Center for Anxiety Informed Consent

Center for Anxiety is a Limited Liability Company that provides management services, administrative oversight, and other non-clinical services such as research consulting, public mental health education, and training of mental health professionals. All clinical services are provided by New York City Psychology, PC. (henceforth referred to as NYCP).

Mental health treatment works in part because of clearly defined responsibilities held by all parties involved. To this end, all treatment we provide is subject to the terms and conditions outlined in this document. We will provide a paper copy of this document upon request.

Treatment may provide significant benefits including reduced anxiety, depression and improved psychological wellbeing and interpersonal functioning. While benefits are expected, no particular outcome can be guaranteed. In addition, some elements of treatment can engender unpleasant emotional experiences and/or lead to the recall of unpleasant memories. While these generally subside over time, your participation may prompt an increase in symptoms or other difficulties, which may in turn negatively impact your social and occupational functioning.

You will receive an initial assessment consisting of an initial telephone meeting with an intake coordinator (~30 minutes), a computer-based assessment (~30 minutes) and a face-to-face evaluation including a structured diagnostic interview (50 minutes). For children, the face-to- face evaluation consists of an 80-minute meeting with separate segments for the parents (30- 50 minutes), and the child (30-50 minutes). The purpose of this assessment is to identify treatment targets and determine an appropriate intervention strategy. Completion of an initial assessment does not guarantee that you will receive treatment in our program. As well, in some cases one or more additional face-to-face evaluations will be necessary as well to complete our assessment, prior to making treatment recommendations. Following your initial assessment, our treatment team will provide you with a diagnosis, a summary of the clinical problem, and a recommended treatment plan, which may include treatment with NYCP, treatment with another provider, or no treatment at all. We will also provide a prognosis and estimation of the length of treatment.

Individual Treatment typically involves weekly or bi-weekly sessions (50-80 minutes) spanning over a period of 5-25 weeks, with follow-up (“booster”) sessions as necessary.

Intensive Treatment involves at least three clinical hours of service per week (150 minutes) to provide focused treatment over a concentrated period of time.

Single-Session Treatment involves a single extended-length treatment session (3-8 hours). This approach is most often used for specific phobias, but can be adapted for Panic Disorder, Obsessive Compulsive Disorder, Trauma-related Disorders, and other conditions.

Family Sessions/Parent Training Sessions focus on educating and coaching parents, family, and community members, regarding the mental health of others. These approaches can involve one or more sessions (50-80 minutes), depending on the individual needs of the patient and significant others.

Pharmacotherapy. NYCP does not prescribe medication. In some cases, we may refer you to a physician or nurse practitioner for a medical evaluation and possible psychopharmacological treatment.

Ongoing Assessment. Ongoing assessment of your symptoms is an integral part of treatment. Therefore, a brief (2-5 minute), computer-based assessment will be completed at each session. These assessments are for your benefit, so your treatment team can be kept informed about your symptoms and customize your treatment program for your specific needs.

Student Involvement in Treatment/Assessment. Graduate students may observe or conduct part or all of your assessment and/or treatment under the supervision of a licensed supervisor. NYCP assumes responsibility for all clinical services provided. You may refuse to involve a student in your care.

Audio/Video Recording of Sessions. For the purposes of quality assurance and training, we may recommend that part or all of treatment sessions be audiotaped and/or videotaped. This is strictly to facilitate internal review and case discussion; audio/video recordings will never be shared with anyone outside of our practice without obtaining your written permission. If recording of sessions has been recommended, you will be verbally notified by your practitioner in advance and you will have the option to decline. NYCP does not permit patients to record sessions or any part thereof without our clinicians’ knowledge and consent.

Emergency Services. NYCP DOES NOT PROVIDE EMERGENCY SERVICES. IF YOU HAVE A CLINICAL EMERGENCY WHILE IN TREATMENT, YOU MUST CALL 9-11 OR GO TO YOUR NEAREST HOSPITAL EMERGENCY DEPARTMENT.

