Practice Policies & Informed Consent

Blair Cobb, LCSW 6251
Ride the Wave Counseling Services
Ridethewavecounsingservices.com
865-560-6770
Outpatient Services Contract
Welcome to my group practice. This document contains important information about my professional services and business policies. Please read it carefully and write down any questions you would like to ask me in our next meeting. When you sign this document before treatment, it will represent an agreement between us, and you will have consented to in-person and telemental health treatment.

Psychotherapy Services
Psychotherapy is not easily described in a general statement and can very from patient to patient depending on presenting symptoms and different modalities used to treat those symptoms. Psychotherapy requires a lot of effort on the individual’s part for it to be most successful. Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings during the session. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees and each individual experience is different. Sometimes psycho therapeutic services are provided primarily to prevent further deterioration of your mental or emotional state which is considered maintenance treatment.

With Telemental Health there are some additional risks that include security/confidentiality. Anyone can take all the right steps to securing information and technology is not 100% secure. I will inform you if there is any evidence that your information as been breached. I ask that you also inform me if you are not in a private setting and someone other than you are in the room listening to the session. It is your choice to opt into receiving both emailing and phone calls from me. Other risks include technology failures. If we have a session and you experience technological failures and loose connection you will need to call me at 865-560-6770 to finish the session. Some benefits to telemental health is that it is easily accessible, convenient, and you can attend your session from the comfort of any private setting.

At our first session I will ask to see your ID to help me identify you, I will also record the physical address where you are located in case of an emergency, and I will make sure I have an emergency contact person that has committed to be available to you in the event of an emergency. If you do not comply with these measures, we cannot do telemental health.

Our first 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. I may make recommendations for in-person therapy for you based on the severity of symptoms, if there is active suicidal ideation, use of alcohol or drugs, relationship concerns that require marriage counseling/family therapy/child sessions/parenting sessions, and/or active self-harm. You should evaluate this information plus your own opinion of whether you feel comfortable working with me. Therapy involves a large commitment of time, money and energy, so I respect that you think carefully about the therapist you select.

If you are being seen by an LMSW at Ride The Wave Counseling Services (Kyle Moore-Price, Samantha Ramsey, and Leanne Potts), they are being supervised by Blair Cobb, LCSW and will meet weekly for case consultation and feedback. Your signature on this document means that you understand that your clinical information will be shared with Blair Cobb, LCSW as efforts to provide you with the best clinical care.

MEETINGS
I will usually schedule one 50-minute session per week at a time we both agree upon, although some sessions may be more frequent if needed. Once an appointment hour is scheduled, you will be expected to pay for it unless you are able to call and reschedule in the same week as your appointment was. If it is possible, then you will be charged for the full session.

If you are in an emergency please call 911, 1-800-suicide, or 1-800-273-talk. I am not available on call and do not respond to emergency situations. If you need to reach me to reschedule and appointment or see if you can get a sooner appointment, please email me or call me at 865-560-6770 allowing for 36 hours to respond.

Professional FEES:
A session fee for in-person or telemental health is $100. You will be charged for this session within 24 hours of your appointment. I do not write any legal documents for you including letters to your attorney and if I am called to testify in court my fee is $250/hour of attendance to the legal proceeding.

BILLING:
You will be expected to pay for each session at the time it is held, you must complete the credit card form in your initial documents. The credit card will be charged as soon as the session is over, unless your insurance is paying 100% of the cost. If your credit card declines you can have a balance due of up to $100 and then no more sessions will be scheduled until the balance is paid. If you have missed 3 consecutive sessions with the therapist, you will be discharged from services and can contact us to receive referral options that are available to you.

If you are seeing an LMSW, they are not paneled with any insurance company. If you have not received prior approval from your insurance to see them we cannot guarantee any attempt to be reimbursed by your insurance.

Good Faith Estimate: It is your right to ask for a receive a Good Faith Estimate in order for there to be no surprises regarding the fees you will be projected to pay. The session fee for a 90837 is $100/session. Most clients begin seeing their therapist once per week for the first 4 months. This would bring your bill to $1600 for every 4 months of therapy on a weekly basis. You can also discuss a different timeline and treatment schedule between you and your therapist based on your mental health and financial needs.

Professional Records:
The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of your records, or I can prepare a summary for you instead. Because these are profession records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, I recommend that you review them with me so that we can discuss the contents.

MINORS
If you are under the age of 18, please be aware that the law may provide your parents the right to examine your treatment records.

Social Media Policy
In order to maintain your privacy I do not give clients access to my social media profiles.

Confidentiality
In general, the privacy of all communication between a client and psychotherapist is protected unless a client reports in writing that all or some of the client’s records can be shared with a specific person. Limitations of confidentiality exist when 1. If a client threatens or attempts to commit suicide or conducts him/herself in a manner that may cause substantial risk or serious bodily harm. 2. If a client threatens grave bodily harm or death to another individual. 3. If the therapist has reasonable suspicion that the client or other named victim is perpetrator, observer of, or actual victim of physical, emotional, or sexual abuse or suspected neglect of children under the age of 18 years old or elderly person. 4. If a court of law subpoena’s records.
If we see one another outside of the therapy session I will not acknowledge you first. Your right to privacy is of the utmost importance to me.

Good Faith Estimate:

You are entitled to receive this “Good Faith Estimate” of what the charges could be for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of psychotherapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here. This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.

The fee for a 50-minute psychotherapy visit (in-person or via telehealth) is $__$100_. Most clients will attend one psychotherapy visit per week, but the frequency of psychotherapy visits that are appropriate in your case may be more or less than once per week, depending upon your needs.

Based upon a fee of $__100__ per visit, if you attend one psychotherapy visit per week, your estimated charge would be $___400__for four visits provided over the course of one month; $__800__for eight visits over two months; or $__1200__for 12 visits over three months. If you attend therapy for a longer period, your total estimated charges will increase according to the number of visits and length of treatment.

You have a right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges).

You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in this Good Faith Estimate.

If you have any questions, please contact Blair Cobb, LCSW