Rita Nesheiwat, MA, MFTI



Rita Nesheiwat, MA, MFT

Licensed Marriage and Family Therapist

(702)321-9546

Consent to Treatment and Terms of Payment

Therapy is a relationship that works in part because of clearly defined rights and

responsibilities held by each person. This frame helps to create the safety to take risks

and the support to become empowered to change. As a client in psychotherapy, you have

certain rights that are important for you to know about because this is your therapy,

whose goal is your well-being. There are also certain limitations to those rights that you

should be aware of. As a therapist, I have corresponding responsibilities to you. Therefore I have prepared the following description of how I work to allow you to make an informed decision about participating in this process. Your participation is completely voluntary.

The Therapeutic Process

Therapy is a learning process in which you come to better understand yourself and your relationships so that you may more successfully handle the situations that brought you here. As a therapist, I believe my role is to help you develop the ability to skillfully address life issues rather than simply give you advice and answers that have worked for me. Although I do not offer a “quick fix,” the approaches I generally use are considered “brief” and through our work you will develop skills that you can continue to use to address similar issues in the future. If at anytime you feel uncomfortable with the process or are unclear about the process, please feel free to discuss your concerns with me—that’s what I am here for.

The length of therapy varies depending on each person’s situation, including the type of problem, severity, history, resources, and personal motivation. Many clients experience moderate gains in the first three sessions, with the majority needing 12-18 sessions to resolve or significantly improve their situations. Clients with more complex situations and/or severe/chronic issues often require more treatment. Sometimes clients find that their initial concern is quickly resolved or less important when new issues are brought to light. This shift in focus is very common and is often considered a form of progress. Most clients experience measurable benefit from coming to therapy, with the vast majority of clients (over 95%) reporting that they partially or entirely met their goals. A small minority does not experience benefits or the situation may worsen, which is therefore a potential risk of seeking treatment. Often, if painful situations have been avoided prior to therapy, things may become worse before they get better while these neglected issues are brought to light for the first time. Additionally, some research suggests that when therapy is provided to one partner in an unhappy relationship, this may make the situation worse. Similarly, certain child and adolescent problems seem to be best handled in family sessions.

Confidentiality

With the exception of certain specific exceptions described below, you have the

absolute right to the confidentiality of your therapy. I cannot and will not tell anyone else

what you have told me, or even that you are in therapy with me without your prior

written permission. Under the provisions of the Health Care Information Act of 1992, I

may legally speak to another health care provider or a member of your family about you

without your prior consent, but I will not do so unless the situation is an emergency. I

will always act so as to protect your privacy even if you do release me in writing to share

information about you. You may direct me to share information with whomever you

chose, and you can change your mind and revoke that permission at any time. You may

request anyone you wish to attend a therapy session with you. You are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA). This law insures the confidentiality of all electronic transmission of information about you. Whenever I transmit information about you electronically (for example, sending bills or faxing information), it will be done with special safeguards to insure confidentiality. If you elect to communicate with me by email at some point in our work together, please be aware that email is not completely confidential. All emails are retained in the logs of your or my internet service provider. While under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrator(s) of the internet service provider. Any email I receive from you, and any responses that I send to you, will be printed out and kept in your treatment record.

The following are legal exceptions to your right to confidentiality. I would inform

you of any time when I think I will have to put these into effect.

1. If I have good reason to believe that you will harm another person, I must

attempt to inform that person and warn them of your intentions. I must also contact the police and ask them to protect your intended victim.

2. If I have good reason to believe that you are abusing or neglecting a child or vulnerable adult, or if you give me information about someone else who is doing this, I must inform Child Protective Services within 48 hours and Adult Protective Services immediately.

3. If I believe that you are in imminent danger of harming yourself, I may legally break confidentiality and call the police or the county crisis team. I am not obligated to do this, and would explore all other options with you before I took this step. If at that point you were unwilling to take steps to guarantee your safety, I would call the crisis team.

4. Any threat to National Security including threats of mass shootings.

5. Your records will be released if you file a complaint with a professional licensing board or insurance carrier.

6. All billing agents and report typists as well as professionals who cover for me, are bound by this confidentiality agreement.

_____Initial here to indicate this section has been read and understood

Record-keeping.

