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Each account must have a unique email address associated with it. Please contact us if you need multiple accounts with the same email address (i.e. related family members).

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Terms and Policy

POLICY AGREEMENT

Professional Consultation

Professional consultation is an important component of a healthy psychotherapy practice. As such, Clinicians regularly participate in clinical, ethical, and legal consultation with appropriate professionals. During such consultations, we will not reveal any personally identifying information regarding you or your situation.


Billing and Payment

Payment will be made at the beginning of a session by cash, check, money order, or credit card. If there are challenges with making a payments and a balance has accrued  to $200 or more, services will be ceased until the balanced is payed.  The fee for service is as follows

$150.00 60-70 minute Assessment

$ 100  45 minute individual

$120  60 minute individual

$30 per group session

For those who prefer not to utilize insurance and request a sliding scale rate, the fee is $80 a session for 5 sessions.

ACT Services LLC reserves the right to periodically adjust fees. You will be notified of any fee adjustment in advance.  Please ask if you wish to discuss a written agreement that specifies an alternative payment procedure.


Scheduling

Appointments are scheduled through Counsol, a HIPPA compliant EMR Electronic medical records software. Counsol will email and text you a reminder 24 hours in advance of your appointment.  We have a 24 hour notice policy. Appointments time is reserved for you alone, so please be courteous when possible to provide as much notice as you can. If you must cancel or reschedule an appointment, we ask that you notify us 24 hours before your scheduled appointment. 

Late arrival: Individual sessions are 45 minutes. If you arrive late, sessions will end on time and not run over into the next person's session.


Husky/ Medicaid:   Counsol will text and email you, reminding you of your upcoming session. When canceling 24 hours before your scheduled appointment, you are able to log into Councol and cancel your appointment. If you No-shows, late reschedule or late cancel 4 times within the year it will result in a discussion and a referral to alternative care.


Sliding Scale/Cigna/ Anthem: When canceling 24 hours before your scheduled appointment, you are able to log into Councol and cancel your appointment without a late fee.  After 24 hours you are not able to cancel your appointment in  Counsol and your card will be changed a fee of $70. The fee applies to no show, late cancelation, and a late reschedule.  Your insurance company is not responsible. 


Illness: To ensure a safe office environment we ask that you call to reschedule if you are sick or have any contagious illness within the last 24 hours.

Weather: Your safety is important and should be top priority when considering New England weather. During hazardous weather please reschedule within 24 hours.


Documentation

Documentation request fee is not coved by insurance, thus the client is responsible for making a payment for clinical documentation. Clients are able to print documentation in Counsol at no charge.

Therapy focus is in providing therapy is on treatment and healing. It is not my intention to become involved in cases that require evaluation (either written or otherwise) or my testifying in court. You should hire a different and neutral mental health professional for any evaluation or testimony you require. The position is based on 2 reasons:

1 Clinician's statement will be biased in your favor because we have a therapeutic relationship and

2 The evaluation/testimony may affect the therapeutic relationship and the relationship must come first. This applies to clients of all ages.

If court ordered, clinicians are legally bound to comply with the court order.  Should services be needed, forensic, legal work in terms of paperwork, research, preparation and or calls it will be billed at my rate of $100 per half hour. Court appearances will be billed a rate of $500 per hour.


Termination of Therapy

You may discontinue therapy at any time. The length of your treatment and the timing of the eventual termination of your treatment depend on the specifics of your treatment plan and the progress you achieve. The clinician will discuss a plan for termination with you as you approach the completion of your treatment goals. If you or your therapist determine that you are not benefiting from treatment, either of us may elect to initiate a discussion of your treatment alternatives. Treatment alternatives may include, among other possibilities, referral, changing your treatment plan, or terminating your therapy. It is best to discuss this in a planned termination session if at all possible.

Services will be terminated by therapist if the client has no-showed 3 sessions within a year.

Services will be terminated by therapist if 2 phone calls have been made after a no show and no contact is made. A discharge letter will be mailed indicating the discharge.

