Required Administrative Forms
Below are explanations of required administrative forms that you must complete prior to your first session. Sessions cannot begin without Forms-on-File.
N.H. Admin. Code § Mhp 502.02 – Mental Health Bill of Rights
NH
Informed Consent Policy
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Sessions cannot begin without your consent and understanding of the therepeutic process. Informed Consents include expecations and limitations of therapy
Notice of Privacy Practices
What is Considered Private?
All of your disclosed information within sessions shall remain private and confidential.
An Exemption to breach confidentiality is if you disclose imminent risk to harm self or others. Clients are encouraged to share thoughts openly without fearing repercussions. I value transparency across sessions while also valuing your and other’s safety.
HIPPA Release of Information (ROI) Policy
What is considered Private?
Disclosed information within sessions shall remain private and confidential. *with exception to above
An ROI Form (release of information) is used if you want your information disclosed to a particular third-party. ex: spouse, guardians, providers, nurses, medical teams, programs, etc.
ROI’s and their limits will be discussed in sessions. Only direct, practical and relevant information will be shared based on your needs. e.g a typical collaboration lasts 5-10 minutes and will be billed and filed to your EHR
An EHR (electronic health record) is a records software that is HIPPA compliant. MCT uses *Therapy Notes to file notes and submit with insurance companies. Notes are used to document dates-of-services and to provide a comprehensive look at the course of treatment. *I will NEVER use Artificial Intelligence recording to write my notes. I personally will write your note.
*HIPPA refers to Health Insurance Portability and Accountability Act
Attendance and Cancelation Policy
What are Attendence Guidelines?
Attendance and participation is valued to ensure productive sessions and continuity of care.
Informed Cancelations: Let me know the day before (within 24 hours) of your session to avoid a cancelation fee
NoCall NoShow NCNS: When you do not let me know of an absence. A cancelation fee will be charged.
You must sign an attendance agreement after ONE NCNS. Clients are Removed from the schedule after TWO NCNS. To be placed back on the schedule, you will enter an automatic 3mo waitlist to give other people an opportunity to receive care. If you are unable to prioritize Therapy, you will be recommended to your nearest CMH community mental health center, or nearest Agency
Contact Policy
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Scheduling
When can you reach me?
I have a complex schedule and only have time to reply in the morning -before 10am and in the evening – after 7pm
I will respond to all other contacts when time becomes avalible. (ex: client cancelations)
I am in sessions across each week-day and will not awnser phonecalls or text messages.
Email is preferred contact to ensure confidentiality and a coherent record of interactions
I will send out Vacation Notices via email 2weeks prior to our scheduled sessions. I will also remind within our sessions.
Payment Authorization Form
How Do I Pay?
I accept the following insurances:
Harvard Pilgrim Health Care
Carelon
United HealthCare
*insurances have Co-Pays. They cover a portion of therapy, and clients are responsible for a remaining amount. *varies per insurance company
This form outlines rationale for why I consider Self-Pay optimal for the therapy process.
ex) if you have a HDHP high-deductible health plan, such as a cheaper plan offered through your employer, or an independent health-plan, Be Aware that HDHP’s and payments are sometimes processed after 4-6weeks by insurance companies. This could result in you paying the Full -Out-of-Pocket price for therapy until your insurance plan reaches its deductible.
Session Review / Treatment Planning
Policy
What documents do I recieve from Sessions?
I value your time and progress across sessions. We will periodically review diagnostic criteria.
You will be given your Diagnostic Outline on your first-day Diagnostic Review on your third-day Diagnostic Update on your third-month from there, Progress reviews every six months
- I will only write specific referals after three months of active engagment