Welcome to Salgado Mental Health Counseling PC / Psychotherapy.

We appreciate you taking a moment out to read this. We wanted to thank-you for choosing us to provide for your counseling needs and goals. We appreciate and acknowledge the courage it takes to want to make a change, and we are delighted, honored and privileged to be working with you through this journey.

We see our clients as human beings who would like to live a healthy and wholesome life. We started Salgado Mental Health Counseling PC / Psychotherapy to aid people like you in achieving their mental health goals. Our philosophy lays in the idea that through conversation and exploration we are able to become aware of a variety of details which is one of the keys to propel the change process. We are hopeful and confident that therapy with us will be a balance of being challenged and supported.

Often our clients want to share with others about their progress and success. We welcome you to share your progress with others if you would like. Please know that should you choose to refer a potential client to work with us that both of your information is confidential and protected under HIPAA guidelines. Salgado Mental Health Counseling PC / Psychotherapy does not share information with others without your consent. 

We very much welcome and appreciate new clients into our practice, so we can also help them achieve the goals that matter to them most. We look forward to getting started with you at your first appointment.  Should you have any questions prior to our appointment please feel free to reach us. 

Thank you!

Closing Your File After 2 Inactive Weeks

Please be mindful that we have a specific number of clients we work with and in order to be fair for clients who are on our waitlist, we reserve the right to discharge your file if you have been inactive for 2 weeks. 

Being inactive would mean that you have not made efforts to: 

-bring up any changes in your life that would contribute to being inactive for 2 or more weeks in your therapy session and made plans accordingly

-make an appointment

-reach out to your therapist outside of the session

-reach out to our administration 

We (your therapist or administration) will try our best to reach out after each week. However, you are responsible to communicate with your therapist or our administration.

If we do not hear from you for those 2 weeks, we will assume you are no longer interested in working with us at this time and will process your file for discharge. If you would like to work with us again in the future, you can reach us back at support@salgadopsychotherapy.com.

Thank you for your time.

APPOINTMENTS AND CANCELLATION FEES

You are responsible for attending each appointment and agree to adhere to the following policy: 

A cancellation fee of $60.00 will be processed if you cancel within 24hrs before your scheduled appointment time or if you do not show up. Each insurance panel has a different policy on whether clinicians can charge for missed appointments. Check your provider's policies regarding cancellations and/or no shows. The client is responsible for covering a cancellation fee ($60). 

24hrs before the scheduled appointment time-

If you cannot keep the scheduled appointment, you can reschedule it yourself by logging in to the client portal as long as it is 24hrs before the appointment. You can also let your therapist/administration know (via any method agreed) you need to cancel/reschedule and we will do it for you.

Within 24hrs of the scheduled appointment time-

You MUST notify your therapist or our office via support@salgadopsychotherapy.com to cancel or reschedule the appointment. If you do not show, this will be subjected to the cancellation fee. The $60 fee will be your responsibility as the client. A cancellation fee invoice will be sent to you and then we will process the payment.

Emergencies will be assessed and considered by the therapist to waive fees. As we understand the state of the world, if you cancel or reschedule consistently, you and your therapist would benefit from re-evaluating your needs, desires, and motivations for treatment at this time. 

Your therapist may periodically take time off for vacation, seminars, and/or become ill. Attempts will be made to give adequate notice of these events. If your therapist is unable to contact you directly, a colleague/assistant may contact you to cancel or reschedule an appointment. We also encourage you to reach out to support@salgadopsychotherapy.com if you had not been able to contact your therapist for more than 1 week.

Should you have any questions please discuss with your therapist. Feel free to reach our administration as well, we are open to hear your comments or concerns.

Thank you,

Salgado Psychotherapy

This document is provided by Salgado Psychotherapy (Salgado Mental Health Counseling PC) to meet the requirements for the No Surprise Act - Good Faith Estimate information that patients now need to receive at the beginning of psychotherapy and clinical treatment. Please sign below acknowledging you were provided this information.

The No Surprises Act was passed in December 2020, under Section 2799B-6 of the Public Health Service Act, with the aim of protecting consumers from receiving unexpected medical bills.

The Good Faith Estimate provision of the No Surprises Act federally mandates that healthcare providers must give clients an estimate of anticipated healthcare items and services, using what is called a "Good Faith Estimate." This took effect on January 1, 2022.

