How to Prepare for your Initial Appointment

This Agreement contains important information about our professional services and business policies. 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. Please read the information carefully and sign at the end of this document. By doing so you are indicating that you have reviewed this information and you are agreeing to the terms. You are free to revoke this agreement or discontinue your work with our organization at any time.

The Therapeutic Process

Family Guiding offers many forms of guidance to aid in your self and/or family development, including what is commonly known as “therapy” or “psychotherapy.” Sessions are 45 to 50 minutes and can occur in your home or at our office. Psychotherapy sessions can be provided on an individual basis, with partners or with the entire family depending on your specific needs. The nature and structure of sessions will vary depend on the particular issues you or your family are experiencing.

Therapy requires an active effort on everyone’s part and may require work in and out of sessions to facilitate success and growth. 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. We cannot promise that your behavior or circumstance will change but are committed to supporting and understanding you/your family in understanding as well as to help you clarify what it is that you want for yourself.

Confidentiality and Limitations

The law protects the privacy of all communications between a client and a psychologist. All information disclosed within sessions is confidential and may not be revealed to anyone without written permission except where disclosure is required by law. Disclosure is required by law in the following circumstances:

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. If a client communicates an immediate threat of serious harm to an identifiable victim, we may be required to notify the potential victim, contact the police, and/or seek hospitalization for the client.
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.

At Family Guiding we are committed to professional growth and as such consult with each other on cases as well as provide supervision to interns and students. During these consultations, we will avoid revealing any information that may identify you personally. If any such situation arises, we will make every effort to discuss it with you fully before taking any action, and will try to limit disclosure to what is necessary.

If you are working directly with a student or intern, information regarding you/your family’s progress in therapy will be shared with a Licensed Psychologist for the purposes of supervision.

There may arise a situation where you will see your therapist accidental outside of the therapy office. Should this occur, we are committed to honoring your privacy and confidentiality, therefore it is best practice not to acknowledge you first. However, if you wish to acknowledge your therapist you may do so but understand the conversation will be brief. It is best not to engage in any lengthy discussions in public or outside of the therapy office.

While this written summary of exception 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 in situations where specific advice is required, formal legal advice may be needed.

Business Policies and Procedures

Payment and Fees:

Our fees range from $175 to $275 and are dependent on the location, length of the session (between 45 to 90 minutes), and the number of family members attending each session. A sliding scale fee may also be arranged if necessary. All fees are negotiated in U.S. currency. Payments can be made by cash, check, or credit card and you will be expected to pay for each session at the time it is held, unless we agree otherwise. In the event that a payment made by check is returned by the bank for non-sufficient funds (NSF), you will be responsible for a $12 Returned Check Fee in addition to replacing the original payment.

Health Insurance:

Dr. Narayan is a participating provider for Blue Cross Blue Shield. Other insurance companies may provide reimbursement for our services as an out-of-network provider. We will provide you with all paperwork necessary to seek reimbursement from your insurance company; however, you are ultimately responsible for determining what services are covered and to what degree.

Cancellation Policy:

All appointments require 24 hours advance notice of cancellation. We will work with you to reschedule your appointment whenever possible. In the event that you need to cancel or reschedule a session, please do so by telephone. Cancellations via text message or email will not be accepted. Please note that if you do not provide 24 hours notice of cancellation or do not show up for a scheduled appointment, you will be responsible for a fee of $100.00. This fee will not be covered by insurance and you will be responsible for payment of the fee at your next scheduled session

Contact Information

You may reach us by telephone at (631) 223-8499. You may also be provided with additional contact information as necessary. Due to the nature of our work, we may not always be available by telephone. When we are unavailable, the telephone is answered by a confidential voicemail that is monitored frequently. Every effort will be made to return your call within 1-2 business days (excluding weekends and holidays). To uphold your privacy and confidentiality we do not communicate via text message or email regarding psychological services.

If you find yourself in an urgent situation, it is up to you to make a judgment about the prudence of waiting for a return call versus calling your primary care physician or 911. If we are away for an extended period, you will be notified beforehand. 

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. This notice described how health information may be used and disclosed and how you can get access to this information. PLEASE REVIEW IT CAREFULLY.

I. OUR PLEDGE REGARDING HEALTH INFORMATION

At Family Guiding Psychological Services, we understand that health information about you and your health care is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from this agency. This is to provide you 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 we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information. We are required by law to:

We are 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.
• We can change the terms of this Notice, and such changes will apply to all information about you. The new Notice will be available upon request and on our website at www.familyguiding.com

II. HOW WE 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 this document will explain what it means and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules and regulations allow health care providers who have direct treatment relationship with the client to use or disclose the client’s personal health information without the client’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. We 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, we may disclose health information in response to a court or administrative order. We 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

Psychotherapy Notes. Your therapist will 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:

• For my use in treating you.
• 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.
• For my use in defending myself in legal proceedings instituted by you.
• For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
• Required by law and the use or disclosure is limited to the requirements of such law.
• Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
• Required by a coroner who is performing duties authorized by law.
• Required to help avert a serious threat to the health and safety of others.

Disclosures to family, friends, or others. We 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.

Marketing Purposes. We will not use or disclose your PHI for marketing purposes.

Sale of PHI. We will not sell your PHI in the regular course of business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AURTHORIZATION

Subject to certain limitations in the law, we 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 our preference is to obtain an Authorization from you before doing so.
5. For law enforcement purposes, including reporting crimes occurring on this 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 our preference is to obtain an Authorization from you, we may provide your PHI in order to comply with workers’ compensation laws.
10. Appointment reminders and health related benefits or services. We may use and disclose your PHI to contact you to remind you that you have an appointment with me. We may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

V. 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 your therapist or this organization not to use or disclose certain PHI for treatment, payment, or health care operations purposes. We are not required to agree to your request, and we 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 We 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 we 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 we have about you. We 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 we 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 we have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided this agency with an Authorization. We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list given you will include disclosures made in the last six years unless you request a shorter time. We will provide the list to you at no charge, but if you make more than one request in the same year, we 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.