This form provides you (client) with information that is additional to that detailed in the Notice of Privacy Practices.


CONFIDENTIALITY:  All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client’s) written permission, except where disclosure is required by law.  Most of the provisions explaining when the law requires disclosure were described to you in the Notice of Privacy Practices that you received with this form.


When Disclosure Is Required By Law: Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent or elder, abuse or neglect; and where a client presents a danger to self, to others, to property, or is gravely disabled (for more details see also Notice of Privacy Practices form).


When Disclosure May Be Required: Disclosure may be required pursuant to a legal proceeding.  If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by your therapist.  In couple and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members.  Your therapist will use his clinical judgment when revealing such information.  Your therapist will not release records to any outside party unless he is authorized to do so by all adult family members who were part of the treatment.


Emergencies:  If there is an emergency during our work together, or in the future after termination, where your therapist becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, he will do whatever he can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care.  For this purpose, he may also contact the person whose name you have provided on the biographical sheet.


Health Insurance & Confidentiality of Records: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims.  If you so instruct your therapist, only the minimum necessary information will be communicated to the carrier. Unless authorize by you explicitly the Psychotherapy Notes will not be disclosed to your insurance carrier.  your therapist ,  has no control or knowledge over what insurance companies do with the information he submits or who has access to this information.  You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy, or to future eligibility to obtain health or life insurance.  The risk stems from the fact that mental health information is entered into insurance companies’ computers and soon will also be reported to the, congress-approved, National Medical Data Bank.  Accessibility to companies’ computers or to the National Medical Data Bank database is always in question, as computers are inherently vulnerable to break-ins and unauthorized access.  Medical data has been reported to have been sold, stolen, or accessed by enforcement agencies; therefore, you are in a vulnerable position.  Primary Care Physicians (PCP):  Disclosure of confidential information is necessary and helpful in order to ensure coordinated care – however – New York state law allows this to be optional.  I believe that this communication is necessary in order to direct your care.  Your PCP has the same ethical and legal obligations to keep your information confidential and protected as I do.  IF, however, you do not want this communication to occur, you will have to put this request in writing and send it to your therapist listed at the bottom of the page.  Finally, by signing this contract you are allowing me to communicate with your PCP.


Confidentiality of E-mail, Cell Phone and Faxes Communication: It is very important to be aware that e-mail and cell phone communication can be relatively easily accessed by unauthorized people and hence, the privacy and confidentiality of such communication can be compromised.  E-mails, in particular, are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e-mails that go through them.  Faxes can easily be sent erroneously to the wrong address.  Please notify your therapist at the beginning of treatment if you decide to avoid or limit in any way the use of any or all of the above-mentioned communication devices.  Please do not use e-mail or faxes for emergencies.


Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) nor your attorney, nor anyone else acting on your behalf will call on your therapist to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.


Consultation: Your therapist consults regularly with other professionals regarding his clients; however, the client’s name or other identifying information is never mentioned.  The client’s identity remains completely anonymous, and confidentiality is fully maintained.


*    Considering all of the above exclusions, if it is still appropriate, upon your request, your therapist will release information to any agency/person you specify unless he concludes that releasing such information might be harmful in any way.



TELEPHONE & EMERGENCY PROCEDURES: If you need to contact your therapist between sessions, please leave a message on his voice mail (585) 624-1350 (Steven’s phone is (585) 752-8249) and your call will be returned as soon as possible. He checks his messages a few times a day, unless he is out of town or otherwise preoccupied.  If an emergency situation arises, please indicate it clearly in your message.  If you need to talk to someone right away, you can call him on his cell phone at (585) 233-9987, the 24-hour crisis line (LifeLine) (585) 275-5151 or the Police (911).


PAYMENTS & INSURANCE REIMBURSEMENT: Clients are expected to pay the standard fee of $95.00 per 45-50 minute session at the beginning of each session unless other arrangements have been made.  Telephone conversations, site visits, report writing and reading, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed otherwise.  Please notify your therapist if any problem arises during the course of therapy regarding your ability to make timely payments.  Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance companies.  Unless agreed upon differently, your therapist will provide you with a copy of your receipt every session, which you can then submit to your insurance company for reimbursement if you so choose.  As was indicated in the section, Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk.  Not all issues/conditions/problems, which are the focus of psychotherapy, are reimbursed by insurance companies.  It is your responsibility to verify the specifics of your coverage.


