Client Forms

Intake Form Adult
Release of Info Adult
Intake Form Minor
Release of Info Minor
Confidentiality Form
Therapist-Client Agreement Contract

Intake Form - Adult

Intake Form Adult

Rita Haley, LMHC
P.O. Box 196,
Manomet, MA 02345
508.581.7092

 

Name of Client

In Case of Emergency

Name of Spouse

Names of Children and Age

$

Release of Information - Adult

Release of Info Adult

Rita Haley, LMHC
P.O. Box 196,
Manomet, MA 02345
508.581.7092

Release of Information

This information is for the purpose of billing, such as submitting claims, and for the purpose of requesting extended treatment if necessary. Information exchanged include diagnostic information and treatment plan, if required by your insurance carrier.

I understand that the exchange of information made between Rita Haley, LMHC, and the parties listed above on lines 1, 2, 3, and/or 4 is for the sole purpose of effectively managing clinical services for me (or my minor child), and may include information about my identify, family, my clinical diagnosis, mental health problems, alcohol and/or drug abuse problems, treatment histories, etc... I further understand that I may ask for clarification about the nature and specifics of this release, and that I must be clear about these specifics before signing below. I may nullify this consent at any time except in cases where exchange of information has already occurred as permitted by this consent. If not nullified, this consent will expire one year from the date after which treatment with Rita Haley, LMHC, has terminated. This is not a consent for the release of medical, educational, or other records. The information exchanged between parties is confidential and protected by law.

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Intake Form - Minor

Intake Form Minor

Rita Haley, LMHC
P.O. Box 196,
Manomet, MA 02345
508.581.7092

 

Name of Client

In Case of Emergency

$

Release of Information - Minor

Release of Info Minor

Rita Haley, LMHC
P.O. Box 196,
Manomet, MA 02345
508.581.7092

Release of Information

This information is for the purpose of billing, such as submitting claims, and for the purpose of requesting extended treatment if necessary. Information exchanged include diagnostic information and treatment plan, if required by your insurance carrier.

I understand that the exchange of information made between Rita Haley, LMHC, and the parties listed above on lines 1, 2, 3, and/or 4 is for the sole purpose of effectively managing clinical services for me (or my minor child), and may include information about my identify, family, my clinical diagnosis, mental health problems, alcohol and/or drug abuse problems, treatment histories, etc... I further understand that I may ask for clarification about the nature and specifics of this release, and that I must be clear about these specifics before signing below. I may nullify this consent at any time except in cases where exchange of information has already occurred as permitted by this consent. If not nullified, this consent will expire one year from the date after which treatment with Rita Haley, LMHC, has terminated. This is not a consent for the release of medical, educational, or other records. The information exchanged between parties is confidential and protected by law.

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Confidentiality Form

Confidentiality Form

Rita Haley, LMHC
P.O. Box 196,
Manomet, MA 02345
508.581.7092

Massachusetts law (and HIPPA) requires that I provide you with the following information concerning confidentiality at the beginning of therapeutic treatment. It is important that you understand this information and your rights to health care privacy. Please read this information carefully. After you have read it, I am happy to answer any questions you may have regarding it.

In general, the confidentiality of all communications between clients and licensed mental health counselors (LMHC) is protected by law, and I can only release information about your therapeutic treatment to others with your written consent. There are, however, a number of exceptions, also defined by Massachusetts law, which you need to be aware of:

  1. If a minor child (a person under the age of 18 years of age) informs me of abuse, physical harm and/ or neglect, or in my professional judgment, I believe that a child is being abused, harmed and/or neglected, I must file a report with the Massachusetts Department of Children and Families.
  2. If an elderly or a disabled person informs me of abuse, physical harm and/ or neglect, or in my professional judgment, I believe that an elderly person or disabled person is being abused, harmed and/or neglected, I must file a report with the appropriate state agency.
  3. If, in my professional judgment, I believe a client is a danger to him/herself, and is threatening harm to him/herself, or discloses a plan to harm/himself, I am required to contact the person's parent and/or other family member, police, or others who can help to provide protection for the client, or seek hospitalization of the client.
  4. If, in my professional judgment, I believe a client is threatening serious bodily harm to another, I am required to take protective actions which may include notifying the potential victim, notifying the police, or seeking the client's hospitalization.
  5. There are some situations in which I am legally required to take action to protect others from harm, even though that may require revealing some information about a client's treatment. Should such a situation occur, I would make every effort to discuss the situation with the client, if possible, before taking any necessary action.
  6. In most judicial proceedings, you have the right to prevent me from providing any information about your treatment. However, in child custody proceedings, adoption proceedings, and proceedings in which your emotional condition is an important element, a judge may require my testimony if he/she determines that the resolution of the issues before him/her require it. Testimony may also be ordered in (A) a legal proceeding relating to psychiatric hospitalization, (B) malpractice and disciplinary proceedings brought against a LMHC, and (C) court- ordered evaluation. In an administrative or judicial proceeding, I am required to comply with a legitimate court order.
  7. If you reveal information which constitutes the misconduct of another LMHC, I am required to report that LMHC to the state licensing board. However, I will not reveal your name or give them any information which would allow you to be identified unless you agree to it.

