Perspectives in Balance, PLLC
Dena Ann (Annie) Dries, PsyD
2311 Mustang Drive, Suite 200
Grapevine, Texas 76051
(617)957-9665
www.perspectivesinbalance.com

Informed Consent for Psychotherapy

General Information
The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

The Therapeutic Process
You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

Confidentiality
The session content and all relevant materials to the client's treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

1.      If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.
2.      If a client threatens grave bodily harm or death to another person.
3.      If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
4.      Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
5.      Suspected neglect of the parties named in items #3 and # 4.
6.      If a court of law issues a legitimate subpoena for information stated on the subpoena.
7.      If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert's report to an attorney.

Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

About the therapist Dena Ann (Annie) Dries, PsyD is a licensed psychologist in the states of Texas (License #38079) and Rhode Island (License # PS01411).

BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

Dena Ann (Annie) Dries, PsyD, Perspectives in Balance, PLLC

CONSENT FOR TELEHEALTH CONSULTATION
   1.      I understand that my health care provider may engage with me through telehealth consultation.
   2.      My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.
   3.      I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
   4.      I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
   5.      I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

CONSENT TO USE THE TELEHEALTH BY SIMPLEPRACTICE SERVICE
Telehealth by SimplePractice is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:
   1.      Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
   2.      Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
   3.      The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.
   4.      I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service - or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service.
   5.      To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.

By signing this form, I certify:
 -         That I have read or had this form read and/or had this form explained to me.
 -         That I fully understand its contents including the risks and benefits of the procedure(s).
 -         That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.

BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

Perspectives in Balance, PLLC
Dena (Annie) Dries, PsyD
2311 Mustang Drive, Suite 200
Grapevine, Texas 76051
(617)957-9665
www.perspectivesinbalance.com

PRACTICE POLICIES FOR PERSPECTIVES IN BALANCE, PLLC

APPOINTMENTS AND CANCELLATIONS
The standard meeting time for psychotherapy is 55 minutes. The cost of a therapy session is 275.00. The initial evaluation will be 80-90 minutes long. The cost of the initial evaluation is 375.00.

Intensive therapy sessions are offered and range from 3 hours and beyond in length with cost starting at 1200.00.

A $20.00 service charge will be charged for any checks returned for any reason for special handling.

Cancellations and re-scheduled sessions will be subject to an out of pocket charge of 150.00 if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE. No shows will be charged the full session rate. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time.

If you need to reschedule an appointment, every effort will be made to accommodate you.

If you miss more than two appointments, I may no longer be able to hold a specific time slot for you.

At the onset of treatment, it is important that you plan to attend weekly sessions for the first 12 to 16 weeks. This allows the therapeutic relationship to form and will positively impact your outcome.

USE OF INSURANCE BENEFITS
I am no longer accepting clients wishing to claim insurance benefits for services rendered. I do not accept any insurance plans.

TELEPHONE ACCESSIBILITY
If you need to contact me between sessions, please leave a message on my voicemail or you may text and let me know you would like to talk. I am often not immediately available; however, I will attempt to return your call or text within 24 hours. If a true emergency situation arises, please call 911 or go to your local emergency room.

SOCIAL MEDIA AND TELECOMMUNICATION
Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc.). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.

ELECTRONIC COMMUNICATION
I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. It is best practice for us to communicate through the secure messaging that you can access by entering the client portal if you need to communicate any sensitive information. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

TELEHEALTH DISCLOSURE
Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine by the State of California. Under the California Telemedicine Act of 1996, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist chose to use information technology for some or all of your treatment, you need to understand that: (1) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. (2) All existing confidentiality protections are equally applicable. (3) Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee. (4) Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent. (5) There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs. Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally the therapist.

MINORS
If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.

TERMINATION
Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.

BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

Perspectives in Balance, PLLC
Dena Ann (Annie) Dries, PsyD
2311 Mustang Drive, Suite 200
Grapevine, Texas 76051
(617)957-9665
www.perspectivesinbalance.com

