OFFICE POLICIES

Psychotherapy can have benefits and risks. Since therapy often involves discussing difficult aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. At the same time, psychotherapy has been shown to improve relationships, to provide solutions to specific problems, and to provide solutions to specific problems, and to reduce feelings of distress. Psychotherapy involves a large commitment of time, money, and energy, so you should be careful about the psychologist you select.

As your psychologist, Dr Hodges is not permitted to complete certain evaluations (e.g., disability or forensic exams), or to write letters regarding emotional support for animals.

Such practices need to be provided by a neutral 3rd party professional.

Please note office policies:

Professional Relationship

Status of Relationship- Should you decide to become a patient at Champion Psychological Services, LLC (CPS, LLC), please keep in mind that Dr Hodges is not your friend. She is your psychologist. You have decided to enter a professional relationship with her.

Location of Appointments

At the present time, all appointments will be held virtually. There are no face-to-face appointments.

Dr Hodges is a NJ Licensed Psychologist and a NJ Licensed Clinical Alcohol and Drug Counselor. Per licensing regulations, all patients must receive their treatment in New Jersey.

Therefore, if you take a vacation out of state, you will need to reschedule your appointments at least 48 hours in advance of your vacation.

Office Closings

At times it becomes necessary to close the office. When this occurs, you will be notified either during your session or in an email. And, during that time, (or shortly thereafter), you will also be provided with information regarding rescheduling any needed appointments.

Therefore, it is your responsibility to check your email messages regularly between sessions.

Patient Appointments and Cancellations

Appointment times are set to accommodate client schedules as often as possible. To properly assist you, I ask that you keep your appointment on a regular basis. I will be glad to discuss any need for a change in scheduling. If you cannot keep your scheduled appointment, please call 609-638-7560.

By law, Dr. Hodges is not permitted to bill your insurance for missed appointments. Therefore, you will be billed for any missed appointments unless Dr Hodges is given 48 hours' notice. When you cancel, Dr. Hodges loses revenue, and you lose treatment services. Additionally, these services are not available to others.

The no-show fee is only a portion of the hourly rate.

If you need to cancel an appointment, please call and leave a message.
Please do not text or send messages via messenger.
These modalities are not HIPAA compliant.

Duration of Appointment

Psychotherapy session “hours” are typically 45 minutes to 50 minutes in duration at most. Psychologists typically use the balance of the hour to document what happened in the session, and begin the next session, at the start of the next hour. This is an acceptable billing practice.

No Show Appointments

If you are 15 minutes late for your appointment without prior notification, you may be billed for a NO SHOW appointment.

If you are 15 minutes late for your appointment without prior notification, your appointment is cancelled.

If you contact the office and state that you will be late, you can have the balance of your 50-minute session. Your session will end as scheduled.

In this case, it is suggested that you CALL state you will be late. Dr. Hodges will receive the message even if she does not answer.

If you NO SHOW an appointment, all subsequent appointments will be cancelled until the $75 No Show fee is paid, and you clarify interest in continuing in treatment. This will prevent you from accruing any additional bills for missing sessions.

For the sake of clarity, if you cancel your appointment on a given day to reschedule later that day, or later in the week, that is considered a “late cancellation” of your appointment, and you will be charged $75 if you do not give 48 hours' notice.

Due to the high demand for psychological services, if you take a leave of absence from treatment, or no-show consecutive appointments, there is no guarantee of scheduling availability.

Billing Discrepancies and Questions

If you notice an error in your bill, please bring it to the attention of the billing office. This office will investigate all relevant, invoices, time stamps of emails, logins, and voicemails to determine allegations of billing errors. If you are due a return of funds all monies will be returned promptly.

If you have a question about your bill, please contact the billing office.
You will be given this information under a separate cover.

Payment/Billing

In any professional relationship, payment for services is an important issue. This is a crucial issue in therapy, where clarity of relationships and responsibilities is a goal of treatment.

Payment, or co-pay is expected at least 15 minutes before your visit. All Electronic Payments are processed via Cardpointe via our secure payment system on our Therapynotes portal.

Dr Hodges will log on after Cardpointe notifies that a payment has been made. It is your responsibility to know how much your copayment, deductible, and coinsurance is and when it is due. You can confirm this information with your insurance company. Please also contact our designated billing company as needed during weekday business hours.

You are responsible for the deductible amount specified by your insurance company. Please advise of any insurance changes immediately.

The following are accepted methods of payment for Telepsychology appointments: Visa, Mastercard, American Express, debit card.

Any bank fees will be your responsibility.

