Mental Health Bill of Rights
“This Mental Health Bill of Rights is provided by law to persons receiving mental health services in the State of New Hampshire. Its purpose is to protect the rights and enhance the well-being of clients, by informing them of key aspects of the clinical relationship. As a client of a New Hampshire Mental Health Practitioner, you have, without asking, the right:
(1) To be treated in a professional, respectful, competent and ethical manner consistent with all applicable state laws and the following professional ethical standards:
a. for psychologists, the American Psychological Association;
b. for independent clinical social workers; the National Association of Social Workers;
c. for pastoral psychotherapists; the American Association of Pastoral Counselors
d. for clinical mental health counselors; the American Mental Health Counselor Association; and
e. for marriage and family therapists; the American Association for Marriage and Family Therapists.
(2) To receive full information about your treatment provider’s knowledge, skills, experience and credentials.
(3) To have the information you disclose to your mental health provider kept confidential within the limits of state and federal law. Communications between mental health providers and clients are typically confidential, unless the law requires their disclosure. Mental health providers will inform you of the legal exceptions to confidentiality, and should such an exception arise, will share only such information as required by law. Examples of such exceptions include but are not limited to:
a. abuse of a child;
b. abuse of an incapacitated adult;
c. Health Information Portability and Accountability Act (HIPAA) regulation compliance;
d. certain rights you may have waived when contracting for third party financial coverage;
e. orders of the court; and
f. significant threats to self, others or property.
(4) To a safe setting and to know that the services provided are effective and of a quality consistent with the standard of care within each profession and to know that sexual relations between a mental health provider and a client or former client are a violation of the law (RSA 330-A:36).
(5) To obtain information, as allowed by law, pertaining to the mental health provider’s assessment, assessment procedures and mental health diagnoses (RSA 330-A:2 VI).
(6) To participate meaningfully in the planning, implementation and termination or referral of your treatment.
(7) To documented informed consent: to be informed of the risks and benefits of the proposed treatment, the risks and benefits of alternative treatments and the risks and benefits of no treatment. When obtaining informed consent for treatment for which safety and effectiveness have not been established, therapists will inform their clients of this and of the voluntary nature of their participation. In addition, clients have the right to be informed of their rights and responsibilities, and of the mental health provider’s practice policies regarding confidentiality, office hours, fees, missed appointments, billing policies, electronic communications, managed care issues, record management, and other relevant matters except as otherwise provided by law.
(8) To obtain information regarding the provision(s) for emergency coverage.
(9) To receive a copy of your mental health record within 30 days upon written request (except as otherwise provided by law), by paying a nominal fee designed to defray the administrative costs of reproducing the record.
(10) To know that your mental health provider is licensed by the State of New Hampshire to provide mental health services.
a. You have the right to obtain information about mental health practice in New Hampshire. You may contact the Board of Mental Health Practice for a list names, addresses, phone numbers and websites of state and national professional associations listed in Mhp 502.02 (a)(1)(a-e).
b. You have the right to discuss questions or concerns about the mental health services you receive with your provider.
c. You have the right to file a complaint with the Board of Mental Health Practice.
(1) To be treated in a professional, respectful, competent and ethical manner consistent with all applicable state laws and the following professional ethical standards:
a. for psychologists, the American Psychological Association;
b. for independent clinical social workers; the National Association of Social Workers;
c. for pastoral psychotherapists; the American Association of Pastoral Counselors
d. for clinical mental health counselors; the American Mental Health Counselor Association; and
e. for marriage and family therapists; the American Association for Marriage and Family Therapists.
(2) To receive full information about your treatment provider’s knowledge, skills, experience and credentials.
(3) To have the information you disclose to your mental health provider kept confidential within the limits of state and federal law. Communications between mental health providers and clients are typically confidential, unless the law requires their disclosure. Mental health providers will inform you of the legal exceptions to confidentiality, and should such an exception arise, will share only such information as required by law. Examples of such exceptions include but are not limited to:
a. abuse of a child;
b. abuse of an incapacitated adult;
c. Health Information Portability and Accountability Act (HIPAA) regulation compliance;
d. certain rights you may have waived when contracting for third party financial coverage;
e. orders of the court; and
f. significant threats to self, others or property.