Legal/Custody Proceedings. NYCP DOES NOT PROVIDE FORENSIC EVALUATIONS AND OUR CLINICIANS ARE NOT TRAINED TO GIVE ANY OPINIONS REGARDING CUSTODY, VISITATION, OR OTHER LEGAL MATTERS. IF LEGAL PROCEEDINGS OCCUR, NYCP’S INVOLVEMENT WILL BE LIMITED TO PROVIDING WRITTEN INFORMATION OR TREATMENT RECORDS AS REQUIRED BY LAW AND/OR UPON AUTHORIZATION BY THE PATIENT (OR PARENT / LEGAL GUARDIAN IN THE CASE OF TREATMENT OF A CHILD UNDER AGE 18).

General Provisions. Children benefit most from therapy when parents / legal guardians are involved and cooperate throughout treatment. Children under the age of 18 require the consent of at least one parent / legal guardian in order to receive services. All parents / legal guardians of children receiving services have the rights to be provided with general information about the child’s therapy, information about any dangers the child might present to self or others, and copies of the child’s treatment record upon request. However, it is important that children develop a trusting relationship with their clinician and feel comfortable sharing their experiences in confidence. Thus, parents / guardians are generally discouraged from asking for specific information about what is said during therapy appointments, particularly for children over age 12.

For Children with Two Parents. Parental cooperation is important to supporting the mental health of children. Parents therefore agree to be involved and cooperate with each other and the clinician throughout treatment. Parents further agree not to terminate the child’s treatment without agreement of the other parent. Our office may release information or records to either parent without any additional authorization of the other parent.

In some cases, it is clinically advisable to involve partners, family members, and others in the treatment process. In such circumstances, patients acknowledge that information about their symptoms, diagnoses, or other personal information may be divulged to others involved in the treatment process, however records will not be released without written consent. In other cases, couples, partners, family members, and others present to treatment as a group. In such instances, NYCP may release written information or treatment records to any member of the couple / family without additional authorization of the other member. While NYCP clinicians will use discretion in protecting private information, we cannot keep secrets from partners, family members, and others involved in treatment, since this could cause harm to the patient, and/or their relationships with others.

In some cases, you may receive group therapy, which involves a clinical intervention delivered to a group of patients together. Group rules and policies are specific to each type of group we provide (e.g., Dialectical Behavior Therapy) and will be made available at the outset of treatment. In addition to these policies, group members must not discuss any identifying information about other group members (including the fact that they are attending group therapy), except with other group members and NYCP clinicians. Patients who do not follow group rules and policies may be required to leave the group. Patients also recognize that while NYCP takes steps to protect privacy, there is always a risk that confidential information may be revealed. NYCP cannot be held responsible for release of private information by others. Patients are encouraged to speak with our staff if they have concerns about confidentiality or Privacy.

When clinically indicated or otherwise necessary, any of our assessment or treatment procedures may be conducted remotely by telehealth (e.g., via telephone, video-phone), or out of the office. Such services may involve the electronic communication of your medical/mental healthcare information to other health care practitioners. All of our standard rules and regulations apply to telehealth and out-of-office sessions. However, telehealth and out-of- office treatments carry greater confidentiality risks, such as being seen in public with one’s therapist or technology breaches that provide third parties with access to sessions. As a result, transmission of your medical information could be interrupted or distorted by unauthorized persons or technical failures. NYCP will make all reasonable and appropriate efforts to maintain your confidentiality during remote sessions. Telehealth-based services and care may not be as complete or effective as face-to-face services. If your clinician believes you would be better served by in-person psychotherapeutic services, you may be referred to a clinician who can provide such services in your area.

Confidentiality. Information that you share with NYCP in the context of treatment will be treated as confidential and private. No information will be released without your consent, except in the following circumstances where we may be ethically and legally obligated to do so: (1) if there is any risk of imminent danger to you or any other person; (2) if there arises any suspicion that a child or elder is being abused, neglected or at risk for abuse or neglect; (3) if we are informed that a fellow healthcare provider engaged in abuse or inappropriate conduct; (4) if you initiate a complaint or tort, we may disclose information relevant to a defense; (5) if a valid court order is issued, our files may be subpoenaed; (6) if your account becomes overdue and you do not pay the amount due or work out a payment plan, limited information may be revealed to facilitate legal measures in order to pursue payment; (7) if your clinician consults with an outside healthcare professional about your treatment, your case may be discussed without revealing your name or other information that might identify you, unless specific consent to do so is provided; (8) If we are treating you for a worker’s compensation claim, we may need to furnish information regarding your symptoms, diagnosis, and treatment to the worker’s compensation board. NYCP and its affiliates (e.g., Center for Anxiety) reserve the right to utilize de-identified information you provide for the purposes for research, training, dissemination, and marketing. Your clinical file will contain information about the problems for which you seek treatment, your diagnosis, your treatment plan, and your progress towards treatment goals. Your file will be stored securely to protect your confidentiality.

