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PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT

Welcome to my practice. This document (the Agreement) contains important
information about my professional services and business policies. It also contains
summary information about the Health Insurance Portability and Accountability Act to
the use and disclosure of your Protected Health Information (PHI) used for the purpose
of treatment, payment, and health care operations.  HIPAA requires that I provide you
with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for
treatment, payment and health care operations. The Notice, which is attached to this
Agreement, explains HIPAA and its application to your personal health information in
greater detail. The law requires that I obtain your signature acknowledging that I have
provided you with this information at the end of this session. Although these
documents are long and sometimes complex, it is very important that you read them
carefully before our next session. We can discuss any questions you have about the
procedures at that time. When you sign this document, it will also represent an
agreement between us. You may revoke this Agreement in writing at any time.  That
revocation will be binding on me unless I have taken action in reliance on it; if there are
obligations imposed on me by your health insurer in order to process or substantiate
claims made under your policy; or if you have not satisfied any financial obligations
you have incurred.

PSYCHOLOGICAL SERVICES
Psychotherapy is not easily described in general statements. It varies depending on
the personalities of the psychologist and patient, and the particular problems you are
experiencing. There are many different methods I may use to deal with the problems
that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it
calls for a very active effort on your part. In order for the therapy to be most
successful, you will have to work on things we talk about both during our sessions
and at home.

Psychotherapy can have benefits and risks.  Psychotherapy often leads to a better
understanding of how your mind and feelings work, better relationships, more
productivity at work, augmentation of physical and mental health, reduction in mental
illness, solutions to specific problems, and significant reductions in feelings of
distress. Although there are no guarantees of what you will experience, research
studies show that treatment with psychotherapy is frequently effective.  Since therapy
often involves discussing unpleasant aspects of your life, you may experience
uncomfortable feelings like sadness, guilt, anger, frustration, anxiety, loneliness,
shame and helplessness.  The goal is to help you move through and resolve such
feelings.  At any time I would be happy to discuss with you alternative forms of
psychotherapy and alternatives to treatment with psychotherapy.  A decision to
pursue alternatives should be made in consultation with a psychologist because some
conditions should be treated with psychotherapy and should not go untreated.

Our first few sessions will involve an evaluation of your needs. By the end of the
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 own 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.  Should you
have any questions or concerns about your therapy and how it is going, it is important
that you discuss these with me. If you continue to have doubts, or if you simply wish to
obtain a different viewpoint, I will be happy to help you set up a meeting with another
mental health professional for a second opinion. Therapy is more effective when you
feel comfortable with your therapist and feel free to discuss anything.

MEETINGS
I provide individual, family and marital therapy, and parental guidance.  I normally
conduct an evaluation that will last from 2 to 4 sessions. During this time, we can both
decide if I am the best person to provide the services that you need in order to meet
your treatment goals, and I will recommend the type of treatment that is best for you. If
psychotherapy is begun, I will usually schedule one to three 45-minute sessions per
week at a time we agree on, although some sessions may be longer or more frequent.
It is important to come regularly in order for therapy to be effective.

Therapy involves a mutual commitment and responsibility.  I will set aside a regular
appointment time for you and will make a commitment to keep that as your time.  You
will be responsible for coming to sessions regularly and paying for them.    Once an
appointment hour is scheduled, you will be expected to pay for it unless you provide 48
hours advance notice of cancellation.   Without such notice, the session time will have
been set aside for you and cannot be used for anyone else.  (Insurance companies
usually do not provide reimbursement for cancelled sessions.)  

PROFESSIONAL FEES
I shall review my per session fee with you. In addition to weekly appointments, I
charge a pro-rated amount for other professional services you may need. Other
services include report writing, telephone conversations lasting longer than 5
minutes, consulting with other professionals with your permission, preparation of
records or treatment summaries, and the time spent performing any other service you
may 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 to testify by another party. I
am committed to providing only private psychotherapy, and not participating in any
legal proceedings.  Should I be required to participate in legal proceedings, because of
the difficulty of legal involvement, I charge more per hour for preparation and
attendance at any legal proceeding.

CONTACTING ME
Should you need to call me between scheduled sessions, please leave a message on
my telephone answering machine, and I will return your call as soon as possible.  
When I am in my office I am not able to answer my phone personally when I am with a
patient.  If you are difficult to reach, please inform me of some times when you will be
available, and also please be sure to leave both your day-time and evening phone
numbers.  Even if I already have your phone numbers in your file, I do not always have
that information with me when I retrieve my phone messages.  It is usually difficult for
me to return calls to beepers.  

I do check my messages after business hours and over the week-ends; however, I do
not provide 24 hour emergency service.  Sometimes it can take me several hours to
return a phone call.  Should you have an emergency and find that you cannot reach me
directly, emergency services are available by going to the nearest hospital's
emergency room, by contacting your family physician, or by calling any of the following
phone numbers:

Switchboard of Miami, Inc. (Crisis and suicide counseling):   (305) 358.4357
Mercy Hospital, Psychiatry Department:  (305) 854.4400, (Admissions, ext. 2759)
Mercy Hospital Emergency Room:  (305) 285.2171
Jackson Memorial Hospital:  (305) 549.6901

I shall schedule an extra session for you if one is needed, as it is usually best to meet
in person, rather than for me to try to provide therapy or guidance by telephone.  If I will
be unavailable for an extended time, I will leave a message on my answering machine,
providing you with the name of a colleague to contact, if necessary, and reminding you
of the date of my return.

CONFIDENTIALITY
The law protects the privacy of all communications between a patient and a
psychologist.  I am the only person in this office who has access to information about
you.  I keep any written notes and charts in locked files.  Notes entered in my
computer are strictly confidential.  My computer is password protected.  My computer
is dedicated solely to my practice and is not used for any other purpose.  I do all billing
and create all written correspondence, so that there is never another person who has
access to any of your information. In order to assure confidentiality, I do not
communicate by fax or by the internet, or by any other electronic means which might
compromise your confidentiality.  I take every reasonable precaution to assure the
strictest privacy and confidentiality.



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Disclaimer | Site Map                                         © 2008 Janice Lindsay-Hartz, Ph.D., P.A.  All Rights Reserved  
Janice Lindsay-Hartz, Ph.D., P.A.
Licensed Clinical Psychologist
Licensed Marriage and Family Therapist
Miami, Florida
OFFICE LOCATION
IN COCONUT GROVE

Near S. Dixie
Highway and
S.W. 22nd Ave.
Miami, FL  33133

TELEPHONE:
(305) 662.4127