Mindful Behaviors . . . with Johnna Pilipchuk, MA, LPA
Service Agreement and Consent for Treatment
Johnna W. Pilipchuk, MA, LPA
919-270-1991
Therapist-Client Service Agreement
Consent for Treatment
Welcome to my practice. This document is designed to help you understand who I am and what you may expect from
our professional relationship. It is very important that you read this document along with the Notice of Privacy
Practices I am required to provide you according to the Health Insurance Portability and Accountability Act
(HIPAA). You will be asked to sign this agreement and also acknowledge I provided you with a copy of the Notice of
Privacy Practices.
Professional Information
I have expertise and special interest in working with adults and adolescents experiencing depression, anxiety, post-
traumatic stress disorder and issues resulting from sexual abuse/incest including dissociative disorders. I also have
additional training in grief and loss. In addition to my degree I continue to update my skills by attending trainings and
I meet regularly with other professionals in order to provide the best care for you. I do make referrals to other
professionals as needed.
About Sessions
In the first session(s) we will discuss the problem that brings you to therapy as well as other factors in your present
life situation. We will discuss your goals, history, and assess our ability to work together. After our initial evaluation I
will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you
decide to continue with therapy. You should evaluate this information along with your opinions of whether you feel
comfortable working with me. Therapy involves a large commitment of time, money and energy, so you should be
very careful about the therapist you select. If you have questions about my procedures, we should discuss them
whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health
professional for a second opinion.
Psychotherapy can have benefits and risks. Risks might include experiencing uncomfortable levels of sadness, guilt,
anxiety, anger, frustration, or difficulties with other people. On the other hand, psychotherapy has also been shown
to have many benefits such as better relationships, solutions to specific problems, and significant reductions in
feelings of distress. Psychotherapy requires your active involvement in order to change thoughts, feelings and/or
behavior. There are no guarantees of what you will experience. However, together we will work to achieve the best
possible results for you.
Scheduling
Sessions are scheduled by mutual agreement for one therapeutic hour (50 minutes) unless otherwise specified. If you
are unable to keep an appointment please call to cancel or reschedule at least 24 hours in advance. If I do not receive
such advance notice, you will be required to pay for the missed appointment. Please note that it is unlawful to bill
insurance for missed appointments.
Professional Fees
My hourly fee is $95. In addition to regular appointments I charge this amount for other professional services you
may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include
letter or report writing, consulting with other professionals with your permission, preparation of records or treatment
summaries, and time spent performing any other service you request of me. If you become involved in legal
proceedings that require my participation you will be expected to pay for all of my professional time, including
preparation and transportation costs, even if I am called by another party. Because of the difficulty of legal
involvement, I charge $125 per hour for preparation and attendance at a legal proceeding.
Telephone Calls and Emergency Procedures
Due to my work schedule, I am often not immediately available by telephone. I do not answer the phone when I am
with a client. When I am unavailable, please leave a message on my answering service. I frequently monitor my
messages and will make every effort to return your call promptly, with the exception of evenings, weekends and
holidays, when I will return the call as soon as possible until 10:00 PM. NOTE: I charge my hourly rate for phone
calls lasting more than 10 minutes. If you are unable to reach me and feel that you can’t wait for me to return your
call, contact your family physician or the nearest emergency room and ask for the psychiatrist on call. If you need
immediate emergency attention, call 911. If I will be unavailable for an extended period of time, I will provide you
with the name of a colleague to contact if necessary.
Limits on Confidentiality
The law protects the privacy of all communications between a client and a psychologist. In most situations, I can
only release information about your treatment to others if you sign a written Authorization form that meets certain
legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance
consent. Your signature on this Agreement provides consent for those activities, as follows:
There are some situations where I am permitted or required to disclose information without either your consent or
Authorization:
There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to
protect others from harm and I may have to reveal some information about a client’s treatment. These situations are
unusual in my practice.
If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit
my disclosure to what is necessary.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential
problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws
governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is
required, formal legal advice may be needed.
Professional Records
You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of
professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking
therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set
for treatment, your progress towards those goals, your medical and social history, your treatment history, any past
treatment records that I receive from other providers, reports of any professional consultations, your billing records,
and any reports that have been sent to anyone, including reports to your insurance carrier. If subpoenaed, the Clinical
Record is sent to the legal party. The other type of record I keep is the Psychotherapy Notes. These are my personal
and private notes about our sessions for my own use and evaluation. They are NOT included in the clinical record and
can only be released under very specific circumstances as outlined by HIPAA.
Minors and Parents
Children of any age have the right to independently consent to and receive mental health treatment without parental
consent and, in that situation, information about that treatment cannot be disclosed to anyone without the child’s
agreement. It is my policy to request an agreement between my client and his/her parents allowing me to share only
general information about the progress of the child’s treatment and his/her attendance at scheduled sessions. Any
other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to
someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will
discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.
Billing and Payments
You will be expected to pay for each session at the time it is held, unless we agree otherwise. If I participate in your
PPO/HMO you are expected to pay your co-payment at the time of the session. Payment schedules for other
professional services will be agreed to when they are requested.