(4) To a safe setting and to know that the services provided are effective and of a quality consistent with the standard of care within each profession and to know that sexual relations between a mental health provider and a client or former client are a violation of the law (RSA 330-A:36).
(5) To obtain information, as allowed by law, pertaining to the mental health provider’s assessment, assessment procedures and mental health diagnoses (RSA 330-A:2 VI).
(6) To participate meaningfully in the planning, implementation and termination or referral of your treatment.
(7) To documented informed consent: to be informed of the risks and benefits of the proposed treatment, the risks and benefits of alternative treatments and the risks and benefits of no treatment. When obtaining informed consent for treatment for which safety and effectiveness have not been established, therapists will inform their clients of this and of the voluntary nature of their participation. In addition, clients have the right to be informed of their rights and responsibilities, and of the mental health provider’s practice policies regarding confidentiality, office hours, fees, missed appointments, billing policies, electronic communications, managed care issues, record management, and other relevant matters except as otherwise provided by law.
(8) To obtain information regarding the provision(s) for emergency coverage.
(9) To receive a copy of your mental health record within 30 days upon written request (except as otherwise provided by law), by paying a nominal fee designed to defray the administrative costs of reproducing the record.
(10) To know that your mental health provider is licensed by the State of New Hampshire to provide mental health services.
a. You have the right to obtain information about mental health practice in New Hampshire. You may contact the Board of Mental Health Practice for a list names, addresses, phone numbers and websites of state and national professional associations listed in Mhp 502.02 (a)(1)(a-e).
b. You have the right to discuss questions or concerns about the mental health services you receive with your provider.
c. You have the right to file a complaint with the Board of Mental Health Practice.
Notice to Clients
THE HEALING AND GROWING PROCESS
Psychotherapy is a relationship-based process that involves working together in an atmosphere of mutual respect and interest. Through working on previous and current life issues, future dilemmas become more manageable. Success in counseling is based on the participant’s willingness to engage in the process. A participant only gets out of counseling what they are willing to put into counseling. As a healing and growing process, things can get worse before they get better. If that happens, please let me know so a plan can be worked on to help keep you heading towards your therapy goals.
I offer professional, yet personal services and am committed to ethics and confidentiality. The decision to obtain help is courageous and can be difficult. I recognize that it is people’s strength that brings them to work with me.
CLIENTS RIGHTS
I acknowledge and support the client’s rights and responsibilities as they are described in the “NH Mental Health Bill of Rights”.
INTAKES, SCREENINGS, ASSESSMENTS, AND EVALUATIONS
Intakes, screenings, assessments, and evaluations each have a specific goal, process, scope, and implication. These will be reviewed with you as well as any potential consequences for participation in or referral to participate in any of these.
CONFIDENTIALITY
Under New Hampshire law, communication between a client and a licensed psychotherapist are privileged (confidential) and may not be disclosed without the specific authorization of the client. Exceptions to this are the following:
· I, as your therapist, may legally speak to a member of your family or another clinician without your prior consent in case of an emergency.
· If you disclose that you intend to/will harm another person, I will attempt to inform that person, as well as the police.
· If you disclose the physical, sexual, or emotional abuse or neglect of a child, or an elderly or vulnerable adult by you or someone else, I am legally required to notify the appropriate protective services and the police within 72 hours of your disclosure.
· If I have good reason to believe that you are in imminent risk of harming yourself, I will legally break confidentiality and inform an appropriate crisis center, hot line, emergency room, the police, etc. When appropriate, I will explore other options with you.
· If you and your spouse are in couple’s therapy and participate in individual sessions with me, what you disclose in the individual sessions may be considered part of the couple’s therapy. Treatment records of couples’ sessions contain information about each person. Therefore, both clients agree that treatment records will only be released by joint consent. In the event of a disagreement, the records will not be released without a court order.
· Unmarried individuals in couples’ therapy do not have the privilege to the same extent that married individuals have due to the legal status of their relationship. However, each person is asked to maintain the confidence of the other.
· If you are in group therapy, what you share in your group therapy is not considered by law to be privileged. Therefore, it is highly recommended that group members not disclose information shared by other group members. Of course, group facilitators maintain confidentiality.