All bills not paid within 60 days may be subject to collections.

If you are having financial difficulties that prevent timely payment, please advise.

Doctor’s Notes, Phone Calls and Medical Records Requests

The following services are not covered by your insurance company. You will be billed separately for:

1. Doctor’s Notes- there is a minimum $25 fee (min 3 business days to complete).

2. Phone Calls- Please note phone calls that are 15 mins, or more are subject to your copayment, or the prorated hourly cash rate.

3. Text Messages/ Messages in Messenger – This office does not routinely acknowledge text messages by current and active patients. Please do not assume the message was received, read, or acted upon.

4. Medical Records Requests- To receive your entire medical record (after signed/written consent), please allow a minimum of 5 to 7 business days for completion. The fee is $75 for the first 100 pages and 20 cents for each additional page. This fee may not include postage.

5. To simplify the billing process, the office reserves the right to bill the flat hourly rate for electronic medical and/or billing records requests.

6. Please note absences related to personal illness or that of a minor child, or parent (that are not accompanied by a current doctor’s note) that lead to late cancellation / no show may be subject to a $75 fee.

7. Any missed session without 48 hours' notice without a reasonable reason (i.e. verifiable death in family, hospitalization, or incarceration) may be subject to the $75 no show/late cancellation fee.

Worker’s Compensation and Legal Cases

This office bills a cash rate for Workers Compensation, and Legal Cases due at each time of Service.

Confidentiality

If you use your health insurance to pay a part of your fees, I must give the insurance company some information. They usually want your diagnosis, the fee, when therapy began, and a treatment plan. It is against the law for insurers to release any information about our office visits without your written consent.

I hope this information will prevent any misunderstandings later. In this way, treatment can proceed efficiently.

If you are having a psychological emergency, you may call the office at (609) 638-7560. If there is no answer, please leave a message. If there is an emergency, please contact /go the nearest hospital immediately. You can also call 911/988 for emergencies.

Please note, this office does not provide 24 hours per day, or 7 days per week for mental health/ substance abuse services. However, if you leave a detailed, clear message, you will receive a response. Responses often occur between sessions, or at the end of the treatment day. Responses can occur by telephone, fax, mail, or email.

Dr Hodges has provided a list of resources you may find helpful on my website. Please print and use them as a resource as often as needed.

Please note, for your convenience my practice email address drhodges@championpsychsvcs.com is a HIPAA secure website. You may email your intake paperwork, insurance documents, etc. to this website.

This email address is to be used for the exchange of information, and not for therapy sessions.

You may also fax pertinent information to CPS, LLC at the following number: 609-581-4762.

In the event of email, or technical failure of any sort, I will contact you with an alternative method to maintain treatment communications.

However, you may leave emergency voicemail messages 24hrs per day.

Please sign below to verify that you have read this orientation and agree to the terms indicated in these policies.

Kind regards,

Carmen Lynn Hodges, PsyD, LCADC

Client Signature

Date

Guardian Signature

Date

Telepsychology

This Informed Consent for Telepsychology has important information about psychotherapy via phone or the Internet. Please note that Champion Psychological Services, LLC (henceforth abbreviated as CPS, LLC) offers telepsychology sessions.

Benefits and Risks of Telepsychology

Telepsychology refers to psychotherapy services that are provided remotely using telecommunications technologies, such as video conferencing or telephone. One of the benefits of telepsychology is that the client and clinician can engage in services without being in the same physical location. Telepsychology, however, requires some technical competence on both our parts to be helpful.

Although there are benefits to telepsychology, there are some differences between in-person psychotherapy and telepsychology, as well as some risks. For example:

• Because telepsychology sessions take place outside the therapist’s private office, there is potential for other people to overhear sessions if you are not in a private place during the session. CPS, LLC will ensure the therapist’s privacy. But it is important for you to make sure you find a private place for the session where you are so that you will not be interrupted and can protect the privacy of the session on your cell phone, or other device. You should participate in therapy only while in a room, or area where other people are not present, and cannot overhear the conversation.

• CPS, LLC reserves the right to end a session and/or terminate a therapeutic relationship if a patient’s actions during the session pose a potential risk of harm to the patient, or others (including CPS Staff).

• Patients are not permitted to use medications that are not prescribed to them, THC, or drink alcoholic beverages during sessions.

• Patients are not permitted to drive any motorized vehicle during sessions.

• Issues related to technology. Technological issues can impact telepsychology. For example, technology may stop working during a session, other people might be able to get access to our private conversation, or stored data could be accessed by unauthorized people, or companies. The latter may occur if CPS is not using a HIPAA-compliant technology service provider, such as Face Time, or a telephone. CPS, LLC currently uses HIPAA-compliant Therapynotes.

