Fonda Hart, RN, LMFT

Licensed Marriage and Family Therapist

Forms

  • Psychotherapy Intake Form

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  • Consent For Treatment Of A Minor

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  • Agreement For Service / Informed Consent

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  • Acknowledgement Of Receipt Of Notice Of Privacy Practices

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Agreement For Service / Informed Consent

  • Introduction

  • This agreement is intended to provide you with important information regarding the policies of Fonda Hart, LMFT (herein “Therapist”) and to clarify the terms of the therapeutic relationship between Therapist and client. Any questions or concerns regarding this Agreement should be discussed with Therapist prior to signing it.

  • Confidentiality

  • Information disclosed by Client is generally confidential and will not be released to any third party without written authorization from Client, except where required or permitted by law. Exceptions to confidentiality include, but are not limited to, reporting child, elder, and dependent adult abuse; when a client makes a serious threat of violence toward a reasonably identifiable victim, or when a client is at risk of harming himself or herself.

    When providing couples therapy, Fonda Hart has a “No Secrets” policy. This means that, if one partner in the couple-ship calls and shares something with the intent of withholding it from the other partner, Therapist will not hold this information as a secret but will work with that partner to bring the information into the couple therapy process. Secrets between one partner and Therapist undermine the effectiveness of the treatment process.

  • Fee and Insurance

  • Client is expected to provide full payment at time of session. Therapist has chosen to operate as an “out of network” therapist and is not a participating member of any insurance panels. A superbill will be provide so that Client may seek reimbursement from his/her insurance.

    If Client does not pay the balance in full, and Therapist has attempted unsuccessfully for 3 months to collect the balance owed, Client will be referred to a collections agency to recover the unpaid balance. When a referral to Collections is made, adjustment or fee reductions will be reversed, and all sessions will be invoiced at the full fee.

    If during the course of therapy, Client requests that Therapist review a medical or legal report, or write a letter or treatment summary, Client agrees to reimburse Therapist for the time spent.

  • 24 Hour Cancellation Policy

  • In the event that Client needs to cancel a session, Therapist is to be notified at least 24 hours in advance. Client is responsible for payment of session fee for any missed sessions if 24-hour notice was not given. Insurance does not reimburse for missed or late-cancelled sessions.

  • Therapist Availability

  • Therapist has a confidential voicemail that allows Client to leave a message at any time. Therapist will make every effort to return calls within 24 hours (or by the next business day), but cannot guarantee calls will be returned immediately. Therapist is unavailable on weekends and holidays and is unable to provide 24-hour crisis service. In the event that Client is feeling unsafe or requires immediate medical or psychiatric assistance, he/she should call 911, or go to the nearest emergency room. Client may text Therapist at her phone number, but Client recognizes that confidentiality cannot be guaranteed.

  • Telemedicine

  • On occasion, Therapist may engage in telephone contact with Client for purposes other than scheduling sessions. Client is responsible for payment of the agreed upon fee for any telephone calls longer than ten minutes. A phone session longer than 15 minutes but less than 30 minutes will be billed at the rate of a 30- minute session. A phone session longer than 40 minutes but less than one hour will be billed at the normal session fee. Insurance companies do not generally reimburse for telephone sessions. Some people prefer to schedule via E-mail rather than telephone. Although Therapist has an encrypted E- mail system, Client should be aware that E-mail is not as secure as telephone and Client assumes the risk for any violation of confidentiality that occurs in the E-mail communication. E-mail communication may be used for scheduling and other logistical needs, but not for therapy.

  • Client Litigation

  • Therapist does not provide court reports, custody or court evaluations. Therapist does not provide testimony unless required to do so by law. If Therapist is subpoenaed, or ordered by court of law, to appear as a witness in an action involving Client, or as Expert Witness, Client agrees to reimburse Therapist for any time spent for preparation, travel, and any other time during which Therapist has made herself available for such an appearance at Therapist’s forensic rate of $200.00 per hour.