MEDIATION & ARBITRATION: All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration.  The mediator shall be a neutral third party chosen by agreement of your therapist and client(s).  The cost of such mediation, if any, shall be split equally, unless otherwise agreed.  In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Livingston County, New York in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed.  Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, your therapist and/or New Horizons of the Genesee Valley, Inc can use legal means (court, collection agency, etc.) to obtain payment.  The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees.  In the case of arbitration, the arbitrator will determine that sum.


THE PROCESS OF THERAPY/EVALUATION: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy.  Working toward these benefits; however, requires effort on your part.  Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior.  Your therapist will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly.  Sometimes more than one approach can be helpful in dealing with a certain situation.  During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in your experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc. or experiencing anxiety, depression, insomnia, etc.  Your therapist may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel very upset, angry, depressed, challenged, or disappointed.  Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended.  Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships.  Sometimes a decision that is positive for one family member is viewed quite negatively by another family member.  Change will sometimes be easy and swift, but more often it will be slow and even frustrating.  There is no guarantee that psychotherapy will yield positive or intended results.  During the course of therapy, your therapist is likely to draw on various psychological approaches according, in part, to the problem that is being treated and his/her assessment of what will best benefit you.  These approaches include behavioral, cognitive-behavioral, psychodynamic, existential, system/family, developmental (adult, child, family), or psycho-educational.


Discussion of Treatment Plan: Within a reasonable period of time after the initiation of treatment, your therapist , CSW will discuss with you (client) his working understanding of the problem, treatment plan, therapeutic objectives, and his view of the possible outcomes of treatment.  If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, your therapist’s expertise in employing them, or about the treatment plan, please ask and you will be answered fully.  You also have the right to ask about other treatments for your condition and their risks and benefits.  If you could benefit from any treatment that your therapist ,  does not provide, he has an ethical obligation to assist you in obtaining those treatments.


Termination:  As set forth above, after the first couple of meetings, your therapist, will assess if he can be of benefit to you.  Your therapist does not accept clients who, in his opinion, he cannot help.  In such a case, he will give you a number of referrals that you can contact.  If at any point during psychotherapy, your therapist assesses that he is not effective in helping you reach the therapeutic goals, he is obliged to discuss it with you and, if appropriate, to terminate treatment.  In such a case, he would give you a number of referrals that may be of help to you.  If you request it and authorize it in writing, your therapist will talk to the psychotherapist of your choice in order to help with the transition.  If at any time you want another professional’s opinion or wish to consult with another therapist, your therapist will assist you in finding someone qualified, and, if he has your written consent, he will provide her or him with the essential information needed.  You have the right to terminate therapy at any time.  If you choose to do so, your therapist will offer to provide you with names of other qualified professionals whose services you might prefer.


Dual Relationships: Not all dual relationships are unethical or avoidable.  Therapy never involves sexual or any other dual relationship that impairs your therapist’s objectivity, clinical judgment, or therapeutic effectiveness or can be exploitative in nature.  He will assess carefully before entering into non-sexual and non-exploitative dual relationships with clients.  The Greater Rochester area is a small community and many clients know each other and your therapist from the community.  Consequently you may bump into someone you know in the waiting room or into your therapist out in the community.  Your therapist will never acknowledge working therapeutically with anyone without his/her written permission.  Many clients choose your therapist as their therapist because they know him before they enter into therapy with him and/or are aware of his stance on the topic.  Nevertheless, your therapist will discuss with you, his client(s), the often-existing complexities, potential benefits, and difficulties that may be involved in such relationships.  Dual or multiple relationships can enhance therapeutic effectiveness but can also detract from it and often it is impossible to know that ahead of time.  It is your, the client’s, responsibility to communicate to your therapist if the dual relationship becomes uncomfortable for you in any way.  Your therapist will always listen carefully and respond accordingly to your feedback.  He will discontinue the dual relationship if he finds it interfering with the effectiveness of the therapeutic process or the welfare of the client and, of course, you can do the same at any time.


CANCELLATION:  Since scheduling of an appointment involves the reservation of time specifically for you, a minimum of 48 hours (2 days) notice is required for re-scheduling or canceling an appointment.  Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification.  Most insurance companies do not reimburse for missed sessions.



I have read the above Agreement and Office Policies and General Information carefully; I understand them and agree to comply with them:




Client/Guardian name                            Date                                         Print



Client/Guardian name                            Date                                         Print




      Therapist Name                              Date                                         Print