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Please note that the nature of psychotherapy is one where we cannot know for certain the exact length of treatment as it is a collaborative and real-world work. For this reason, we ask that you do your own calculations. To determine the total estimated cost of therapeutic and clinical services over the course of 1 year, multiply your fee per session by the number of anticipated sessions (not including missed sessions for illness, holidays, vacation, etc.). 

*If you are a client who is using their health insurance, please check emails sent by Alma, directly contact your insurance carrier, or ask your therapist to know your co-pay rates.

*If you are a client who is paying a full fee out of pocket, you can see the rate on each appointment made. You can ask your therapist as well.

*If you are a client who is paying out of pocket for immigration evaluation, you will be given the fees/rates at the initial consultation. If you are unclear, please ask the provider doing your evaluation.

*If you are a client who has a sliding scale/low-rate agreement, you will also be able to see this on each appointment made as well as in the sliding scale/low-rate contract. You can also ask your therapist.

We pride ourselves in being transparent with our clinical and therapeutic work as well as our rates. We would not start working with a client without prior conversation about our services, health insurance we take, and our fees.

Please sign acknowledging this information

Thank you for your cooperation!

Client Rights & Therapist Duties

This document contains important information about federal law, the Health Insurance Portability and Accountability Act (HIPAA), that provides privacy protections and patient rights with regard 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 we 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 explains HIPAA and its application to your PHI in greater detail.

The law requires that we obtain your signature acknowledging that we have provided you with this.  If you have any questions, it is your right and obligation to ask so we can have a further discussion prior to signing this document.  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 unless I have taken action in reliance on it.

LIMITS ON CONFIDENTIALITY

The law protects the privacy of all communication between a patient and a therapist.  In most situations, we 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 some situations where we are permitted or required to disclose information without either your consent or authorization. If such a situation arises, we will limit our disclosure to what is necessary.  Reasons we may have to release your information without authorization:

 - If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist/psychotherapist-patient privilege law.  We cannot provide any information without your (or your legal representative's) written authorization, or a court order, or if we receive a subpoena of which you have been properly notified and you have failed to inform us that you oppose the subpoena.  If you are involved in or contemplating litigation, you should consult with an attorney to determine whether a court would be likely to order us to disclose information.

 - If a government agency is requesting the information for health oversight activities, within its appropriate legal authority, we may be required to provide it for them.

 - If a patient files a complaint or lawsuit against us, we may disclose relevant information regarding that patient in order to defend ourselves.

 - If a patient files a worker's compensation claim, and we are providing necessary treatment related to that claim, we must, upon appropriate request, submit treatment reports to the appropriate parties, including the patient's employer, the insurance carrier or an authorized qualified rehabilitation provider.

 - We may disclose the minimum necessary health information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  Our business associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

There are some situations in which we are legally obligated to take actions, which we believe are necessary to attempt to protect others from harm, and we may have to reveal some information about a patient's treatment:

 - If we know, or have reason to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child's welfare, the law requires that we file a report with the New York Abuse Hotline or Child Protective Services.  Once such a report is filed, we may be required to provide additional information.

 - If we know or have reasonable cause to suspect that a vulnerable adult has been abused, neglected, or exploited, the law requires that we file a report with the New York Abuse Hotline or Adult Protective Services.  Once such a report is filed, we may be required to provide additional information.

 - If we believe that there is a clear and immediate probability of physical harm to the patient, to other individuals, or to society, we may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police or to seek hospitalization of the patient.

CLIENT RIGHTS AND THERAPIST DUTIES

Use and Disclosure of Protected Health Information:

-          For Treatment - We use and disclose your health information internally in the course of your treatment.  If we wish to provide information outside of our practice for your treatment by another health care provider, we will have you sign an authorization for release of information.  Furthermore, an authorization is required for most uses and disclosures of psychotherapy notes.

-          For Payment - We may use and disclose your health information to obtain payment for services provided to you as delineated in the Therapy Agreement.

-          For Operations - We may use and disclose your health information as part of our internal operations.  For example, this could mean a review of records to assure quality.  I may also use your information to tell you about services, educational activities, and programs that I feel might be of interest to you.

Patient's Rights:

-          Right to Treatment - You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category. 

