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).
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. 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).
TREATMENT OF CHILDREN (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.
TREATMENT OF COUPLES AND FAMILIES
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
TELEHEALTH AND OUT-OF-OFFICE ASSESSMENT/TREATMENT
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).
YOUR RIGHTS & RESPONSIBILITIES
Assessment Fees. Fees for initial assessments range from $250-1395.
Treatment Fees. Fees for all treatments are billed at the rate of $100-600/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. 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. Treatments
may be cancelled or rescheduled with no penalty with at least two business-days notice (48
hours). Cancellations or rescheduling of sessions after this time will not be refunded. “No
shows” will not be refunded for any reason (e.g., if forgot you scheduled an appointment). No
credit (time or monetary) will be given for late arrivals to scheduled appointments. Please note
insurance typically does not cover or reimburse for missed appointments.
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
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
NOTE: At least one parent / legal guardian must provide consent for patients < 18 years old.
For children with two parents, we ask that both sign this consent form. Each person providing
consent should complete a separate form.
Date Format: MM slash DD slash YYYY
I have read and understood this entire policy statement. I understand, accept, and agree to
abide by ALL the terms in both these agreements including the above-mentioned cancellation
policy. I further consent to participate in assessment and/or treatment.