (800) 854-7771, or Suicide Prevention Hotline (310) 391-1253. If an emergency situation arises please immediately call 911. Please do not use email or voicemail for emergencies. Your doctor may not always check her email or voicemail daily.
Confidentiality. All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law.
When Disclosure is or May Be Required By Law. Some of the circumstances where disclosure is required or may be required by law are: where there is a reasonable suspicion of child, dependent, or elder abuse or neglect; where a patient presents a danger to self, others, property, or is gravely disabled; or when a patient’s family members communicate to your doctor that the patient presents a danger to others. Disclosure may also be required pursuant to a legal proceeding by or against you. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by your doctor.
Emergency. If there is an emergency during therapy, or in the future after termination, where your doctor becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, she will do whatever she can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, she may also contact the person whose name you have provided as your emergency contact.
Litigation. Sometimes patients become involved in litigation while they are in psychotherapy or after therapy has been completed. In some cases, patients (or the opposing attorney) may want the records disclosed to the legal system. Due to the nature of the psychotherapeutic process and the fact that it often involves making a full disclosure regarding many personal matters, patients’ records are generally confidential and private in nature. Patients should know that very serious consequences can result from disclosing therapy records to the legal system. Such disclosures may negatively affect the outcome of custody disputes or other legal matters and may negatively affect the therapeutic relationship. If you or the opposing attorney are considering requesting your doctor’s disclosure of the records, your doctor will do her best to discuss with you the risks and benefits of doing so. As noted in this document, you have the right to review your own psychotherapy records anytime.
Consultation. Your doctor regularly consults with other professionals regarding her patients. However, each patient’s identity remains completely anonymous and confidentiality is fully maintained.
E–mails, Cell Phones, and Computers. Computers, unencrypted email, and texts (which are part of the clinical records) can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. Your doctor’s computer is equipped with a firewall, a virus protection system, and a password. While data on your doctor’s computer is encrypted, emails and texts are not. Further, there is always a possibility that emails and texts can be erroneously sent to the wrong address and computers. As such, Introspection Beverly Hills encourages the absolute minimum sharing of clinical information via electronic media.
Audio or Video Recording. In certain treatment modalities, such as psychodynamics and psychoanalysis, it is typical to audio or video record treatment sessions. In such cases, your doctor may audio and/or video record the sessions. Unless otherwise agreed to in advance and in writing, you may not audio or video record the therapy sessions, phone calls, or any other services provided by your doctor.
Consent for Telehealth Consultations
One of the purposes of this form is to obtain your consent for a telehealth consultation with an Introspection Beverly Hills, APPC provider. Telehealth involves the use of audio, video or other electronic communications (for example, Zoom) to interact with you for the purpose of diagnosis, therapy, follow-up and/or education. During your telehealth consultation, details of your medical history and personal health information may be discussed with other health professionals through the use of interactive video, audio and telecommunications technology. The benefits of telemedicine include having convenient access to providers, additional medical information and education.
I have read the above Clinic Policies, Procedures, Confidentiality, and Informed Consent for Psychological Services carefully. I understand them and agree to comply with them.
Payment Policy and Assignment of Benefits
Patient FAQs & Payment Policy
Thank you for partnering with us on your journey to Introspection. We are committed to providing you with quality wellness and health care services. The following policies have been developed by Introspection Beverly Hills (the “Group”) to address frequently asked questions (FAQs) including matters related to payment for services and insurance.
Please read it, ask us any questions you may have, and sign in the space provided. We believe receiving and paying for healthcare can be better. It should be simple, clear and transparent. You should be able to register online, in advance before you visit a doctor’s office, and you should know what the price is before you schedule any services.
Prices & Services
$250 – 50-minute session with a Psychologist
Therapeutic Relationship. The true value of the services we provide is based on a successful relationship. Results aren’t achieved in one visit or with one pill. Individuals who achieve their goals do so in the context of a meaningful relationship with our care team. In fact, the best predictor of results is the quality of the relationship individuals enjoy with our team. A successful relationship requires honest and transparent communication.
What is Therapy? Imagine the life you want and take action to achieve that life. Therapy is about examining the “why” behind the choices you’re making. It involves effort to increase your understanding of yourself, and requires you to establish goals for the life you imagine. With increased self-awareness you can take action to realize the life you imagine.
How Do We Provide Therapy? Patients meet with psychologists usually weekly or bi-monthly for 50-minute sessions for talk therapy. At Introspection Beverly Hills, we schedule you for a one-year series of sessions. The purpose of these sessions is to check-in, discuss goals, develop insight and translate that insight into a plan for action.
Insurance. We participate in most insurance plans. If you are not insured by a plan we do business with, payment in full is expected at the time of scheduling a visit. Please bring a current insurance card with you, or we may require you to pay in advance for the visit. Knowing your insurance benefits is your responsibility. Please contact your insurance with any questions you may have regarding your coverage.
Co-payments, co-insurance and deductibles. All co-payments, co-insurance and deductibles must be paid at the time of check in for a service. In the unusual event that a required co-payment, co-insurance, or deductible amount is not collected at the time of check in for a service, your signature on this policy provides your consent and authorization for us to charge the credit card we have on file for you in the amount of any required co-payment, co-insurance, or deductible that is required pursuant to the terms of your insurance policy.