-          Right to Confidentiality - You have the right to have your health care information protected.  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.  I will agree to such unless a law requires us to share that information.

-          Right to Request Restrictions - You have the right to request restrictions on certain uses and disclosures of protected health information about you.  However, I am not required to agree to a restriction you request.

-          Right to Receive Confidential Communications by Alternative Means and at Alternative Locations - You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations.

-          Right to Inspect and Copy - You have the right to inspect or obtain a copy (or both) of PHI.  Records must be requested in writing and release of information must be completed.  Furthermore, there is a copying fee charge of 0 per page.  Please make your request well in advance and allow 2 weeks to receive the copies.  If we refuse your request for access to your records, you have a right of review, which I will discuss with you upon request.

-          Right to Amend - If you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information.  You have to make this request in writing.  You must tell us the reasons you want to make these changes, and I will decide if it is and if I refuse to do so, I will tell you why within 60 days. 

-          Right to a Copy of This Notice - If you received the paperwork electronically, you have a copy in your email.  If you completed this paperwork in the office at your first session a copy will be provided to you per your request or at any time.

-          Right to an Accounting - You generally have the right to receive an accounting of disclosures of PHI regarding you.  On your request, we will discuss with you the details of the accounting process.

-          Right to Choose Someone to Act for You - 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. 

-          Right to Choose - You have the right to decide not to receive services with me.  If you wish, we will provide you with names of other qualified professionals. 

-          Right to Terminate - You have the right to terminate therapeutic services with us at any time without any legal or financial obligations other than those already accrued.  We ask that you discuss your decision with us in session before terminating or at least contact us by phone letting us know you are terminating services.

-          Right to Release Information with Written Consent - With your written consent, any part of your record can be released to any person or agency you designate. Together, we will discuss whether or not we think releasing the information in question to that person or agency might be harmful to you.

Therapist's Duties:

 - We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.  We reserve the right to change the privacy policies and practices described in this notice.  Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.  If we revise our policies and procedures, we will provide you with a revised notice.

 

COMPLAINTS

If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact us, the State of New York Department of Health, or the Secretary of the U.S. Department of Health and Human Services.

YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE.

PART I: THERAPEUTIC PROCESS

If you are a client who is doing an immigration evaluation, this policy and its details may differ due to the nature of the evaluation. Please refer to the policies emailed to you for more information about your evaluation.

BENEFITS/OUTCOMES

The therapeutic process seeks to meet goals established by all persons involved, usually revolving around a specific complaint(s). Participating in therapy may include benefits such as the resolution of presenting problems as well as improved intrapersonal and interpersonal relationships. The therapeutic process may reduce distress, enhance stress management, and increase one's ability to cope with problems related to work, family, personal, relational, etc. Participating in therapy can lead to greater understanding of personal and relational goals and values. This can increase relational harmony and lead to greater happiness. Progress will be assessed on a regular basis and feedback from clients will be elicited to ensure the most effective therapeutic services are provided. There can be no guarantees made regarding the ultimate outcome of therapy. 

EXPECTATIONS

In order for clients to reach their therapeutic goals, their involvement and engagement is essential. Therapy is not a quick fix. It takes time and effort, and therefore, may move slower than your expectations. During the therapy process, we assess the person, identify goals, review progress, and modify the treatment plan as needed. 

RISKS

In working to achieve therapeutic benefits, clients must take action to achieve desired results. Although change is inevitable, it can be uncomfortable at times. Resolving unpleasant events and making changes in relationship patterns may arouse unexpected emotional reactions. Seeking to resolve problems can similarly lead to discomfort as well as relational changes that may not be originally intended. We will work collaboratively toward a desirable outcome; however, it is possible that the goals of therapy may not be reached. 

GENERAL STRUCTURE OF THERAPY

● Intake Phase - During the first session, therapeutic process, structure, policies and procedures will be discussed. We will also explore your experiences surrounding the presenting problem(s). 

● Assessment Phase - The initial evaluation may last 2-4 sessions. During this assessment phase, we will be getting to know you. we will ask questions to gain an understanding of your worldview, strengths, concerns, needs, relationship dynamics, etc. During this relationship building process, we will be gathering a lot of information to aid in the therapeutic approach best suited for your needs and goals. If it is determined that we are not the best fit for your therapeutic needs, we will provide referrals for more appropriate treatment. 