If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I
have the option of using legal means to secure the payment. This may involve hiring a collection agency or going
through small claims court which will require me to disclose otherwise confidential information. In most collection
situations, the only information I release regarding a client’s treatment is his/her name, the nature of services provided,
and the amount due. If such legal action is necessary, its costs will be included in the claim.
Insurance Reimbursement
In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have
available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for
mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the
benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of
my fees. It is very important that you find out exactly what mental health services your insurance policy covers.
You should carefully read the section in your insurance coverage booklet that describes mental health services. If you
have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever
information I can based on my experience and will be happy to help you in understanding the information you receive
from your insurance company.
Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes
difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as
HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These
plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with
a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of
sessions. While much can be accomplished in short-term therapy, some clients feel that they need more services after
insurance benefits end.
You should also be aware that your contract with your health insurance company requires that I provide it with
information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I
am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire
Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is
necessary for the purpose requested. This information will become part of the insurance company files and will
probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have
no control over what they do with it once it is in their hands. In some cases, they may share the information with a
national medical information databank. I will provide you with a copy of any report I submit, if you request it. By
signing this Agreement, you agree that I can provide requested information to your carrier.
Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish
with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It
is important to remember that you always have the right to pay for my services yourself to avoid the problems
described.
Your signature below or on the Services Signature Sheet indicates that you have read the information in this document
and agree to abide by its terms during our professional relationship. Your signature also acknowledges you received a
copy of my Notice of Privacy Practices as mandated by HIPAA.
_________________________________________________
Print client name
_________________________________________________
Client Signature (or guardian if client is a minor)
________________
Date
919-270-1991
Therapist-Client Service Agreement
Consent for Treatment
Welcome to my practice. This document is designed to help you understand who I am and what you may expect from
our professional relationship. It is very important that you read this document along with the Notice of Privacy
Practices I am required to provide you according to the Health Insurance Portability and Accountability Act
(HIPAA). You will be asked to sign this agreement and also acknowledge I provided you with a copy of the Notice of
Privacy Practices.
Professional Information
- MA Counseling Psychology, Goddard College, 1995
- Licensed Psychological Associate by the NC Psychology Board (LPA)
- Member NC Psychological Association (NCPA)
- 15 years experience working with individual adults and adolescents
- Trained in Dialectical Behavioral Therapy (DBT)
- Trained in working with Dissociative Disorders
I have expertise and special interest in working with adults and adolescents experiencing depression, anxiety, post-
traumatic stress disorder and issues resulting from sexual abuse/incest including dissociative disorders. I also have
additional training in grief and loss. In addition to my degree I continue to update my skills by attending trainings and
I meet regularly with other professionals in order to provide the best care for you. I do make referrals to other
professionals as needed.
About Sessions
In the first session(s) we will discuss the problem that brings you to therapy as well as other factors in your present
life situation. We will discuss your goals, history, and assess our ability to work together. After our initial evaluation I
will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you
decide to continue with therapy. You should evaluate this information along with your opinions of whether you feel
comfortable working with me. Therapy involves a large commitment of time, money and energy, so you should be
very careful about the therapist you select. If you have questions about my procedures, we should discuss them
whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health
professional for a second opinion.
Psychotherapy can have benefits and risks. Risks might include experiencing uncomfortable levels of sadness, guilt,
anxiety, anger, frustration, or difficulties with other people. On the other hand, psychotherapy has also been shown
to have many benefits such as better relationships, solutions to specific problems, and significant reductions in
feelings of distress. Psychotherapy requires your active involvement in order to change thoughts, feelings and/or
behavior. There are no guarantees of what you will experience. However, together we will work to achieve the best
possible results for you.
Scheduling
Sessions are scheduled by mutual agreement for one therapeutic hour (50 minutes) unless otherwise specified. If you
are unable to keep an appointment please call to cancel or reschedule at least 24 hours in advance. If I do not receive
such advance notice, you will be required to pay for the missed appointment. Please note that it is unlawful to bill
insurance for missed appointments.
Professional Fees
My hourly fee is $95. In addition to regular appointments I charge this amount for other professional services you
may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include
letter or report writing, consulting with other professionals with your permission, preparation of records or treatment
summaries, and time spent performing any other service you request of me. If you become involved in legal
proceedings that require my participation you will be expected to pay for all of my professional time, including
preparation and transportation costs, even if I am called by another party. Because of the difficulty of legal
involvement, I charge $125 per hour for preparation and attendance at a legal proceeding.
Telephone Calls and Emergency Procedures
Due to my work schedule, I am often not immediately available by telephone. I do not answer the phone when I am
with a client. When I am unavailable, please leave a message on my answering service. I frequently monitor my
messages and will make every effort to return your call promptly, with the exception of evenings, weekends and
holidays, when I will return the call as soon as possible until 10:00 PM. NOTE: I charge my hourly rate for phone
calls lasting more than 10 minutes. If you are unable to reach me and feel that you can’t wait for me to return your
call, contact your family physician or the nearest emergency room and ask for the psychiatrist on call. If you need
immediate emergency attention, call 911. If I will be unavailable for an extended period of time, I will provide you
with the name of a colleague to contact if necessary.