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

 -         Make sure that protected health information ("PHI") that identifies you is kept private.
 -         Give you this notice of my legal duties and privacy practices with respect to health information.
 -         Follow the terms of the notice that is currently in effect.
 -         I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client's personal health information without the patient's written authorization, to carry out the health care provider's own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word "treatment" includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
   1.      Psychotherapy Notes. I do keep "psychotherapy notes" as that term is defined in 45 CFR 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
      a. For my use in treating you.
      b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
      c. For my use in defending myself in legal proceedings instituted by you.
      d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
      e. Required by law and the use or disclosure is limited to the requirements of such law.
      f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
      g. Required by a coroner who is performing duties authorized by law.
      h. Required to help avert a serious threat to the health and safety of others.
   2.      Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
   3.      Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:
   1.      When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
   2.      For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone's health or safety.
   3.      For health oversight activities, including audits and investigations.
   4.      For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
   5.      For law enforcement purposes, including reporting crimes occurring on my premises.
   6.      To coroners or medical examiners, when such individuals are performing duties authorized by law.
   7.      For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
   8.      Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
   9.      For workers' compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers' compensation laws.
   10.  Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
   1.       Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
   1.      The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say "no" if I believe it would affect your health care.
   2.      The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
   3.      The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.
   4.      The Right to See and Get Copies of Your PHI. Other than "psychotherapy notes," you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.
   5.      The Right to Get a List of the Disclosures I Have Made.You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.
   6.      The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say "no" to your request, but I will tell you why in writing within 60 days of receiving your request.
   7.      The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on 1/1/2020.

Acknowledgement of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.

BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

Perspectives in Balance, PLLC
Dena (Annie) Dries, PsyD

2311 Mustang Drive, Suite 200

Grapevine, Texas 76051

(617)957-9665
www.perspectivesinbalance.com

WAIVER OF INSURANCE
I hereby acknowledge the the provider is not accepting insurance and waive the use of my insurance plan for treatment. I agree to pay for services rendered out of pocket and understand that I will be unable to retroactively ask that sessions be applied to my insurance plan or benefits.

BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

Perspectives in Balance, PLLC
Dena Ann (Annie) Dries, PsyD
2311 Mustang Drive, Suite 200
Grapevine, Texas 76051
(617)957-9665

www.perspectivesinbalance.com

Under The No Surprises Act, healthcare providers are now required to share a good faith estimate for the potential cost of services rendered in order to avoid surprise medical bills. The following is a good faith estimate for psychotherapy services.

Date of Good Faith Estimate: This estimate is for psychotherapy services and is valid for one year from today's date.

Brief explanation of estimate for new patients:
The estimate below is the range of costs that are likely for most new patients. Until I do an initial evaluation and we start to work together, I will not have a clear picture of your specific diagnosis, issues and needs. I typically see therapy patients for at least 12 sessions and some patients continue treatment on a weekly or monthly basis to maintain improved functioning for a year or longer which could be up to 52 sessions per year. Total cost of sessions could range from 4,050 to to 16,050 per year depending upon diagnosis, severity of symptoms and frequency of treatment. In some cases a patient's issues may be more complicated, so we may need additional sessions during the time covered by this estimate.

Brief explanation for continuing patients: The estimate below is the range of costs that I think are likely for your care over the time period covered by this estimate. However, depending on how treatment progresses, more or fewer sessions may be needed.

Contact: If you have questions about this estimate, please contact me at (617)957-9665 or dr.dries@perspectivesinbalance.com.

Details of the Estimate
The following is a detailed list of expected charges for psychological services scheduled which would include your initial psychological evaluation and ongoing therapy sessions to occur weekly for at least 2 months. We may then determine to meet biweekly or monthly. Some clients continue to benefit from weekly sessions. The estimated costs are valid for 12 months from the date of this Good Faith Estimate, unless I send you an updated estimate.

Service - Initial evaluation with Psychotherapy sessions to follow

Diagnosis Code - Diagnosis will be determined after initial evaluation. This quote covers the range of possible diagnoses that are most frequently encountered such as Adjustment disorders, Generalized Anxiety, OCD, Depression, PTSD, and Phobias.

Initial Evaluation - Service code - 90791
Quantity - 1 session
Cost per unit - $350.00
Expected cost - $350.00

Psychotherapy Sessions - Service Code - 90837
Quantity - 12 - 52 sessions
Cost per unit - $250.00
Expected cost range- $3,600 - 15,600
Total estimated cost- $4,050 - 16,050

Psychologist providing services- Dena Ann Dries, PsyD
NPI number- 1235390600
TIN- 119602370

Disclaimer
This Good Faith Estimate shows the costs of services that are reasonably expected for the expected services to address your mental health care needs. The estimate is based on the information known to me when I did the estimate.

The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.

You may contact the [psychologist/psychology practice] at the contact listed above to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.

You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.

There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

To learn more and get a form to start the process, go to:

www.cms.gov/nosurprises or call CMS at 1-800-985-3059.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call CMS at 1-800-985-3059 .

This Good Faith Estimate is not a contract. It does not obligate you to accept the services listed above.