Intake Forms 2

1 informed consent
2 Release of Information
3 HIPAA Disclosures
4 Medicare Disclosures
  • Date Format: MM slash DD slash YYYY
  • Center for Anxiety Informed Consent

     

    CENTER FOR ANXIETY
    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).

    INTRODUCTION
    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.

    BENEFITS AND RISKS OF TREATMENT
    Treatment may provide significant benefits including reduced anxiety, depression and improved psychological wellbeing and interpersonal functioning. However, some elements of treatment can engender intensely 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.

    INITIAL ASSESSMENT
    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 meetings with the parents (~50 minutes), and the child (~30 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.

    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.

    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 daily sessions (3-8 hours) over a period of 2-20 days (1-4 weeks) to provide focused treatment over a concentrated period of time.

    Single-Session Treatment involves a single treatment session (3-8 hours). This approach is most often used for specific phobias.

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

    Telehealth and Out-of-office Treatment. When clinically indicated or otherwise necessary, any of our assessment or treatment procedures may be conducted remotely (e.g., by telephone, video-phone) or out of the office. All of our standard rules and regulations apply to telehealth and out-of-office sessions, however please be advised that remote treatment carries greater confidentiality risks than in-office treatment (e.g., technology breaches that provide third parties with access to sessions). NYCP will make all reasonable and appropriate efforts to maintain your confidentiality during remote sessions.

    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. 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, however you may refuse to involve a student in your care.

    Audio/Video Recording of Sessions. For the purposes of quality assurance and training, we offer some patients the opportunity to have part or all of their treatment sessions audiotaped and/or videotaped, in order to allow for supervisory review and case discussion. This is not mandatory but recommended for some patients, since greater oversight can lead to better care and ultimately improved results. Recordings will not be disseminated outside of our practice in order to protect confidentiality and privacy. Should you agree to have your treatment recorded, you may revoke your consent at any time. NYCP does not permit patients to record sessions or any part thereof, without the written knowledge and consent of our clinic director David H. Rosmarin, PhD. If you would like to record any part of a session, please contact Dr. Rosmarin at info@centerforanxiety.org

    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.

    OUR RESPONSIBILITIES
    Confidentiality. Information that you share with NYCP in the context of treatment is governed by the regulation of the Health Insurance Portability & Accountability Act (HIPAA). Your protected health information is therefore confidential and 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 of the abuse of a healthcare provider; (4) if you initiate a complaint or tort, we may disclose information relevant to a defense; (5) if a valid court order is issued. In addition, NYCP and its affiliates (e.g., Center for Anxiety; JPSYCH) reserve the right to utilize 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, our Director of Clinical Services, and/or our Founder/Director David H. Rosmarin, PhD, ABPP. Concerns, complaints and issues will be addressed in a professional and respectful manner and in a timely manner (within 1-business day).

    YOUR RIGHTS & RESPONSIBILITIES
    Assessment Fees. Fees for initial assessments range from $200 -250.

    Treatment Fees. Fees for all treatments are billed at the rate of $175-250 per 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. However, 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.

    Cancellation Policy. Intake assessments may not be cancelled or rescheduled – assessment fees are not refundable for any reason and must be rendered at the time of booking. Treatment sessions (post-intake) may be cancelled or rescheduled with no penalty if at least two business-days notice (48 hours) is provided, but cancellations or rescheduling of sessions after this time will not be refunded. No credit (time or monetary) will be given for late arrivals to scheduled appointments. For our Dialectical Behavior Therapy (DBT) program, payment is required for all DBT group sessions within a given module and cannot be waived whether or not each session is attended, regardless of reasons for missing, and with or without advanced notice.

    Late Payment. All payment is due at time of the provision of services by credit card, cash, or personal check. If you cannot pay for services due to financial hardship, please contact our office to arrange a payment plan. Patients who do not contact the office to make arrangements in advance will incur a $25 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 $50 fee to cover these costs. Bounced checks will incur a $25 service fee to cover bank and administrative charges.

    Termination. You may terminate treatment at any time and we are happy to help 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.

     

    INFORMED CONSENT

  • Date Format: MM slash DD slash YYYY

At A Glance

Sunday - Thursday,
9:00am - 9:00pm

Friday, 9:00am - 2:00pm

Telephone: 646-837-5557
Toll Free: 888-837-7473
Fax: 646-837-5495
info@centerforanxiety.org

The Center for Anxiety™ is a Limited Liability Company (LLC) that is owned and operated by David H. Rosmarin, Ph.D. The Center provides consultation in psychological research by designing, implementing and examining results from research protocols to help facilitate evaluation of treatment outcomes, and training for mental health professionals in evidence-based treatments for anxiety symptoms. All clinical services described on this website are provided by NYC Psychology Inc., a Professional Corporation (PC) that is also owned and operated by David H. Rosmarin, Ph.D.; Usage & Privacy Policy