I keep very brief records, noting only that you have been here, what interventions

happened in session, and the topics we discussed. If you prefer that I keep no records,

you must give me a written request to this effect for your file and I will only note that you

attended therapy in the record. Under the provisions of the Health Care Information Act

of 1992, you have the right to a copy of your file at any time. You have the right to

request that I correct any errors in your file. You have the right to request that I make a

copy of your file available to any other health care provider at your written request. I

maintain your records in a secure location that cannot be accessed by anyone else. Files will be help for 7 years. After that they will be destroyed.

Diagnosis

If a third party such as an insurance company is paying for part of your bill, I am

normally required to give a diagnosis to that third party in order to be paid. Diagnoses are

technical terms that describe the nature of your problems and something about whether

they are short-term or long-term problems. If I do use a diagnosis, I will discuss it with

you. All of the diagnoses come from a book titled the DSM-V. EAP insurance does not require a reportable diagnosis however once you utilize your managed care benefits a diagnosis will be required.

Billing Policies & Fees and Length of Sessions:

**My fee for a 50 minute session is $100; 75-minute sessions are $150.

1. The fee for services or your copay is due at the conclusion of each session. Any overpayments will be returned to you once we have received full payment for services by the insurance provider. If you no show your session or cancel less than 24 hours prior to your appointment, you will be responsible for the full rate of the session.

2. The client is always responsible for the payment of costs incurred for services rendered, regardless of benefits. This means that if for whatever reason a claim from this office is denied, you are responsible for the remaining balance of the bill.

3. Your appointment time has been set aside specifically for you. You are responsible for coming to your session on time. If you are late for your session, we will still end on time and your full regular session fee will apply.

4. We charge $35 per 15 minutes or portion thereof of therapy over the phone. Incidental costs, such as those incurred via international calls, will also be billed at our cost.

5. If you are unable to attend your appointment, you MUST cancel at least 24 hours in advance. If you do not cancel more than 24 hours in advance or miss a session without canceling, you maybe responsible to pay the full regular session fee.

6. If you request that I write reports for schools, employers, attorneys, doctors, courts, Child Protective Services, etc., you will be charged for the time it takes to write the report at a rate of $35 per 15 minute interval.

****I DO NOT PROVIDE LETTERS FOR EMOTIONAL SUPPORT PETS.

7. Court-related services policy: I do not participate in any court-related services for clients, including depositions, hearings, consultations with lawyers, or attendance at courtroom proceedings. I ask that you respect the integrity of the therapeutic process and refrain from asking for my participation. However, if we are required to participate in Court Appearances: Our rate for court appearances is $400 per hour or portion thereof, including transportation time, plus any applicable travel/lodging costs, to be paid from client’s attorney’s retainer. Please note: as providers of therapeutic services we do not render opinions regarding child visitation or child custody.

8. If a check is returned for insufficient funds, a $25.00 fee will be assessed in addition to the session fee.

9. We do not encourage the giving of gifts, and we may not accept any gift of substantial value.

_____Initial here to indicate this section has been read and understood

Methods of Payment:

We offer multiple methods of payment. Sessions can be paid in cash, with check or by credit/debit card. If you chose to use credit card there is a 2.8% processing fee that you will incur at the time of payment. This rate will be calculated and added to each credit card transaction that you use credit card.

_____Initial here to indicate this section has been read and understood

Diagnostic purpose

If you elect to use your insurance plan to assist in the payment for treatment, then the insurance carrier and the National Information Center will have access to your diagnosis code and other pertinent data needed for claim processing.

_____Initial here to indicate this section has been read and understood.

Your Responsibilities as a Therapy Client

You are responsible for coming to your session on time and at the time we have

scheduled. Sessions last for 50 minutes. If you are late, we will end on time and not run

over into the next person's session. If you miss a session without canceling, or cancel

with less than twenty-four hours notice, you must pay for that session at our next

regularly scheduled meeting. The answering machine has a time and date stamp which

will keep track of the time that you called me to cancel. I cannot bill these sessions to

your insurance. The only exception to this rule is if there is an emergency. If you no show for two sessions in a row and do not respond to my attempts to reschedule, I will

assume that you have dropped therapy and will open the slot to someone else.

