CHAMPION PSYCHOLOGICAL SERVICES, LLC

P.O. Box 2623 Mercerville, NJ 08619

Carmen Lynn Hodges, Psy.D., LCADC

New Jersey Licensed Psychologist #35S10049600

New Jersey Licensed Clinical Alcohol & Drug Counselor #37LC0006900

drhodges@championpsychsvcs.com

Phone:609-638-7560

Fax:609-581-4762

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 reduce feelings of distress. Psychotherapy involves a large commitment of time, money, and energy, so you should be careful about the psychologist you select.

Also, please note as your psychologist I am not permitted to perform for you certain evaluations (e.g., disability or forensic exams) or to write letters regarding emotional support animals.

Please note office policies:

Location of Appointments & Electronic Equipment Needed

At the present time all appointments are held virtually. There are no face to face appointments. That said, the use of a computer/smartphone, email, or tablet is very important for the success the therapy process. Patients will require a camera and microphone, a bit of privacy to sit and use their device, and the commitment to regularly check their email for important messages.

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 transpired in the session. And, begin the next session, at the start of the next hour.

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. If there is an emergency closing, you will receive a phone call, and perhaps voicemail. And, during that time, (or shortly thereafter), you will also be provided with information regarding rescheduling any needed appointments.

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, I am not permitted to bill insurance for missed appointments. Therefore, you will be billed for any missed appointments unless I am given 24-hours notice.

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.

No Show Appointments

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

If you NO SHOW an appointment, all subsequent appointments will be cancelled until patient pays No Show fee, and clarifies interest in continuing in treatment. This will prevent you from accruing any additional bills for missing sessions.

Please note, 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.

Cash Rate

You may choose to contract 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 $200 for an initial session and $180 for follow-up 45-minute to 50-minute sessions.

I can provide a sliding scale to clients who qualify.

These fees are subject to change.

In Network Provider Statement

This office is an in network provider for many insurance companies, and if you are using your insurance, this office accepts the insurance payment, along with your copay, coinsurance and/or deductible should they apply, as full payment.

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 15 minutes before your visit. All Electronic Payments are processed via Square.com via our secure payment system on our website (www.championpsychsvcs.com).

I will log on after Square notifies that a copayment has been made. It is your responsibility to know how much your copayment , and deductible, and coinsurance is and when it is due. You can confirm this information with your insurance company. Please also contact my billing company as needed during weekday business hours at 877-587-7851.

Please note that you are responsible for your deductible amount as 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. Any bank fees will be your responsibility.

All bills not paid within 60 days are subject to collections.

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

Doctor’s Notes, Phone Calls and Medical Records Requests

Note: if the following services are not covered by your insurance company, you will be billed separately:

  • A. Doctor’s Notes- there is a minimum $25 fee (min 3 business days to complete);
  • B. Phone Calls- Please note phone calls that are 15 mins, or more are subject to your copayment , or the prorated hourly cash rate;
  • C. Medical Records Requests- To receive your entire medical record (after signed/written consent), please allow 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 includes postage.

Worker’s Compensation and Legal Cases

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

These fees are subject to change

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 first began, and a treatment plan or summary of treatment. 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 misunderstanding later. In this way, treatment can proceed efficiently.

If you are having a psychological emergency, you may call me at (609) 638-7560 if you need to speak with me. Leave a message if I am unable to pick up the phone when you call, I will get back to you as soon as possible. If there is an emergency, please contact /go the nearest hospital immediately.

Please note, I am not available 24 hours per day, or 7 days per week.

I have provided some additional resources you may also find helpful on my website. Please print and use them as a resource.

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.

However, this site is to be used for the exchange of information and not for therapy sessions.

You may also fax pertinent information to my private office at the following number: 609-581-4762.

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

I am looking forward to working with you,

Carmen Lynn Hodges, PsyD, LCADC



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:

  • Risks to confidentiality. 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.
  • 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 HIPAAcompliant 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 we will determine what is clinically appropriate, including referral to your nearest emergency room, Crisis Center, or a call to 911. However, please be aware, 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 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:


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 I will wait two (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.

Champion Psychological Service, LLC - FEES

Fees If No Insurance Coverage for Teletherapy with CPS, LLC

You may choose to contract for telepsychology services as a private pay or 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 $200 for an initial session and $180 for follow-up 45-minute to 50-minute sessions.

I can provide a sliding scale to clients who qualify.

These fees are subject to change.

Copayments

All copayments 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, 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, I am not permitted to bill insurance for missed appointments. Therefore, you may be billed $50 for each missed appointment unless I am given 24-hour notice.

If you have a credit/debit card on file via Square, your credit/debit card will be charged the $50 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.

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.


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