Champion Psychological Services, LLC (CPS, LLC)

Crisis management and intervention. CPS, LLC recognizes that telepsychology is not an appropriate intervention for crisis management. If you are in crisis, you may certainly call CPS, LLC and I will determine what is clinically appropriate, including making referral to your nearest emergency room, Crisis Center, call 988, or call 911.

Please be aware that CPS LLC staff are not available 24 hours per day/ 7 days per week. CPS, LLC staff will return your call as soon as possible.

Electronic Communications

You may need certain computer, or cell phone systems to use telepsychology services. You are solely responsible for any cost to you to obtain necessary equipment, accessories, or software to take part in telepsychology.

Confidentiality

CPS LLC has a legal, and ethical responsibility to make best efforts to protect all communications that are a part of telepsychology. However, the nature of electronic communications technologies is such that it cannot guarantee that communications will be kept confidential, or that other people may not gain access to these communications. As with any electronic communication, there is an inherent risk that electronic communications may be compromised, unsecured, or accessed by others.

You should also take reasonable steps to ensure the security of communications (for example, using only secure networks for telepsychology sessions and having passwords to protect the device you use for telepsychology).

Please do not share the password you use for telepsychology.

If you are having a psychological emergency, you may call CPS LLC staff at (609) 638-7560. If you need to speak with the staff, leave a message.

If staff are unable to pick up the phone when you call, CPS LLC staff will get back to you as soon as possible. If there is an emergency, please contact /go the nearest hospital immediately. Please note, staff are not available 24 hours per day, or 7 days per week. Assessing and evaluating threats and other emergencies can be more difficult when conducting telepsychology than in traditional in-person therapy. To address some of these difficulties, CPS, LLC staff will create an emergency plan before engaging in telepsychology services. CPS LLC staff ask you to identify an emergency contact person who is near your location whom CPS, LLC staff will contact in the event of a crisis or emergency to assist in addressing the situation. By signing this form, you are allowing staff to contact your emergency contact person as needed during such a crisis or emergency.

Name of Emergency Contact:

Phone Number:
Relationship:

If the session is interrupted due to an emergency, address that issue first, and call me back after you have obtained emergency services.

If the session is interrupted and you are not having an emergency, disconnect from the session and Dr Hodges will wait up to (2) minutes and then recontact you via the telepsychology platform on which we agreed to conduct therapy. If there is a technological failure and we are unable to resume the connection, we may need to use another platform or reschedule the session. Dr Hodges may also try to reach you by telephone/email.

Champion Psychological Service, LLC - FEES

Fees If No Insurance Coverage for Telepsychology with CPS, LLC

You may choose to pay for telepsychology services as a private payor if your insurance does not cover such treatment. You will agree to be billed. Payment is required at the time of service.

Currently, the rate for the initial session is $225 for an initial session and $180 for follow-up 45-minute to 50-minute sessions.

Dr Hodges can provide a sliding scale to clients who qualify for this consideration.

These fees are subject to change.

Copayments

All payments and fees for treatment are required 15 minutes before the start of each session.

Appointments and Cancellations

Appointment times are set to accommodate client schedules as often as possible. To properly assist you, Dr. Hodges asks that you keep your appointment on a regular basis. I will be glad to discuss any need for a change in scheduling. If you cannot keep your scheduled appointment, please call 609-638-7560 and leave a voicemail message. All patients are encouraged to use one phone number and email address for therapy and treatment of communications.

By law, Dr. Hodges is not permitted to bill your insurance for missed appointments. Therefore, you may be billed $ 75 for each missed appointment unless Dr Hodges is given 48-hours advance notice.

If you have a credit/debit card on file via Cardpointe, your credit/debit card may be charged with the $75 missed appointment fee automatically.

If you need to cancel an appointment, please call and leave a message. Please do not text or send messages via messenger. You only need to leave a message.

Records

CPS, LLC will maintain a record of the telepsychology session in the same way records are currently maintained for in-person sessions.

Informed Consent

This agreement is intended as a supplement to the Client Information and Informed Consent signed and agreed to at the onset of our clinical work together and does not amend any of the terms of that agreement.

Your signature below indicates agreement with the terms and conditions of this document.

You may be asked to sign a new agreement if: you leave treatment and restart, if there is some confusion about the terms, if this form is revised. You may also re-sign this form once per treatment year at a minimum.

Client SignatureDate
Guardian SignatureDate
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