There are several other matters concerning confidentiality of which you should be aware:

  • I may find it helpful occasionally to consult with other professionals regarding a case. In these consultations, I make every effort to avoid revealing any identifying information about my client. Consultants are also legally bound to keep mental or behavioral health care information confidential.
  • I am required by law to keep appropriate treatment records. Although I do not usually make records available, the law requires me to produce them upon your written request.
  • If you choose third party reimbursement, I am required to provide the insurer with dates of service, procedure codes, a diagnosis establishing a medical necessity, and charges. Sometimes, a treatment plan, treatment summary, and/or actual session entries are required for authorization and reimbursement. Massachusetts law prohibits all insurers from releasing any data about outpatient behavioral or mental health care without your permission. I cannot be responsible for what your insurer may do with information that I am required to provide them for authorization and reimbursement.
  • If you are under 18 years of age, please be aware that while specific content of our communications will remain confidential, your parents do have the right to receive general information on how your treatment is proceeding and a summary of the treatment when it is complete.

It is important we discuss any questions you may have regarding this disclosure concerning the limits of confidentiality. If you are interested in reading more specific material about current Massachusetts law and HIPPA, please ask. The laws that govern these issues are quite complex; while I am available to discuss these issues with you and answer questions in a broad sense, should you need more specific advice, formal legal consultation may be desirable.

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Therapist - Client Agreement Contract

Therapist-Client Agreement Contract

Rita Haley, LMHC
Therapist-Client Agreement Contract

Therapy Services Contract

Welcome to my practice. This document contains important information about my professional services and business policies. Please read it carefully. We will then review it together. When you sign this document, it will represent an agreement between us.

Psychotherapy Services

Psychotherapy is not easily described in general statements. There are several different reasons, contexts, situations, concerns and symptoms which motivate an individual to seek psychotherapy. Thus, there exist a number of different treatment modalities to address a variety of needs and symptoms. There is no one size fits all when it comes to psychotherapy.

Psychotherapy does require active participation on your part, and a commitment to your treatment. In order for treatment to be successful, you will have to attend your scheduled appointments, participate in the session and do “homework” outside of sessions.

Psychotherapy does not guarantee you will feel better, your problems will be resolved, your relationships will be improved, etc. However, research demonstrates that those who participate in a cognitive-behavior therapy feel more empowered, less distressed, better able to cope with stressors, and thus better able solve problems in their life, resolve differences in their relationships and have an improved overall sense of emotional (and maybe even physical) well being.

Canceling and Rescheduling Appointments

I am a self-employed, fee-for-service therapist. I am not paid by an employer, I am paid by the service and can only bill your insurance company for reimbursement for your appointment if you attend the session. If you need to cancel or reschedule an appointment, 24 hours notice is required or you will be charged for that appointment. If the cancelation is under 24 hours notice, you will be charged $40. If you fail to attend the appointment without notice, you will be charged the full amount of the contracted fee as set by your insurance carrier. The fees will need to be paid before you can schedule a new appointment. This can be done by mailing a check, paying by credit card over the phone or using PayPal.


Professional Fees

My fee schedule is as follows:

Initial Diagnostic Consult:

$175

Individual Therapy, 45 min:

$125

Individual Therapy, 60 min:

$155

Couples/Family Therapy:

$175

Reports, letters, completion of forms

not required by your insurance

$40 per 30 min

Phone consults with collaterals on your behalf

(ie, case managers, school personnel, etc.)

$10 per 15 min

Copy of Medical Record (including summary)

$40 per 30 min

Court or Deposition Services:

$200 per hr

Insurance Reimbursement

If you have a health insurance policy, it will usually provide some coverage for behavioral health treatment (typically, the contracted fee minus your co-payment/cost-share). A health insurance carrier (for example, Tufts) has over a 1000 different plans. There is no way for me to tell what plan you have and what it does and does not cover. It is your responsibility to know what is covered by your health plan. Procedure fees not covered by your plan, deductibles and co-payments are your responsibility. I reserve the right to use a third party to collect outstanding balances on fees not paid as well as legal proceeding in small claims court in an attempt to collect outstanding debt.

 

 

Professional Records

The laws and standards of my profession require I keep treatment records. You may submit a written request to examine or receive a copy of your records. In most instances, a written summary of your treatment will satisfy the various instances an individual may require a copy of his/her medical records. Fees will apply.

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Address:

P. O. Box 196, 
Manomet, MA 02345

Phone:

508.581.7092

Email:

rita.haley.lmhc @ gmail.com
© Rita Haley, LMHC 
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