Professionalism. We commit to treat you with professionalism, dignity and respect. We will try to provide you with timely, accurate, and complete information regarding your treatment plan, our services, professional fees, and other treatment-related matters. You are encouraged to discuss your treatment experience with your treatment team, our patient care managers, and our Director of Clinical Services. Concerns, complaints and issues will be addressed in a professional and respectful manner and in a timely manner (within 1-business day).

Assessment Fees. Fees for initial assessments range from $250-895.

Treatment Fees. Fees for all treatments are billed at the rate of $200-600/clinical hour (50- minutes). Support time for writing notes and brief communications with patients and other providers are typically not billed, but we reserve the right to bill for extended therapist time between sessions (> 15 minutes) in 0.25hr increments. Fees include therapist time only; over the course of treatment, patients may be encouraged to acquire books or other materials, or engage in activities (e.g., join a gym) that could result in additional expenses. Treatment fees are subject to change at any time with at least 60 days advance notice.

Insurance. NYCP does not accept payments directly from private insurance companies. We can provide you with detailed receipts with applicable CPT codes for all treatment received as well as supporting information and documentation to assist you in receiving reimbursement upon request. NYCP is not a Medicare provider. We cannot accept any payments from Medicare or provide insurance receipts for reimbursement from Medicare. It is illegal for you to submit insurance receipts from NYCP to Medicare for reimbursement under any circumstances.

Third Party Payment. In the event that a third party (e.g., family member, community organization, insurance agency) pays for treatment sessions, the patient will personally be held responsible if we are unable to collect. In the event that there is more than one unpaid session for a period of 30 days, we reserve the right to terminate treatment. Patients agree that we may provide information about their treatment to third party payors.

CANCELLATION POLICY

This policy applies to all in-person and telehealth appointments. By scheduling an appointment with Center for Anxiety, you acknowledge and agree to abide by this cancellation policy. Please note insurance typically does not cover or reimburse for missed appointments.

Cancellation Notice: We understand that unforeseen circumstances may arise, requiring you to cancel or reschedule your appointment. To avoid any charges, please provide at least one full business day’s notice for cancellations or rescheduling. Center for Anxiety conducts business on Sunday through Friday (Saturday is the only non-business day). This means if your appointment is on Monday at 1pm and you need to cancel you must contact us by Sunday at 1pm. Since we are closed on Saturday, if your appointment is on Sunday at 1pm and you need to cancel you must contact us by Friday at 1pm.

Communication: Please communicate any scheduling conflicts or emergencies promptly. You can reach us by emailing [email protected] at 646-837-5557 during business hours. Please email your clinician as well.

Late Cancellation Fee: Cancellations or rescheduling made less than one full business day before the scheduled appointment time will result in a late cancellation fee equivalent to the fee for the appointment that was scheduled. This fee will be billed directly to the patient.

No-Show Policy: If you are unable to attend your scheduled appointment and do not notify us at least one full business day in advance, resulting in a no-show, you will be billed the fee for the appointment that was scheduled.

Late Arrival: If you arrive more than 20 minutes late for your scheduled appointment, it will be considered a no-show and you will be billed the full fee for the appointment that was scheduled. If you communicate with your clinician that you are running late, we will try to meet with you for the remaining session time, but we are under no obligation to do so. We reserve the right to terminate treatment for patients who consistently exhibit a pattern of arriving excessively late.

Rescheduling Requests: You may request to reschedule your appointment to later in the week if you are making the request with more than 24 hours notice. Your clinician will do their best to accommodate your request if their schedule permits. If you are making a request to reschedule your session less than 24 hours prior to the time of your session but up until the start time of it, your clinician will try to accommodate your request with a same day re-schedule, pending availability. However, if they cannot accommodate a same-day reschedule, you will be charged for the session as initially scheduled. Communication: Please communicate any reschedule requests as soon as possible. Please email your clinician and copy [email protected].