● Goal Development/Treatment Planning - After gathering background information, we will collaborate to identify your therapeutic goals. If therapy is court ordered, goals will encompass your goals and court ordered treatment goals, based on documentation from the court (please provide any court documents for review). Goals will be discussed throughout the therapeutic process. 

● Intervention Phase - This phase occurs anywhere from session two until discharge/termination/stopping therapy. Actively participating in therapy sessions, utilizing solutions discussed, and completing any assignments between sessions could be beneficial. Progress will be reviewed and goals adjusted as needed. 

● Discharge/Termination/Stopping Therapy - As you progress and get closer to completing goals, we will collaboratively discuss a transition plan for discharge/termination if desired. 

LENGTH OF THERAPY

Therapy sessions are typically weekly for 45-60 minutes depending upon the nature of the presenting challenges and insurance authorizations. It is difficult to initially predict how many sessions will be needed. We will collaboratively discuss from session to session what the next steps are and how often therapy sessions will occur.

APPOINTMENTS AND CANCELLATIONS

You are responsible for attending each appointment and agree to adhere to the following policy: If you cannot keep the scheduled appointment, you MUST notify our office to cancel or reschedule the appointment prior to 24 hrs of the scheduled appointment time; emergencies will be assessed and considered by the therapist or administration to waive fees. A cancellation fee will be $60.00 of a regular session fee (unless otherwise stated in writing). This will be generated as an invoice on our portal and payments will be made through here. If you cancel or reschedule consistently, we may re-evaluate your needs, desires, and motivations for treatment at this time. Each insurance panel has a different policy on whether clinicians can charge for missed appointments. Check your provider's policies regarding cancellations and/or no shows. The client is responsible for covering a cancellation fee. 

Psychotherapy is a uniquely personal service; therefore, consultations/sessions may be briefly interrupted. Therapists may periodically take time off for vacation, seminars, and/or become ill. Attempts will be made to give adequate notice of these events. If we are unable to contact you directly, a colleague/assistant may contact you to cancel or reschedule an appointment. 

FEES

The fee for each therapy session varies on the clinician and the client (also different depending on if the client uses an insurance plan). Payment is due after the held session. Acceptable forms of payment are: (if in person session) exact-amount cash, debit card and credit card through our portal. If the client is utilizing an insurance plan, co-pays are paid through the insurance-processing company (either Alma or Headway, please speak with your therapist which company is being used). In the event that a scheduled appointment time is missed or cancelled less than 24 hours in advance, please refer to the "Appointments and Cancellations" policy above. The clinician reserves the right to terminate the counseling relationship if more than 2 agreed upon sessions are missed without proper notification. 

TRIAL, COURT ORDERED APPEARANCES, LITIGATION

Rarely, but on occasion, a court will order a therapist to testify, be deposed, or appear in court for a matter relating to your treatment or case. In order to protect your confidentiality, we suggest considering whether or not getting involved in the court system is beneficial for your well-being. If we get called into court by you or your attorney, you will be charged a fee of $300 per hour to include travel time, court time, preparing documents, etc. 

COPIES OF MEDICAL RECORDS

Should you request a copy of your records please allow for a review in one (or more depending on the document) of your session and at least 2 weeks to prepare for you. 

PHONE CONTACTS AND EMERGENCIES

Because our practice is virtual, you may contact us via email at support@salgadopsychotherapy.com at any time. Please allow between 24hrs - 48hrs for a response. You may also call us at 516-853-6138 Monday - Friday 10am - 8pm, leave a voicemail, and a return call will be made within 24hrs or as soon as there is availability. You may also make arrangements with your current therapist/clinician about what is the best form of communication for both. 

In case of an emergency, you can access emergency assistance by calling the National Suicide Prevention Lifeline at 1-800-273-8255. If either you or someone else is in danger of being harmed, dial 911. 

PART II: CONFIDENTIALITY

Anything said in therapy is confidential and, we the therapist, may not be able to reveal to a third party without written authorization, except for the following limitations: 

● Child Abuse: Child abuse and/or neglect, which include but are not limited to domestic violence in the presence of a child, child on child sexual acting out/abuse, physical abuse, etc. If you reveal information about current child abuse or child neglect, we are required by law to report this to the appropriate authority. 

