AMY BECKMAN, LCSW
McLean Professional Park
1499 Chain Bridge Rd., Suite 200
McLean, VA 22101
(703) 356-3239
northernvirginiapsychotherapy.com
POLICIES AND CLIENT INFORMATION
Welcome to my practice. It is my goal to provide you with appropriate, high quality, supportive psychotherapy services. The following information is a description of my policies concerning your therapy. Please feel free to discuss any of these topics with me.
CONFIDENTIALITY: The services that you receive are confidential, private, and personal. During our initial sessions we will discuss your rights to privacy. HIPPA forms ensuring you of all your rights to confidentiality will be provided. Please be aware that your written permission is required for the release of any information, with a few exceptions. In cases of suspected of child abuse, suicidal intent, or clear and imminent danger to you or others, I am required to notify the appropriate authorities. During the course of therapy we may communicate via the internet, however, privacy cannot be guaranteed in these circumstances. Your billing record is accessible only to me and personnel whom I have authorized to perform billing services.
APPOINTMENTS: When you arrive for your appointments please have a seat in the lobby. The first two initial sessions are scheduled for 60 minutes. Ongoing individual therapy sessions are 50 minutes in duration. Couples or family sessions are scheduled for 60 or 75 minutes. Continuity in therapy is critical to ensure that you receive the full benefit and effectiveness of these services. The time of your appointment has been specifically reserved for you. In order not to be charged a full fee for missed appointments, cancellations must be received at least 24 hours in advance. Insurance companies do not pay for missed appointments. If you are forced to cancel a session without sufficient notice, you may request a make-up session, however, I cannot assure you that a make-up session will be available. If I am unable to keep a scheduled appointment, you will be contacted as soon as possible and you will not be charged.
INSURANCE: Please consult your insurance company for specific information about your mental health benefits. Payment for services rendered is your responsibility. I will provide you with a completed uniform insurance claim form (HCFA 1500) at the end of each month. It will be your responsibility for submitting to and managing the reimbursements from your insurance company. I will only bill insurance companies directly in limited circumstances. Such billing arrangements must be made in advance.
FEE INFORMATION:
Initial two sessions $$200 - $250.00.
Ongoing sessions:
50 minute sessions are $175.00.
60 minute sessions are $200.00.
75 minute sessions are $250.00.
I will inform you in advance whenever my fees will be increased.
Every client receiving services shall be responsible for the full payment for services. I expect clients to make a payment at each session or upon receipt of a bill. Your bill will be e-mailed as a PDF at the end of each month. Payments are due upon receipt and should be made directly to me. If at any time you find there are any problems regarding payment of fees or you need to make arrangements for a payment plan, I will be glad to speak to you regarding your concern.
A finance charge of one and one-half per cent (1.5%) per month (annual percentage rate of 18%) on all past due accounts will be applied for bills more than 60 days past due.
There may be circumstances when you will be charged for my time outside of your therapy sessions, such as consultation time between me and other health care professionals, telephone consultations with you, preparation of special reports, or communication with your insurance company for prior authorizations for further therapy sessions. Generally, charges will only be applied for time spent providing these services in excess of 15 minutes.
AVAILABILITY: I may be reached via a voice mail system that is checked frequently throughout the day. Every effort will be made to promptly return phone calls. In the event of an emergency, contact your physician, call 911 or go to your local hospital’s emergency room. If I am out of town and you need assistance, information will be left on my voice mail recording directing you to a covering clinician.
TREATMENT IS A PARTNERSHIP: Please feel free to discuss any of your thoughts or concerns about your therapy at any time during our work together. Throughout all stages of therapy, openness and honesty are integral to success. Ending our work together is also an important part of the therapy process and often provides unique opportunities for learning. Given the importance of closure, I strongly encourage you to plan for the ending of your therapy during session time and not over the phone or via e-mail.
Thank you for your decision to work with me. If you have any questions or concerns at any time during the course of your therapy, please feel free to discuss them with me.
ACKNOWLEDGEMENT OF RECEIPT OF THE
POLICIES AND CLIENT INFORMATION STATEMENT
I have read the Policies and Client Information statement of Amy Beckman’s psychotherapy practice. I have discussed this with her and I understand and agree that the policies stated apply to me and I have retained a copy.
Client, Parent or Guardian signature: ________________________________________
Date:____________________________________
Please sign and date this acknowledgement and return to Ms. Beckman.
Rev. 1-20