Office phone: 916-678-1703 (free first consultation); Office fax: 707-402-0223; email@example.com
Please read the entire document carefully and be sure to ask your therapist any questions that you may have regarding its contents.
Information about your psychotherapist:
At an appropriate time, I will will discuss my professional background with you and provide you with information regarding my experience, education, special interests, and professional orientation. You are free to ask questions at any time about my background, experience and professional orientation. I am Marriage Family Therapist. I am trained in working with children, adolescents, adults, couples, and groups. My training and experience is supplemented by attending conferences, continuing education, consulting with colleagues, and reading journals, guidelines and other publications.
Information about this practice:
- The practice is currently serving only those participating in telehealth services.
- The name of this practice is Roger Mark Holcomb, LMFT, a.k.a. Holcomb Telehealth Counseling
- My California Marriage Family Therapist license number is LMFT47406
- My name preference is Mark.
All fees are to be paid prior to the commencement of therapy. Please ask me if you wish to discuss a written agreement that specifies an alternative payment procedure.
The fee for service is $165.00 per individual therapy session.
The fee for service is $190.00 per conjoint (marital /family) therapy session.
The fee for service is $65.00 per per person for group therapy session. (6 person minimum to start)
The fee for copies of records is $0.25/page, $0.10/page from attorney for an active case, plus postage.
The fee for reasonable clerical costs in locating and making records is $4.00/quarter hour.
The fee for authoring custom requested letters/documentation is $40.00/page.
Court related fees:
Preparation time is $220.00/hour including submission of records.
Phone calls: $220.00/hour
Time required in giving testimony: $250.00/hour
Time away from office due to deposition or testimony: $220.00/hour
All attorney fees and costs incurred by therapist because of legal action.
Filling a document with the court: $100.00
The minimum charge for a court appearance: $1500.00
A retainer of $1500.00 is due in advance. If a subpoena or notice to meet attorney is received without a minimum of 48-hour notice, there will be an additional $250.00 “express” charge. In addition, if the case is reset with less than 72 business hours’ notice, then the client will be charged $500 (in addition to the retainer of $1500).
Individual sessions are approximately 50 minutes in length.
Couples and family sessions are approximately 80 minutes.
Group Therapy sessions are approximately 80 minutes.
Sessions may be lengthened according to need.
It is customary for time at the end of sessions for charting and preparation between patients.
Dual or Sequential Relationships Policy:
It is my intention to not engage in psychotherapy with anyone where a dual or sequential relationship exists that may cause harm or exploit. As of the re-writing of this policy, 7/13/2018, I am an employee of Health Net Federal Services. Due to this employment I will not provide psychotherapy or consulting services to any Centene or subsidiary company employees, or its contractors or subcontractors, if harm or exploitation cannot be avoided. I also work with Tricare West beneficiaries as a Disease Management Specialist. I will not provide psychotherapy services to any Tricare West beneficiary on my Disease Management work roster. All Centene employees or Tricare West beneficiaries will be evaluated for potential harm or exploitation prior to engaging in psychotherapy services.
In the event that you are either a Centene family of companies’ employee, contractor or subcontractor, or a Tricare beneficiary seeking psychotherapy, please let me know before we engage in a therapeutic relationship. I am sorry for the inconvenience but making certain that my only interest is providing you with ethical conflict free services is paramount.
If I am a contracted provider for your insurance company, I will discuss the procedures for billing your insurance. The amount of reimbursement and the amount of any co-payments or deductible depends on the requirements of your specific insurance plan and my contract with them. You should be aware that insurance plans generally limit coverage to certain diagnosable mental health conditions. You should also be aware that you are responsible for verifying and understanding the limits of your insurance coverage. Although I am happy to assist your efforts to seek insurance reimbursement, I am unable to guarantee whether your insurance will provide payment for the services provided to you. Please discuss any questions or concerns that you may have about this with me. If for some reason you find that you are unable to continue paying for your therapy, you should inform me immediately. I will help you to consider any options that may be available to you at that time. If I am an out of network provider and your insurance company will accept a superbill, I will provide you with one. A superbill is an itemized form used by healthcare providers to reflect rendered services.