Non-covered services. Please be aware that some – and perhaps all – of the services you receive may be deemed non-covered by insurers. In some cases, we are unable to determine whether the services will be covered at the time of the visit. In those cases, we will submit a bill to you after your visit if your insurer notifies us that the services were not covered. Services such as consultation with other medical or legal entities are not billable to insurance. You will be personally financially responsible for payment of these bills and by signing this policy, you agree that it is your responsibility to pay for these services and hereby authorize us to charge your credit card on file at our rate of $250 per hour for these services.
Proof of insurance. We must obtain a copy of your current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for paying the price for the services you received.
Claims submission. We will submit your claims only to insurers that we are in network with. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract, and if they deny the service as a result of your failure to provide the proper information, you may be responsible for payment.
Coverage changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. In the event that the insurer does not make timely payment, we will encourage you to follow-up with your insurer and make sure you are receiving the benefits you pay for.
Timely payment. When not using insurance, full payment is made prior to receiving services. When you use insurance, if your insurer has not paid our group for services in the typical timeframe expected, future appointments for services may be postponed or discontinued at our sole discretion. If this happens, we will notify you.
Valid method of payment on file. To be a patient of our group you must maintain a valid method of payment on file such as a credit card or debit card bearing the Visa, Mastercard, American Express or Discover logo. When paying for products or services, you must use a credit card or debit card. For safety and security reasons, we do not accept cash or check.
Outstanding Balances. All outstanding balances not paid at the time of scheduling a service will be automatically billed to your method of payment on file. By signing this agreement, you give us authority to do so.
Twenty-Four (24) Hour Cancellation Policy. You will be scheduled for a weekly or bi-monthly series of sessions for a period of one year. You must cancel your appointment 24 hours prior to your appointment time to provide sufficient notice and avoid paying the Late Cancellation & Missed Appointment Price.
Saturday, Sunday or Monday Appointments. If you have a Saturday, Sunday or Monday appointment you must cancel by 4pm on Friday to avoid the Late Cancellation & Missed Appointment fee.
How to Cancel an Appointment. Sufficient notice can be provided by sending an email to scheduling@introspectionbeverlyhills.com or calling the office at 424-421-4514. If you call the office, you MUST leave a voicemail if you do not speak directly with a team member.
Never send an email to a NOREPLY email or send text messages – that is NOT sufficient notice as these are not received.
Late Cancellation, late-arrival, & Missed Appointment Prices. If you miss your appointment without sufficient notice you are financially responsible for the time that was reserved for you. As no service is rendered we are unable to bill your insurance and you are responsible entirely for paying the price of the session you reserved. Arriving more than 25 minutes late for a session constitutes a no-show. No-shows are treated as missed appointments and you will be responsible for full payment.
Authorization of Payment for Services & Communication Methods
- I authorize the Group to charge my card on file for services rendered, as well as for late cancellations, no-shows or late arrivals.
- I understand that unpaid balances that I personally owe to the Group will be turned over to a collection agency and appreciate that appointments will not be provided if I have unpaid balances outstanding.
- I understand that furnishing my email address authorizes the communication of potentially sensitive material via email. I understand that email may not be secure. I will not email my doctor regarding emergencies, but instead, I will call 911 immediately.
- I authorize the Group to use SMS Text Messaging, Email and Phone Calls to provide appointment reminders to me and consent to the download of my medication history.
- I understand my doctors work by appointment only.
Assignment of Benefits
- I hereby authorize and assign providers associated with the Group to receive reimbursement from my insurance carrier for payments associated with services rendered to me.
- I hereby authorize the Group to furnish my insurance carrier with all information necessary to process any insurance claims for medical services, and to act on my behalf if necessary.
Our practice is committed to providing the best treatment to our patients. Thank you for understanding these FAQs and our payment policy. Our group’s payment policy is based in part on the standard payment policy developed and recommended by the American Academy of Family Physicians. Please let us know if you have any questions or concerns.
I have read and understand the payment policy and agree to abide by its guidelines.
HIPAA Privacy and Release of Information Authorization
I hereby authorize Introspection Beverly Hills and its affiliates, its employees and agents, to use and disclose protected health information (e.g., information relating to the diagnosis, treatment, claims payment, and health care services provided or to be provided to me and which identifies my name, address, social security number, Member ID number) for the purpose of helping me to resolve claims and health benefit coverage issues.
I understand that any personal health information or other information released to the person or organization identified above may be subject to re-disclosure by such person/organization and may no longer be protected by applicable federal and state privacy laws.
I understand that I have a right to revoke this authorization by providing written notice to. However, this authorization may not be revoked if, it’s employees or agents have taken action on this authorization prior to receiving my written notice. I also understand that I have a right to have a copy of this authorization.
I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
I further understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my eligibility for benefits or enrollment or payment for or coverage of services.
I have been advised of this practice’s Privacy Practices, Release of Billing Information policy, Assignment of Benefits policy, and grant the practice Medication History Authority.
If applicable, Legal Representatives sign below:
By signing this form, I represent that I am the legal representative of the Member identified above and will provide written proof (e.g., Power of Attorney, living will, guardianship papers, etc.) that I am legally authorized to act on the Member’s behalf with respect to this authorization form.