Exception Allowance: Recognizing that unforeseen emergencies can arise, such as illness or unexpected work commitments, we acknowledge the need for flexibility. To address this, upon a patient’s request, we will grant a maximum of one policy exception every six months. This exception effectively waives any session fee for one late cancellation or no-show. Additionally, we permit one reschedule within the same week for requests made with less than 24 hours’ notice, limited to once every six months. To avail themselves of these allowances, patients must communicate their exceptional circumstance via email to their clinician and copy [email protected].

Payment of Fees: Late cancellation and no-show fees are the responsibility of the patient and must be paid in full before scheduling any future appointments.

Reminder Services: We offer appointment reminders through text or email. Please ensure that your contact information is up-to-date to receive these reminders..

Late Payment. All payment is due prior to provision of services by credit card, cash, or personal check. Bounced checks will incur a $50 service fee to cover bank and administrative charges. Unpaid invoices will incur a $50 service fee after 30 days to cover administrative and other costs associated with collection. After 60 days, unpaid accounts are turned over to a collection agency and will incur an additional $100 fee to cover these costs.

Termination. You may terminate treatment at any time. Should you terminate and require further treatment, we will try to facilitate a referral to another practitioner upon request. NYCP reserves the right to terminate treatment at any point if you act in a caustic, abusive, violent or threatening manner to any member of our staff. In such circumstances, refunds will not be provided.

Revoking Consent. You may revoke consent to release your confidential information and/or treatment records at any time, provided that the revocation is done in writing. However, we can only protect the release of information subsequent to the date of revocation; NYCP cannot assure the protection of confidentiality if we have previously released information to others.

FUTURE CHANGES TO OUR POLICIES

We may change the policies described in this notice, as well as other policies, from time-to- time. We will do our best to notify you of such changes via email or in writing. Patients agree to abide by NYCP’s revised policies, whether or not additional written consent to do so is provided.

NOTE: At least one parent / legal guardian must sign this form to provide consent for patients < 18 years old. Please complete the form with the patients information, but sign your name below.

If there are multiple people providing consent, each person should complete a separate form.

Authorization for the Release of Healthcare Information

I understand that I may refuse to sign this authorization without affecting my eligibility for treatment. I further understand that I may withdraw this authorization at any time by submitting a written request. Authorization may be withdrawn except to the extent that action has already been taken in reliance on this authorization. I further understand that information released on this authorization is no longer protected (e.g., if re-disclosed by the recipient). To the extent to which my file contains information regarding alcohol and/or drug treatment (protected by Federal Regulations 42 CFR, Part 2) or HIV antibody/antigen testing (protected by NYS Law), I authorize disclosure of such information.

Note: At least one parent / legal guardian must sign this form for patients < 18

I have reviewed and agree to the above terms:

Medicare Disclosure

This notice provides important information about our billing practices. Please review it Carefully.

I understand that NYC Psychology Inc. (NYCP) has opted-out of Medicare. All services provided by all practitioners operating under the auspices of NYCP are NOT covered by Medicare.

As a patient receiving services, I accept full responsibility for payment of all charges for services furnished by NYCP. I understand that Medicare limits do not apply to what NYCP may charge for services.

I agree not to submit a claim for services rendered by NYCP to Medicare, or to ask NYCP to submit any claim to Medicare on my behalf.

I further understand that Medicare may not provide me with reimbursements or payments for any services provided (e.g., for services that would have otherwise been covered by Medicare if there were no private contract and a proper Medicare claim had been submitted).

I understand that I have the right to obtain Medicare-covered items and services from other physicians and practitioners who have not opted out of Medicare, and that I am not compelled to receive services from NYCP or other providers who have opted out of Medicare.

I understand that Medigap plans do not make payments for items and services not paid for by Medicare. I understand that supplemental plans may also elect not to make payments for items and services not paid for by Medicare.

I am not entering into this private contract during a time when I require emergency or urgent care services.

I understand that NYCP will retain a copy of this contract indefinitely, and that NYCP will provide a copy of this private contract to Center for Medicare/Medicaid Services (CMS) upon request.

Note: At least one parent / legal guardian must sign this form for patients < 18