Limits on Confidentiality
The law protects the privacy of all communications between a client and a psychologist. In most situations, I can
only release information about your treatment to others if you sign a written Authorization form that meets certain
legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance
consent. Your signature on this Agreement provides consent for those activities, as follows:
- I may occasionally find it helpful to consult other health and mental health professionals about a case. During
a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are
also legally bound to keep the information confidential. If you don’t object, I will not tell you about these
consultations unless I feel that it is important to our work together.
- Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this
Agreement.
- If I believe that a client presents an imminent danger to his/her health or safety, I may be obligated to seek
hospitalization for him/her, or to contact family members or others who can help provide protection.
There are some situations where I am permitted or required to disclose information without either your consent or
Authorization:
- If you are involved in a court proceeding and a request is made for information concerning the professional
services that I provided you, such information is protected by the psychologist-client privilege law. I cannot
provide any information without your written authorization, or a court order. If you are involved in or
contemplating litigation, you should consult with your attorney to determine whether a court would be likely
to order me to disclose information.
- If a government agency is requesting the information for health oversight activities, I may be required to
provide it for them.
- If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in
order to defend myself.
- If a client files a worker’s compensation claim, and my services are being compensated through workers
compensation benefits, I must, upon appropriate request, provide a copy of the client’s record to the client’s
employer or the North Carolina Industrial Commission.
There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to
protect others from harm and I may have to reveal some information about a client’s treatment. These situations are
unusual in my practice.
- If I have cause to suspect that a child under 18 is abused or neglected, or if I have reasonable cause to believe
that a disabled adult is in need of protective services, the law requires that I file a report with the County
Director of Social Services. Once such a report is filed, I may be required to provide additional information.
- If I believe that a client presents an imminent danger to the health and safety of another, I may be required to
disclose information in order to take protective actions, including initiating hospitalization, warning the
potential victim, if identifiable, and/or calling the police.
If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit
my disclosure to what is necessary.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential
problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws
governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is
required, formal legal advice may be needed.
Professional Records
You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of
professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking
therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set
for treatment, your progress towards those goals, your medical and social history, your treatment history, any past
treatment records that I receive from other providers, reports of any professional consultations, your billing records,
and any reports that have been sent to anyone, including reports to your insurance carrier. If subpoenaed, the Clinical
Record is sent to the legal party. The other type of record I keep is the Psychotherapy Notes. These are my personal
and private notes about our sessions for my own use and evaluation. They are NOT included in the clinical record and
can only be released under very specific circumstances as outlined by HIPAA.
Minors and Parents
Children of any age have the right to independently consent to and receive mental health treatment without parental
consent and, in that situation, information about that treatment cannot be disclosed to anyone without the child’s
agreement. It is my policy to request an agreement between my client and his/her parents allowing me to share only
general information about the progress of the child’s treatment and his/her attendance at scheduled sessions. Any
other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to
someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will
discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.
Billing and Payments
You will be expected to pay for each session at the time it is held, unless we agree otherwise. If I participate in your
PPO/HMO you are expected to pay your co-payment at the time of the session. Payment schedules for other
professional services will be agreed to when they are requested.
If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I
have the option of using legal means to secure the payment. This may involve hiring a collection agency or going
through small claims court which will require me to disclose otherwise confidential information. In most collection
situations, the only information I release regarding a client’s treatment is his/her name, the nature of services provided,
and the amount due. If such legal action is necessary, its costs will be included in the claim.
Insurance Reimbursement
In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have
available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for
mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the
benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of
my fees. It is very important that you find out exactly what mental health services your insurance policy covers.
You should carefully read the section in your insurance coverage booklet that describes mental health services. If you
have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever
information I can based on my experience and will be happy to help you in understanding the information you receive
from your insurance company.
Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes
difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as
HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These
plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with
a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of
sessions. While much can be accomplished in short-term therapy, some clients feel that they need more services after
insurance benefits end.
You should also be aware that your contract with your health insurance company requires that I provide it with
information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I
am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire
Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is
necessary for the purpose requested. This information will become part of the insurance company files and will
probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have
no control over what they do with it once it is in their hands. In some cases, they may share the information with a
national medical information databank. I will provide you with a copy of any report I submit, if you request it. By
signing this Agreement, you agree that I can provide requested information to your carrier.
Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish
with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It
is important to remember that you always have the right to pay for my services yourself to avoid the problems
described.
Your signature below or on the Services Signature Sheet indicates that you have read the information in this document
and agree to abide by its terms during our professional relationship. Your signature also acknowledges you received a
copy of my Notice of Privacy Practices as mandated by HIPAA.
_________________________________________________
Print client name
_________________________________________________
Client Signature (or guardian if client is a minor)
________________
Date