Please read the following document which contains important information about professional services and business policies. Additional information is available on the Policies, Appointments, Contact Info, and FAQs areas of the Web site, which you are strongly encouraged to read. If you have any questions, please be sure to ask. Your acceptance of this agreement will allow you to proceed with the receipt of services. Work with a professional mental health provider often leads to improvement in one's self and relationships, resolution of specific problems, and reduced feelings of distress. However, there are no guarantees of what you may experience or the outcome of a particular situation. The office setting is where most work typically takes place, but this is not always practical or possible for certain people. It is important to remember that telephone services shouldn't be utilized as formal diagnostic or psychological treatment modalities. Sometimes a client may require in-person treatment from a healthcare provider. Information provided through distance formats is for educational purposes, and is to be used only by those who are 18 years of age or older.
Efforts will be made to schedule an appointment time that is mutually agreeable. Depending upon the type of service requested, effective treatment often involves consistent, ongoing sessions. You will always be given as much notice as possible about sessions that need to be rescheduled, and you are asked to do the same. If you cancel an appointment with less than 24 hours notice due to a non-emergency you will be held financially responsible for the session. Insurance, if applicable, will not cover the cost of missed sessions, so responsibility for the full fee will be yours. In case of emergencies such as illness or accidents, exceptions to this policy may be made.
Fees for services will vary depending upon the type of service chosen, but generally range from two to three dollars per minute. Length of session may also vary with the type of service, but are often divided into brief and full sessions occurring on average once weekly. Consultation and evaluation services tend not to be ongoing, unlike psychotherapy, counseling, coaching, or clinical hypnotherapy. The details can be discussed with you upon request. Services such as report writing, preparation of records, and time spent performing tasks other than direct communication with you during sessions will be charged accordingly.
Payment is necessary prior to or at the time of service, depending upon payment method. Payment may be made by check, cash, or money order. If a check is returned for any reason, any outstanding balance and all future payments must be made either by cash, money order, or bank/cashier's check. There will be a $25 charge for any check returned by the bank. Please note that it is generally inadvisable to send cash through the mail. If using telephone services, a check, money order, or equivalent form of payment must be received prior to the scheduled session. Past due accounts may be addressed through legal means such as small claims court or use of a collection agency. Please note that this would necessitate the release of basic identifying information about you to the court or collection agency.
Insurance may cover certain services, such as assessment, evaluation, psychotherapy, and counseling, but only if provided in the office setting. Consultation, clinical hypnotherapy, and life coaching are typically not covered. Upon request, a letterhead receipt for services can be provided to you that you can submit to your insurance company after having paid for your session yourself. In certain cases (e.g. local HMOs), you are required to make a co-payment at the time of service and billing for the balance will be done directly through this office. Release of identifying information is required for the submission of claims. Insurance coverage varies widely and it is your responsibility to understand the terms and limitations of your policy.
In general, all services provided by Tara Russow, Ph.D. through Russow Consulting are strictly confidential. No information may be released to any third party without your specific consent, usually in writing. Exceptions to this are in cases of child, elder, or dependent/disabled adult abuse, and in cases where you indicate you might hurt yourself or another, or cause damage to their property or family. In these cases of suicidal intent, homicidal intent, or abuse of another person healthcare providers are mandated by law to report the information to the appropriate authorities so as to protect you or the intended victim from harm. Also, in rare cases a court may require disclosure of professional records or testimony to assist in legal proceedings, since most courts have the power to subpoena records if they are deemed relevant.
Records of all professional services rendered will be stored in a secure location. Because these records may contain information that can be misinterpreted by someone who is not a mental health professional, they are generally not released to clients. If deemed necessary and clinically appropriate, the contents of the record can be discussed with you. If necessary I can also provide a treatment summary to another healthcare professional upon request. This will be treated as a professional clinical service and you will be charged accordingly.
Russow Consulting understands the sensitive nature of services to its clients. We are committed to respecting your privacy within the bounds of the law. All personally identifiable information such as name, mailing address, telephone & fax numbers, email address, and payment information will not be disclosed to anyone unless specifically allowed or required.
You can call and either speak with someone directly or leave a voice message if no one is available to take your call. There is an electronic relay system as well as a back up voice mail system. Your call will be returned as soon as possible although due to the nature of this work it may take awhile to respond. You are welcome to leave another message if you do not get a return call within a timely manner because in very rare instances electronic systems fail and messages are lost. If you are difficult to reach, please leave some times and numbers when you might be accessible. If you feel you are in a severe crisis, please contact your physician, a local emergency room, a crisis intervention center, a friend or relative, or call 911.
The client agrees that use of any and all services provided by Russow Consulting is entirely at the client's own risk. Services are provide "as is", without warranty of any kind, either express or implied. Specifically, any and all warranties are disclaimed, including without limitation any warranties concerning the availability, quality, accuracy or content of information, products or treatment services, or outcome. This disclaimer of liability applies to any damages or injury caused by the failure of performance, error, omission, interruption, deletion, defect, delay in operation of transmission, computer virus or breakdown, communication line failure, theft, destruction or unauthorized access to, alteration of, or use of record, whether for breach of contract, tortious behavior, negligence, or under any other cause of action. Neither the provider nor any of its agents, affiliates, or content providers shall be liable for any direct, indirect, special or consequential damages arising out of the use of the service or inability to gain access to or use the service or out of any breach of any warranty. The client hereby acknowledges that the provisions of this section shall apply to all content on these services.
Russow Consulting and/or Dr. Russow agree to provide you with the desired services subject to the terms of the agreement listed above. Additional information is available on the Web site and also through direct communication. We reserve the right to modify this agreement at any time. You agree to use the services in a manner consistent with all applicable laws and regulations, and in accordance with the terms and conditions specified above.
Client Signature: _______________________________
Printed Name: ________________________________
Date: _______________