● Vulnerable Adult Abuse: Vulnerable adult abuse or neglect. If information is revealed about vulnerable adult or elder abuse, we are required by law to report this to the appropriate authority. 

● Self-Harm: Threats, plans or attempts to harm oneself. We are permitted to take steps to protect the client's safety, which may include disclosure of confidential information. 

● Harm to Others: Threats regarding harm to another person. If you threaten bodily harm or death to another person, we are required by law to report this to the appropriate authority. 

● Court Orders & Legal Issued Subpoenas: If we receive a subpoena for your records, we will contact you so you may take whatever steps you deem necessary to prevent the release of your confidential information. We will contact you twice by phone. If we cannot get in touch with you by phone, we will send you written correspondence via email and/or post mail. If a court of law issues a legitimate court order, we are required by law to provide the information specifically described in the order. Despite any attempts to contact you and keep your records confidential, we are required to comply with a court order. 

● Law Enforcement and Public health: A public health authority that is authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability; to a health oversight agency for oversight activities authorized by law, including audits; civil, administrative, or criminal investigations; inspections; licensure or disciplinary actions; civil, administrative, or criminal proceedings or action; limited information (such as name, address DOB, dates of treatment, etc.) to a law enforcement official for the purpose of identifying or locating a suspect, fugitive, material witness, or missing person; and information that your clinician believes in good faith establishes that a crime has been committed on the premises. 

● Governmental Oversight Activities: To an appropriate agency information directly relating to the receipt of health care, claim for public benefits related to mental health, or qualification for, or receipt of, public benefits or services when your mental health is integral to the claim for benefits or services, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence. 

● Upon Your Death: To a law enforcement official for the purpose of alerting of your death if there is a suspicion that such death may have resulted from criminal conduct; to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death, or other duties as authorized by law. 

● Victim of a Crime: Limited information, in response to a law enforcement official's request for information about you if you are suspected to be a victim of a crime; however, except in limited circumstances, we will attempt to get your permission to release information first. 

● Court Ordered Therapy: If therapy is court ordered and we agree to work together, the court may request records or documentation of participation in services. We will discuss and review the information and/or documentation with you in session prior to sending it to the court. 

● Written Request: Clients must sign a release of information form before any information may be sent to a third party. A summary of visits may be given in lieu of actual "psychotherapy/progress notes." If therapy sessions involve more than one person, each person over the age of 18 MUST sign the release of information before information is released. 

● Fee Disputes: In the case of a credit/debit card dispute, we reserve the right to provide the necessary documentation (i.e. your signature on the "Therapy Consent & Agreement" that covers the cancellation policy to your bank or credit card company should a dispute of a charge occur. If there is a financial balance on account, a bill will be sent to the home address on the intake form unless otherwise noted. 

● Couples and Family Counseling & "No Secret" Policy: When working with couples, all laws of confidentiality exist. We request that neither partner attempt to triangulate the therapist into keeping a "secret" that is detrimental to the couple or family's therapy goal. If one partner requests that the therapist keep a "secret" in confidence, the therapist may choose to end the therapeutic relationship and give referrals for other therapists as our work and your goals then become counter-productive. However, if one party requests a copy of couples or family therapy records in which they participated, an authorization from each participant (or their representatives and/or guardians) in the sessions will be requested before the records can be released. 

● Dual Relationships & Public: Our relationship is strictly professional. In order to preserve this relationship, it is imperative that there is no relationship outside of the counseling relationship (ie: social, business, or friendship). If we run into each other in a public setting, the therapist will not acknowledge you as this would jeopardize confidentiality. If you were to acknowledge the therapist, you are giving consent to breach confidentiality; your confidentiality will be at risk. 

● Social Media: No friend requests on ourpersonal social media outlets (Facebook, LinkedIn, Pinterest, Instagram, Twitter, etc.) will be accepted from current or former clients. If you choose to comment on our professional social media pages or posts, you do so at your own risk and may breach confidentiality. We cannot be held liable if someone identifies you as a client. Posts and information on social media are meant to be educational and should not replace therapy. If you are a current client of ours, please do not contact us regarding your therapeutic process through any social media site or platform. They are not confidential, nor are they monitored, and may become part of medical records. 