Services to a Minor Client:

If the client is a minor, the parent/guardian has the right to refuse treatment for the minor. It is my policy to generally obtain consent from both legal parents/guardians for services to a minor. Should one parent actively deny consent to treatment, I generally will not provide treatment services. Even in the situation of divorce or where one parent seeks and pays for treatment, the other legal parent has a right to consent/deny treatment and has full access to their child’s records (unless these rights are waived as described below). Please indicate (initial below) if the other parent/guardian, with legal parenting rights, does not have knowledge of, or has disagreed with, therapy for this child.

_____Initial here to indicate this section has been read and understood.

Guns/Weapons

Guns or weapons of any kind are forbidden from being brought into the office or the building for any reason at all. Please leave your gun/weapon at home or locked in your vehicle.

Confidential Communications

Technology:

All communication with my clients is either done in the therapy room, except for communication that needs to take place in reference to appointment scheduling. Please note that my phone number is a cellular phone with a voice mail. My number is private as is my voice mail; however, I cannot guarantee the confidentiality of technology beyond my control. Email and text are not appropriate forms of communication.

Voice Messages

Outside of session, my preferred method of communication is by phone and voice messages, as I am able to best protect your confidentiality when you leave messages on my voicemail. I try to respond to voicemail messages within 24 hours on business days; thus, please call 911 for life threatening emergencies. Unless otherwise requested, I will leave messages for you on the mobile number you provided.

Text Messages and Email

You may also communicate regarding scheduling and business matters via text (702-321-9546) and email (ritanesheiwat.mft@); please do not send personal or confidential information via email or text message as I cannot guarantee the confidentiality of these communications. OUTSIDE OF SCHEDULING APPOINEMENTS, NO COMMUNICATIONS VIA TEXT OR EMAIL WILL BE PERMITTED. THERAPIST IS NOT RESPONSIBLE FOR ANY INFORMATION THAT CLIENT SENDS VIA TEXT OUTSIDE OF SCHEDULING. PLEASE CALL 911 IN THE CASE OF AN EMERGENCY. In addition, I do not provide psychotherapy via Internet, and therefore I do not provide interventions, assessments, advice, or otherwise “treat clients” via email or text because of the increased potential for error. If you have a therapy-related question, it will generally be addressed in our next meeting when I can appropriately and professionally assess you and the situation.

Dual Relationships/Social Media

A Dual Relationship is where the active or primary working relationship co-exists with a supervisory, therapeutic, academic, personal or familial relationship, which might cause (at times) complications, a conflict of interest or a positive or negative bias.

This being said, any forms of a relationship outside of the therapeutic relationship will be declined to maintain professionalism. Any forms of contact via social media will also be declined. This includes but is not limited to Facebook, LinkedIn, Instagram, Myspace, Twitter, Google Plus, Pinterest, Snap Chat etc.

“No Secrets” Policy with Couples

When working with couples, I employ a “no secrets” policy, which means I do not keep secret information gathered in individual conversations (whether on the phone or in an individual session) if the information revealed in some way violates that integrity of the couples therapy, such as revealing an affair, substance problem, or intent to leave the relationship. Such information will need to be revealed to the other partner for therapy to effectively continue.

Crisis Contact Information

As an independent practitioner, I am unable to personally provide continuous 24-hour crisis services. For all life threatening emergencies, you should always call 911 immediately. For other crisis situations, you may call me on my mobile phone (number is on my business card) and I will return your call as soon as possible, usually within 24 hours if I am in the country. If you need more immediate services or after hour services, you should use the list of emergency contact numbers on the backside of my business card, which includes

contact information for the suicide hotline, general crisis hotline, local shelters, and other resources. In case of a medical or psychiatric emergency during session, I will contact the person you specify below and hereby release me to speak to in such circumstances:

Termination and Referral

You have the right to terminate services at any time. I am happy to discuss any concerns you have and will help you locate alternative services if desired. If for any reason, I feel that I am not able to help you make significant progress or that I do not have the expertise to best assist you, I will refer you to a person or program that can.

Collaboration with Other Professionals

In order to provide quality services, I often need to collaborate with other professionals, such as your physician, psychiatrist, past therapists, and/or other mental health professionals. You will be asked to complete a release of information authorizing these exchanges; in some cases, I may not be able to provide services without this.