For example, if I am an uncontracted provider (and you do not have out of network coverage), you will be billed for the entire individual session fee amount of $165.00. If you have insurance your insurance may partially reimburse you per their policy and rate. However, you will pay the fee upfront, submit what ever documentation they require (superbill), and then await for their reimbursement. Please check with your insurer to make certain this is a viable option for you.
Also, if you have out of network coverage I will charge you the entire session fee and and will bill your insurance company directly for the session(s). For example, if we had an individual session fee amount of $165.00 and your insurance company paid $80.00, you will then be responsible for an $85.00 balance. Together, their payment and your payment equal $165.00.
All communications between you and I will be held in strict confidence unless you provide written permission to release information about your treatment. If you participate in marital or family therapy, I will not disclose confidential information about your treatment unless all person(s) who participated in the treatment with you provide their written authorization to release. (In addition, I will not disclose information communicated privately to him or her by one family member, to any other family member without written permission.) This will be made very clear to couples and families at the first appointment. There are exceptions to confidentiality. For example, therapists are required to report instances of suspected child, dependent adult, or elder abuse.
Therapists are also required or permitted to break confidentiality when they have determined that a patient presents a serious danger of physical violence to another person or when a patient is a danger to him or herself.
Minors and Confidentiality:
Communications between therapists and patients who are minors (under the age of 18) are confidential.
However, parents and other guardians who provide authorization for their child’s treatment are often involved in their treatment. Consequently may discuss the treatment progress of a minor patient with the parent or caretaker. Minor patients and their parents are urged to discuss any questions or concerns that they have on this topic with me. All parents will be asked about their legal custody status and may be asked to provide custody agreement documentation in support of their child’s treatment.
Appointment Scheduling and Cancellation Policies:
Sessions are typically scheduled to occur one time per week at the same time and day if possible. I may suggest a different amount of therapy depending on the nature and severity of your concerns. Your consistent attendance greatly contributes to a successful outcome. In order to cancel or reschedule an appointment, you are expected to notify me at least 48 hours in advance of your appointment. If you do not provide me with at least 48 hours’ notice, you are responsible for payment for the missed session. Please understand that your insurance company will not pay for missed or cancelled sessions.
You are welcome to phone me in between sessions. However, as a rule, it is my belief that important issues are better addressed within regularly scheduled sessions. You may leave a message for me at any time on my confidential voicemail. If you wish that I return your call, please be sure to leave your name and phone number(s), along with a brief message concerning the nature of your call. Non-urgent phone calls are returned during my normal working hours within 24 hours. Unless urgency is specified, no calls are returned on weekends. If you have an urgent need to speak with me, please indicate that fact in your message and follow any instructions that are provided by my voicemail. In the event of a medical or psychiatric emergency, and the situation allows, please have someone drive you to the “ER” or assist you with a “911” call. If there is an immediate threat to your safety or the safety of others, call “911” and request emergency assistance.
You should also be aware of the following resources that are available in the Sacramento community to assist individuals who are in crisis:
- National Crisis Hotline: (800) 273-8255
- WIND Youth Shelter: (916) 561-4900
- WEAVE Domestic Violence Help: (916) 448-2321
- Sierra Vista Psychiatric Hospital: (916) 288-0300
- Heritage Oaks Psychiatric Hospital: (916) 489-3336
- National Alliance on Mental Illness (NAMI): (916) 364-1642
- Sacramento County Mental Health Access Team: (916) 875-1055
Due to the lack of protection during some data exchanges, I choose to respond to all messages by phone or through patient portal instant messaging. As a patient, you have access to patient portal privileges. This allows for HIPAA compliant messaging, appointment making, as well as credit card payments.
Termination of Therapy:
The length of your treatment and the timing of the eventual termination of your treatment depend on the specifics of your treatment plan and the progress you achieve. It is a good idea to plan for your termination, in collaboration with me. I will discuss a plan for termination with you as you approach the completion of your treatment goals. You may discontinue therapy at any time. If you or I determine that you are not benefiting from treatment, either of us may elect to initiate a discussion of your treatment alternatives.
If you decide to enter treatment you will encounter this form again in your patient portal for acknowledgment.