Informed Consent for Minors:
Please complete this form if you are the legal guardian of the patient
INFORMED CONSENT FOR SERVICES: MINOR
WELCOME: At Joye Psychology & Wellness, we employ a highly trained team of individuals with training and experience in a wide range of behavioral child and adolescent mental-health issues. Specialized behavioral health services are available for children, adolescents, and their families.
CONFIDENTIALITY: We take seriously our responsibility to hold in confidence what you share with us. In general, communications between a patient and mental-health practitioner are protected by law. We also maintain records of all patients and professional contacts, which are restricted to internal use, and their confidentiality is strictly safeguarded at all times. Written or verbal information regarding your file at our clinic is released only with your expressed written permission and only to specific and clearly identified individuals. However, there are some exceptions listed below:
1) In some legal proceedings, a judge may order our testimony if she/he determines the issues demand it.
2) There are some situations in which we are legally obligated to take action to protect others from harm, even if some information must be revealed about a patient. By law, we are required to report any suspicions of child abuse, elderly abuse, or abuse of other protected populations. Also, in cases of danger or imminent risk of harm to a patient or others, we may be required to take protective actions, including notifying potential victims, contacting family members who can provide protection, or seeking hospitalization. These situations occur rarely, and we will make every effort to discuss the matter with you before disclosing information.
At times, we may find it helpful to consult with other professionals, including other professionals at Joye Psychology & Wellness not directly involved in your care, about your case. During these consultations, every effort will be made to avoid revealing any identifying information about the patient or family. The consultant(s) are also bound to keep all information confidential. In general, these consultations will not be discussed with you unless we believe it is central to your treatment.
TRAINING AND SUPERVISION: Joye Psychology & Wellness is a training facility. Psychology and counseling students and postdoctoral residents may observe sessions and administer services (under the supervision of a licensed professional) as part of their training. You may, at any time, request that students not observe sessions or help with assessments and/or treatment.
ASSESSMENT APPROACH: During the initial session, we will talk about why you are here and about your current concerns. We will then select a battery of measures that best answers your concerns. The assessment plan will be presented to you for approval before moving forward. Testing will be completed across multiple sessions if needed for you and your family. Once all parent and teacher forms have been returned and testing is completed, you will receive a written report within 30 days. We will not release the full report if your account balance has not been paid.
TREATMENT APPROACH: We use an active, practical, brief, and research-supported approach to treatment. We will work directly with you on current problems and concerns and make accommodations to help improve the patient’s and/or family’s functioning. These accommodations may require parents/guardians to make changes in their own interactions with their child and/or other family members, both in the clinic and at home. In some cases, especially with very young children, this approach to treatment may involve physical interactions with the patient, including, but not limited to, physical guidance and physical enforcement of instructions or commands. If at any time before or during treatment you are unclear about these methods, please discuss your concerns with us.
During the initial sessions, we will talk about why you are here and about your current concerns. A general treatment plan will be developed with your input and reviewed within the first one or two sessions. Additional sessions are usually scheduled weekly or every other week, and each scheduled session typically lasts 50 minutes. The number of additional sessions depends on the nature and severity of the issue, but 10 to 15 visits is common.
MINORS: Both treatment and assessment sometimes involve individual work with children and usually involves individual work with adolescents. Treatment is most effective when a trusting relationship exists between the psychologist and patient. One goal of treatment is to provide a stronger relationship between children and their parents; however, it is often necessary for children/teens to develop a “zone of privacy” whereby they feel free to discuss personal matters with greater freedom. This is particularly true for adolescents, who are naturally developing a greater sense of independence and autonomy. By signing this agreement, you waive your right of access to your child’s treatment records. We will provide you with general information about treatment status, and you will be informed if there is ever a suspicion your child is at serious risk of harming him/herself or another person.
TELE-MENTAL HEALTH: In some rare cases we do allow sessions via tele-mental health. We exclusively use the platform doxy.me, a free and HIPAA-compliant software. You must have an internet connection or wireless data to use this platform. Your therapist will provide more information for using this system.
FEES: We bill a set amount to all insurances, but each insurance sets their own rates that are lower than the billed amount. How much you will owe depends on what insurance coverage you have, and we are happy to check your rates for you prior to your first session. The fees below are subject to change; for current rates, please call the main office.
Assessment fees billed to insurance are as follows: $300 for an intake session and $250 an hour for each hour of assessment and report writing. Feedback sessions are also billed at $250 per hour. After the initial intake session, we will put together an assessment plan (with total cost) for your approval based on your individual insurance plan.
Therapy fees billed to insurance are as follows: $300 for an intake session, which includes the clinic visit, records review, scoring and interpretation of behavior ratings, and initial treatment planning, and $250 for a 53 to 60-minute therapy session. If you do not need the full therapy session, fees are $200 per session for a 38 to 52-minute session and $140 for a 16 to 37-minute session.
If you do not want to use your insurance for services, please ask us about self-pay discounts.
The patient (or the patient’s authorized representative) retains responsibility for payment of all fees, whether or not they are covered by insurance. Collection of co-pays and deductibles is required by law for all providers accepting insurance reimbursement, so unpaid balances will be sent to collections. It is expected that you will pay all fees at the time of your office visit. If you have questions or concerns regarding fee payment, please contact us prior to your scheduled appointment.
SECONDARY INSURANCE REIMBURSEMENT: If you have secondary insurance, you must provide this information prior to your first appointment. If you do not, we will only be able to bill your primary insurance, and you will be responsible for any copays charged by your primary insurance.
CANCELLATION POLICY: You are responsible for canceling your appointment (or your child’s appointment) with AT LEAST 24 hours notice. Cancelled sessions without at least 24 hours notice will result in a cancellation fee of $50. Your appointment is reserved for you, and it can be filled with a patient from the wait list only if we have time to fill the appointment. Late cancellations and no shows hurt everyone.
IN CASE OF AN EMERGENCY: Joye Psychology & Wellness is considered to be an outpatient facility, and we are set up to accommodate individuals who are reasonably safe and resourceful. We do not carry cell phones/pagers nor are we available at all times. If at any time this does not feel like sufficient support, please inform me and we can discuss additional resources or transfer your case to a provider or clinic with 24-hour availability. Generally, we will return phone calls within two business days. If you have a mental health emergency, we encourage you not to wait for a call back, but to call 9-1-1 or go to the nearest emergency room.
YOUR SATISFACTION IS IMPORTANT: Please feel free to raise any concerns about treatment with either your provider or Dr. Joye (office@JoyePsyc.com) at any time. An open, honest relationship with your mental-health provider is crucial to the successful resolution of your concerns.