  • Privacy Practices

  • Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. I. I HAVE A LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH lNFORMATION (PHI) As your healthcare provider, I am legally required to protect the privacy of your PHI. This includes information that can be used to identify you that I've created or received about your past, present, or future health or condition, the provision of health care to you, or the payment of this health care. I must provide you with this Notice about my privacy practices, and such Notice must explain how, when, and why I will “use” and “disclose” your PHI. A “use” of PHI occurs when I share, examine, utilize, apply, or analyze such information within my practice; PHI is “disclosed” when it is released, transferred, has been given to, or is otherwise divulged to a third party outside of my practice. With some exceptions, I may not use or disclose any more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made. And, I am legally required to follow the privacy practices described in this Notice. However, I reserve the right to change the terms of this Notice and my privacy policies at any time. Any changes will apply to PHI on file with me already. Before I make any important changes to my policies, I will promptly change this written Notice and post a new copy of it in my office and on my website (if applicable). You can also request a copy of this Notice from me, or you can view a copy of it in my office or at my website, which is located at www.fresnocounseling.com. II. HOW I MAY USE AND DISCLOSE YOUR PHI. I will use and disclose your PHI for various reasons. For some of these uses or disclosures, I will need your prior written authorization; for others, however, I do not. Listed below are the different categories of my uses and disclosures along with some examples of each category. A. Uses and Disclosures Relating to Treatment, Payment, or Health Care Operations Do Not Require Your Prior Written Consent. I can use and disclose your PHI without your consent for the following reasons: 1. For Treatment. I can use your PHI within my practice to provide you with mental health treatment, including discussing or sharing your PHI with my trainees and interns. I can disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are involved in your care. For example, if a psychiatrist is treating you, I can disclose your PHI to your psychiatrist to coordinate your care. 2. To Obtain Payment for Treatment. I can use and disclose your PHI to bill and collect payment for the treatment and services provided by me to you. For example, I might send your PHI to your insurance company or health plan to get paid for the health care services that I have provided to you. I may also provide your PHI to my business associates, such as billing companies, claims processing companies, and others that process my health care claims. 3. For Health Care Operations. I can use and disclose your PHI to operate my practice. For example, I might use your PHI to evaluate the quality of health care services that you received or to evaluate the performance of the health care professionals who provided such services to you. I may also provide your PHI to my accountant, attorney, consultants, or others to further my health care operations. 4. Patient Incapacitation or Emergency. I may also disclose your PHI to others without your consent if you are incapacitated or if an emergency exists. For example, your consent isn't required if you need emergency treatment, as long as I try to get your consent after treatment is rendered, or if I try to get your consent but you are unable to communicate with me (for example, if you are unconscious or in severe pain) and I think that you would consent to such treatment if you were able to do so. B. Certain Other Uses and Disclosures Also Do Not Require Your Consent or Authorization. I can use and disclose your PHI without your consent or authorization for the following reasons: 1. When federal, state, or local laws require disclosure. For example, I may have to make a disclosure to applicable governmental officials when a law requires me to report information to government agencies and law enforcement personnel about victims of abuse or neglect. 2. When judicial or administrative proceedings require disclosure. For example, if you are involved in a lawsuit or a claim for workers’ compensation benefits, I may have to use or disclose your PHI in response to a court or administrative order. I may also have to use or disclose your PHI in response to a subpoena. 3. When law enforcement requires disclosure. For example, I may have to use or disclose your PHI in response to a search warrant. 4. When public health activities require disclosure. For example, I may have to use or disclose your PHI to report to a government official an adverse reaction that you have to a medication. 5. When health oversight activities require disclosure. For example, I may have to provide information to assist the government in conducting an investigation or inspection of a health care provider or organization. 6. To avert a serious threat to health or safety. For example, I may have to use or disclose your PHI to avert a serious threat to the health or safety of others. However, any such disclosures will only be made to someone able to prevent the threatened harm from occurring. 7. For specialized government functions. If you are in the military, I may have to use or disclose your PHI for national security purposes, including protecting the President of the United States or conducting intelligence operations. 8. To remind you about appointments and to inform you of health-related benefits or services. For example, I may have to use or disclose your PHI to remind you of your appointments, or to give you information about treatment alternatives, other health care services, or other health care benefits I offer that may be of interest to you. C. Certain Uses and Disclosures Require You to Have the Opportunity to Object. 1. Disclosures to Family, Friends, or Others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

  • Acknowledgement

  • By signing below, Client acknowledges that he/she has reviewed and fully understands the terms and conditions of this Agreement. Client has discussed any questions with Therapist and has his/her concerns addressed to Client’s satisfaction. Client agrees to abide by the terms and conditions of this Agreement and consents to participate in psychotherapy with Therapist. Client has a right to terminate therapy at any point. Therapist also maintains the right to terminate the treatment process if warranted. In that case, Therapist will offer names of other therapists who may be a good therapeutic fit for Client.
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