● Electronic Communication: If you need to contact your therapist outside of our sessions, please make arrangements with them about what form of communication is best for both. 

    â—‹ Clients often use text or email as a convenient way to communicate in their personal lives. However, texting introduces unique challenges into the therapist-client relationship. Texting is not a substitute for sessions. Texting is not confidential. Phones can be lost or stolen. DO NOT communicate sensitive information over text. The identity of the person texting is unknown as someone else may have possession of the client's phone. 

    â—‹ Do not use email for emergencies. In the case of an emergency call 911, your local emergency hotline or go to the nearest emergency room. Additionally, e-mail is not a substitute for sessions. If you need to be seen, please call to book an appointment. 

    â—‹ Our emails ending in @salgadopsychotherapy.com are HIPAA compliant and confidential. Do not communicate sensitive medical or mental health information via other forms of email. 

    â—‹ Furthermore, if you send email from a work computer, your employer has the legal right to read it. E-mail is a part of your medical record. 

● Sessions Outside the Office: All sessions are currently virtual. We will notify you if this changes and there are options for in-person sessions.

PART III: HEALTH INSURANCE

YOUR INSURANCE COMPANY

Currently, Headway and Alma are used as the platform to aid insurance (5 specific insurance plans) claims related processes. Those 2 companies serve as the middle 'person (s)' between the therapist and your insurance company (if using one). By using insurance, we are required to give a mental health diagnosis that goes in your medical record. The clinical diagnosis is based on your current symptoms even though you may have been previously diagnosed. We will discuss your diagnosis during the session. Your insurance company will know the times and dates of services provided. They may request further information to authorize additional services regarding treatment; Headway/Alma will notify me and/or you in the event this comes up. 

IMPORTANT: Some psychiatric diagnoses are not eligible for reimbursement. In the event of non-coverage or denial of payment of a session held, you will be responsible to pay for services provided. Salgado Mental Health Counseling PC reserves the right to seek payment of unpaid balances by collection agency or legal recourse after reasonable notice to the client. 

PRE-AUTHORIZATION & REDUCED CONFIDENTIALITY

When visits are authorized, usually only a few sessions are granted at a time. When these sessions are complete, we may need to justify the need for continued service, potentially causing a delay in treatment. If insurance is requesting information for continued services, confidentiality cannot be guaranteed. Sometimes, additional sessions are not authorized, leading to an end of the therapeutic relationship even if therapeutic goals are not met. 

POTENTIAL NEGATIVE IMPACTS OF A DIAGNOSIS

Insurance companies require clinicians to give a mental health diagnosis (i.e., "major depression" or "obsessive-compulsive disorder") for reimbursement. Psychiatric diagnoses may impact you in the following ways (depending on your disclosure and requirements of establishment): 

1. Denial of insurance when applying for disability or life insurance; 

2. Company (mis)control of information when claims are processed; 

3. Loss of confidentiality due to the increased number of persons handling claims; 

4. Loss of employment and/or repercussions of a diagnosis in situations where you may be required to reveal a mental health disorder diagnosis on your record. This includes but is not limited to: applying for a job, financial aid, and/or concealed weapons permits. 

5. A psychiatric diagnosis can be brought into a court case without your consent if documents are subpoena (please see 'Confidentiality limitations above). It is important that you're an informed consumer. This allows you to take charge regarding your health and medical record. At times, having a diagnosis can be helpful when requesting certain services.

PART III: REASONS WHY SOME CLINICIANS DO NOT ACCEPT INSURANCE

● Reduced Ability to Choose: Most health care plans today (insurance, PPO, HMO, etc.) offer little coverage and/or reimbursement for mental health services. Most HMOs and PPOs require "preauthorization" before you can receive services. This means you must call the company and justify why you are seeking therapeutic services in order for you to receive reimbursement. The insurance representative, who may or may not be a mental health professional, will decide whether services will be allowed. If authorization is given, you are often restricted to seeing the providers on the insurance company's list. Reimbursement is reduced if you choose someone who is not on the contracted list (out-of-network providers); consequently, your choice of providers is often significantly restricted. 