Please Ask Questions

You may have questions about my qualification, therapy, or anything not addressed here. It is your right to have a complete explanation for any questions you may have at this time. Also, please feel free to ask me any questions or share any concerns that might arise during the process of therapy. Although I know this may be uncomfortable at times, your openness and honestly will allow me to better serve you.

Complaints

If you're unhappy with what's happening in therapy, I hope you'll talk about it

with me so that I can respond to your concerns. I will take such criticism seriously, and

with care and respect. You are also free to discuss your complaints about me with anyone you wish, and do not have any responsibility to maintain confidentiality about what I do that you don't like, since you are the person who has the right to decide what you want kept confidential.

I/We have read and understand the above conditions of treatment, confidentiality practices, and terms of payment and hereby consent to treatment.

____________________________________ _________

Client (or Parent) Signature Date

Date of Birth (guardian) _________ SSN # (Guardian) _______________________

____________________________________ _________

Client (or Parent) Signature Date

Date of Birth (guardian) _________ SSN # (Guardian) _______________________

____________________________________ _________

Therapist Signature Date

Consent to Treatment of Minors

This section must be completed by the parent or legal guardian of each child who attends session. Some custody agreements require the signatures of both parents for treatment; please notify the therapist if this is your situation.

Confidentiality with Minors

My role as a therapist to help minors learn to communicate openly and directly with their parents, and thus, I typically involve parents in the counseling process. That said, when children are making poor and dangerous decisions parents will be brought into the conversation as soon as possible, which in the case of many situations— such as self-harm or suicidal ideation—is immediately.

In addition, If both parents have legal rights to the minor then both parents must sign the consent to treat form. If only 1 parent maintains fully custody of minor then court documentation to support this must be presented prior to the initiation of therapeutic services.

I hereby consent to treatment of my child(ren) per the terms outlined in the above pages of this document:

Child 1:__________________________ Date of Birth:______________

Child 2:__________________________ Date of Birth:______________

Child 3:__________________________ Date of Birth:______________

Child 4:__________________________ Date of Birth:______________

____________________________________ _____________________

Parent/Guardian Signature Date

____________________________________ _____________________

Parent/Guardian Signature Date

____________________________________ _____________________

Minor’s Signature (13 and older) Date

____________________________________ _____________________

Therapist Signature Date

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003 and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or

received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment:

We may use or disclose your health information to a physician or other healthcare provider providing treatment to you or for the management of healthcare and related services. It also includes but is not limited to consultations and referrals between one or more providers. For example, a MINES Case Manager may contact a provider on your behalf to facilitate your access to mental health treatment.

Payment: We may use and disclose your health information to obtain payment for services provided to you. For example, MINES may contact a benefit plan to obtain information concerning billing for services, co-pay information, etc.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, case management, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. For example, we will require providers to submit appropriate credentialing information for membership in our PPO

network.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Client Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using

our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, xrays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or client under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages).

CLIENT RIGHTS

Access: You have the right to inspect or obtain copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $1.00 for each page to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.) If access is denied, you or your personal representative will be provided with a written denial, setting forth the basis for the denial, a

description of how you may appeal the decision and a description of how you may complain to the Secretary of the U.S. Department of Health and Human Services.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing). Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended). We may deny your request under certain circumstances. We have 60 days after the request is made to act on the request. A single 30 day extension is permissible if we are unable to comply by the deadline. If the request is denied in whole or in part, we will provide you with a written denial that explains the basis for the denial. You or your personal representative may then submit

a written statement disagreeing with the denial and have that statement included with any future disclosures of your Protected Health Information (PHI).

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written

complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

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_________ Please initial that you understand that weapons are not allowed in the office building.

Your preferred phone number for confidential voicemails: (___) ___-_____ θ Mobile

___________ †湉瑩慩敨敲琠湩楤慣整礠畯⁲湵敤獲慴摮湩⁧景琠敨氠浩瑩摥挠湯楦敤瑮慩楬祴漠⁦整瑸洠獥慳敧⁳湡⁤浥楡桳畯摬礠畯 Initial here to indicate your understanding of the limited confidentiality of text messages and email should you choose to use these for communication.

________ Initial here to indicate your understanding of the “no secrets” policy with couples and families.

Contact in case of a Medical or Psychiatric Emergency

Name:________________ Phone:________________ Relation:__________________

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