AGREEMENT FOR PSYCHOTHERAPY SERVICES
MELISSA MOSE, M.A. LMFT – Psychotherapy & Educational Consulting
PAYMENT: Payment is due at the end of each session unless other arrangements are made. Please notify me if any problem arises during the course of therapy regarding your ability to make timely payment. Returned checks are charged an additional
$ 20.00 fee. Telephone conversations beyond 15 minutes, site visits, report writing and reading, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged the same rate, unless indicated and agreed otherwise.
INSURANCE: Patients who carry insurance should remember that professional services are rendered and charged to the patient and not the insurance company. I will provide you with a statement that you can submit to your insurance company for reimbursement. Reduction or rejection of your claim by your insurance company does not relieve you of your financial obligation.
CONFIDENTIALITY: All information disclosed within sessions, including that of minors is confidential and may not be revealed to anyone without your written permission, except where disclosure is permitted or required by law. Disclosures may be required in the following circumstances.
When Disclosure is Required By Law:
1. When there is reasonable suspicion of child, dependent, or elder abuse or neglect:
2. When a patient presents a danger to self, to others, to property, or is gravely disabled (for more details see also
Notice of Privacy Practices form).
3. When patient is suicidal.
4. Physical injury due to violence.
5. When disclosure is required pursuant to a legal proceeding.
6. If you place your mental status at issue in litigation by you, the defendant may have the right to obtain
psychotherapy records and/or my testimony. In couple and family therapy, or when different family members are
seen individually, confidentiality and privileged do not apply between the couple and or family members. I will
use my clinical judgment when revealing such information. I will not release records to any outside party unless
authorized to do so by all adult family members who were part of the treatment.
I receive regular professional consultation. In such cases, neither your name or any identifying information about you is revealed.
Health Insurance & Confidentiality of Records: Disclosure of confidential may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. If you so instruct me, the minimum necessary information will be communicated to the carrier. I have no control over or knowledge of what insurance companies do with the information s/he submits or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy, or to future eligibility to obtain health or life insurance.
Confidentiality of E-mail, Cell Phone and Faxes Communication: It is very important to be aware that e-mail and cell phone communication can be relatively easily accessed by unauthorized people and hence, the privacy and confidentiality of such
communication can be compromised. E-mails, in particular, are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e-mails that go through them.
Faxes can easily be sent erroneously to the wrong address. Please notify me at the beginning of treatment if you decide to avoid or limit in any way the use of any or all of the above mentioned communication devices. Please do not use e-mail or faxes for emergencies. I agree to receive communication by Melissa Mose by her cell phone.
Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) or your attorney, nor anyone else acting on your behalf will call on Melissa Mose to testify in court or at any other legal proceeding, nor will a disclosure of the psychotherapy records be requested.
Telephone & Emergency Procedures: If you need to contact me between sessions, please leave a message and your call will be returned as soon as possible. When I am out of town or otherwise unavailable, a qualified professional will cover for me. If an emergency situation arises, clearly leave your name, number and nature of the crises. If you need help immediately, you can call 911 or a 24-hour crisis line or your closest emergency room.
If there is an emergency during our work together, or in the future after termination, where I become concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, I will do whatever I can within the limits of the law, to prevent you form injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, I may also contact the person whose name you have provided on the biographical sheet.
MEDIATION & ARBITRATION: All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a precondition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of Melissa Mose and client(s). The cost of such mediation , if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Los Angeles County, in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, Melissa Mose can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorney’s fees. In the case of arbitration, the arbitrator will determine that sum.
THE PROCESS OF THERAPY/EVALUATION: 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 an effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. I will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in your experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc. or experiencing anxiety, depression, insomnia, etc. I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that 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. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, I may draw on various psychological approaches according, in part, to the problem that is being treated and my assessment of what will best benefit you. These approaches include behavioral, cognitive-behavioral, psychodynamic, existential, system/family, developmental (adult, child, family), or psycho-educational.
Discussion of Treatment Plan: Within a reasonable period of time after the initiation of treatment, I will discuss with you, the patient, your working understanding of the problem, treatment plan, therapeutic objectives, and your view of possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks , my expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits. If you could benefit from any treatment that I do not provide, I have an ethical obligation to assist you in obtaining those treatments.
Termination: As set forth above, after the first couple of meetings, we will assess if it is a benefit to you. I do not accept patients, who, in my opinion, I cannot help. In such a case, I will give you a number of referrals that you can contact. If at any point during psychotherapy, I assess that I am not effective in helping you reach the therapeutic goals, I am obliged to discuss it with you and, if appropriate, to terminate treatment. In such a case, I would give you a number of referrals that may be of help to you. If you request it and authorize it in writing, I will talk to the psychotherapist of your choice in order to help with the transition. If at any time you want another professional’s opinion or wish to consult with another therapist, I will assist you in finding someone qualified, and, if I have your written consent, I will provide her or him with the necessary information needed. You have the right to terminate therapy at any time. If you choose to do so, I will offer to provide you with the names of other qualified professionals whose services you might prefer.
Cancellation: The scheduling of an appointment involves the reservation of time specifically to us. To avoid being charged for a missed session, please inform me of your cancellation at least 24 hours in advance.