● Pre-Authorization and Reduced Confidentiality: Insurance typically authorizes several therapy sessions at a time. When these sessions are finished, your therapist must justify the need for continued services. Sometimes additional sessions are not authorized, leading to an end of the therapeutic relationship even if therapeutic goals are not completely met. Your insurance company may require additional clinical information that is confidential in order to approve or justify a continuation of services. Confidentiality cannot be assured or guaranteed when an insurance company requires information to approve continued services. Even if the therapist justifies the need for ongoing services, your insurance company may decline services. Your insurance company dictates if treatment will or will not be covered. Note: Personal information might be added to national medical information data banks regarding treatment. 

● Negative Impacts of a Psychiatric Diagnosis: Insurance companies require clinicians to give a mental health diagnosis (i.e., "major depression" or "obsessive-compulsive disorder") for reimbursement. Psychiatric diagnoses may impact you in the following ways: 

1. Denial of insurance when applying for disability or life insurance; 2. Company (mis)control of information when claims are processed; 3. Loss of confidentiality due to the increased number of persons handling claims; 4. Loss of employment and/or repercussions of a diagnosis in situations where you may be required to reveal a mental health disorder diagnosis on your record. This includes but is not limited to: applying for a job, financial aid, and/or concealed weapons permits. 5. A psychiatric diagnosis can be brought into a court case (ie: divorce court, family law, criminal, etc.). It is also important to note that some psychiatric diagnoses are not eligible for reimbursement.

Working with clinicians who are out-of-network providers (clinicians that do not take insurance): 

These involve enhanced quality of care and other advantages: 

1. You are in control of your care, including choosing your therapist, length of treatment, etc. 

2. Increased privacy and confidentiality (except for limits of confidentiality). 

3. Not having a mental health disorder diagnosis on record. 

4. Consulting with therapists on non-psychiatric issues that are important to you that aren't billable by insurance.

We still provide services for clients who have specific insurance plans as well as clients who pay out-of-pocket as we want people to have more access to mental health care with specialty providers.

PART IV: CONSENT

1. I have read and understand the information contained in the 'Therapy Agreement, Policies and Consent.' I have discussed any questions that I have regarding this information with my therapist. My signature below indicates that I am voluntarily giving my informed consent to receive counseling services and agree to abide by the agreement and policies listed in this consent. I authorize my assigned therapist from Salgado Mental Health Counseling to provide counseling services that are considered necessary and advisable. 

2. I authorize the release of treatment and diagnosis information (as described in Part III, above) necessary to process bills for services to my insurance company (if applicable), and request payment of benefits to Salgado Mental Health Counseling PC. I acknowledge that I am financially responsible for payment whether or not covered by insurance. I understand, in the event that fees are not covered by insurance, my therapist or Salgado Mental Health Counseling PC may utilize payment recovery procedures after reasonable notice to me, including a collection company or collection attorney. 

3. (If applicable) Consent to Treatment of Minor Child(ren): I hereby certify that I have the legal right to seek counseling treatment for minor(s) in my custody and give permission to Salgado Mental Health Counseling PC to provide treatment to my minor child(ren). If I have unilateral decision-making capacity to obtain counseling services for my minor, I will provide the appropriate court documentation to Salgado Mental Health Counseling PC prior to or at the initial session. Otherwise, I will have the other legal parent/guardian sign this consent for treatment prior to the initial session.

CARD ON FILE

For clients who pay out of pocket:

In order to ensure that payments for services rendered are being made we are requiring a credit/debit card to be added to our system. You have the autonomy and agency to make your own payments. We will only process payments after sessions if you give us your consent or if you have an outstanding balance for more than 1 month/4 weeks.

*For clients doing immigration evaluations, payments will be processed before our first evaluation session.You can make the payment yourself through this system or we will process it before the first evaluation session.

For clients who use insurance and have co-pays:

Your co-pays will be done and processed through Alma - you do have the option to add your card there and select to have automatic payments. In order to ensure that co-pays for services rendered are being made we are requiring a credit/debit card to be added to (this) our system. You have the autonomy and agency to make your own payments through Alma. We will only process payments through our system if you have an outstanding balance for more than 1 month/4 weeks.

COLLECTIONS

In the event that we are not able to process and/or receive your payment and you continue to have an outstanding balance for more than 90 days, we will make efforts to contact you and remind you of this. If we get no response after multiple attempts, we reserve the right to send your account to a collection agency and add any fees necessary in order for us to obtain your full balance amount. 

We appreciate your understanding and agreement.