Communication

ACT Services LLC clinicians can be reached by phone at 860-505-9017. Currently the contact number is not able to receive text messages. Email communication should only be done through Counsol, as it HIPPA compliant. In the event of a medical emergency or an emergency involving a threat to your safety or the safety of others, please call 911 to request emergency assistance, go to the nearest emergency room, and/or call the Mobile Crisis at 211. 

Social Media

ACT Services LLC and Clinicians have social media accounts but in order to keep treatment confidential, Clinicians and ACT Services LLC will not engage in any contact from clients on social media. Engaging with ACT Services LLC or your clinician this way could compromise your confidentiality. It may also create the possibility that these exchanges become a part of your legal medical record and will need to be documented and archived in your chart. If you need to contact me between sessions, the best way to do so is by phone.

            There will be no cell phones or recordings during sessions.


Credentials

Kasandra Marbury        Licensed Clinical Social Worker          License # 009389 


Acknowledgement

By signing below, I  have reviewed and fully understand the terms and conditions of this Agreement. I  have discussed such terms and conditions with the therapist and have had any questions with regard to its terms and conditions answered to Patient' satisfaction. Patient agree to abide by the terms and conditions of this Agreement and consent to participate in psychotherapy with the Therapist. Moreover, Patient agree to hold Therapist free and harmless from any claims, demands, or suits for damages from ="msonormal">
( Type Full Name )
Privacy Practice

Your Information. Your Rights. Our Responsibilities. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

- You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.

- We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

-You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.  We may say "no" to your request, but we'll tell you why in writing within 60 days.

-You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. - We will say "yes" to all reasonable requests.

- You can ask us not to use or share certain health information for treatment, payment, or our operations.  We are not required to agree to your request, and we may say "no" if it would affect your care.  If you pay for a service or health care item out of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say "yes" unless a law requires us to share that information.

-You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why. - We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make).

- You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

-If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. - We will make sure the person has this authority and can act for you before we take any action.

-You can complain if you feel we have violated your rights by contacting us using the information on the back page. - You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696- 6775, or visiting www.hhs.gov/ocr/privacy/hipaa/ complaints/. - We will not retaliate against you for filing a complaint.

Your Choice

-You can complain if you feel we have violated your rights by contacting us using the information on the back page. -

-You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696- 6775, or visiting www.hhs.gov/ocr/privacy/hipaa/ complaints/.

-We will not retaliate against you for filing a complaint.

- In these cases, you have both the right and choice to tell us to: share information with your family, close friends, or others involved in your care,  share information in a disaster relief situation,  include your information in a hospital directory If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety

-In these cases we never share your information unless you give us written permission: Marketing purposes, Sale of your information, Most sharing of psychotherapy notes

- In the case of fundraising: We may contact you for fundraising efforts, but you can tell us not to contact you again.

OUR USES AND DISCLOSURE

How do we typically use or share your health information? We typically use or share your health information in the following ways.

We can use your health information and share it with other professionals who are treating you. Example: A doctor treating you for an injury asks another doctor about your overall health condition.

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

 Example: We use health information about you to manage your treatment and services.

We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information? We are allowed or required to share your information in other ways - usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

-We can share health information about you for certain situations such as: - Preventing disease - Helping with product recalls - Reporting adverse reactions to medications - Reporting suspected abuse, neglect, or domestic violence - Preventing or reducing a serious threat to anyone's health or safety

-We can use or share your information for health research.

-We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law.

- We can share health information about you with organ procurement organizations.

-We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

-We can use or share health information about you:  For workers' compensation claims, For law enforcement purposes or with a law enforcement official,  With health oversight agencies for activities authorized by law,  For special government functions such as military, national security, and presidential protective services

-We can share health information about you in response to a court or administrative order, or in response to a subpoena.

OUR RESPONSIBLITIES

-We are required by law to maintain the privacy and security of your protected health information.

- We will let you know promptly if a breach occurs that may have compromised the privacy or -security of your information.

-We must follow the duties and privacy practices described in this notice and give you a copy of it.

-We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind. For more information see: www.hhs.gov/ocr/privacy/hipaa/ understanding/consumers/noticepp.html.

 Changes to the Terms of This Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Signing my name below acknowledges that I have received a copy of Notice of Privacy Practice and have had an opportunity to ask questions about this information. I have received this information in a language I  was able to understand and comprehend. 

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