· If a court order is issued for the release of your records, I will request, but do not need your signed authorization.
· I regularly engage in peer collaboration/case reviews with other clinicians, as a requirement of my continued licensure. All such communications are confidential.
· Any information related to substance abuse or HIV or any other STD will only be released after that category is acknowledged on the release form by the signer initializing that particular action.
· Once information is sent outside this office, I cannot control and am no longer responsible for its use and dissemination.
· Any recorded message left on my clinical voicemail – (802) 727 0494 – is confidential, and may also be used as evidence in a civil or criminal proceeding, if this use is compelled by an overriding statute, ordered by a court with the appropriate jurisdiction, or permission is granted to do so by the client, the client’s guardian, designee, surviving trustee or parent.
· I take reasonable steps to ensure the confidentiality of all my clients. However, I cannot protect information once it leaves the building by phone, email, regular mail, or is picked up by a client or a person the client authorized.
· All Mental Health Counseling cases are subject to review by relevant state licensing Boards at any time.
SPECIAL CONCERNS WITH REGARDS TO MINORS AND CONFIDENTIALITY
• Although communications between a client and a licensed psychotherapist are confidential, parents of a minor child (even non-custodial parents) have a right to access the counselor and authorize release of information. If this is a concern, please discuss it with me BEFORE beginning treatment. I find there is less resistance to the counseling when all parties consent to the counseling and participate to the extent that the court allows.
· In cases of a minor, the child is the client and their communications are confidential. Thus, any communications from anyone other than the client are not considered protected and can be shared with other parties involved in the case. These communications can also become part of the notes and thus could be seen by outside parties if the notes were requested to be released.
· According to Berg vs. Berg, a minor’s notes can be released with the written consent of both parents or with a court order.
• If the client is an adolescent, the content of the therapy session will be considered confidential unless there is reason to believe that the adolescent is a danger to themself or other people. These risky behaviors may or may not include drug use, risky sexual behaviors, illegal activities, etc.
• It is important to the success of the therapy that a safe place is set up for the child and that all involve agree to honor the therapeutic space. Conflicts among the adults in the child’s life adversely impact the child and counteract any positive gains made by therapy. It is often suggested that parents and/or guardians seek their own individual counseling to help manage those inter-relational stresses. On occasions, conflicts among parents due to bringing the child to counseling or because of court proceeding can become so strong that it is actually more detrimental to the child to attend counseling because of the immense tension between the parents. Children are megaphones for the conflicts in the family and in these situations, I reserve the right to withdraw from the case in order to decrease issues of stress between the parents.
• Non-biological parents and/or guardian must have documentation from the court or a release from both parents that they can be informed of information pertaining to minors, set up appointments, pick up the minor, etc. Releases can be written to limit access to certain information if desired (i.e. one could limit information to setting up appointments but not treatment planning).
• In the State of New Hampshire, either parent can bring a child to counseling and either parent can take a child out of counseling. Thus, I seek to have both parents sign the informed consent, meet with the counselor, ask questions, provide information, learn how to help their child, etc. Where a parent is not involved in a child’s life, then a letter from the other parent or guardian and/or a court document is needed stating the situation. Where custody and decision-making have been given to one parent by the court, the non-custodial parent still has “parental rights” meaning they have the right to know what is going on with their child…even if they do not have the right to make decisions for that child.
CONFIDENTIALITY AND THE WAITING ROOM
This waiting room is a common area in which I, as a clinician, am committed to partnering with you to maintain your confidentiality. To do so I request that:
· All client(s), parent(s), guardian(s)agree to wait to talk with the clinician about concerns or updates until we are in the session room
· Parents ask to update me about their child at the beginning of the session and then proceed to the session room for the discussion
· All agree that the session ends at the door of the counseling room
· All agree to hold phone conversations outside the waiting room
· All maintain awareness of any information they choose to share with other people in the waiting room
· All parents/guardians agree that are to stay in the waiting room unless a specific arrangement has been made with the clinician
CUSTODY AND RELEASES
This Informed Consent Form is a consent for treatment. In the case of a minor, any and all people who have legal decision-making authority for the child (meaning “legal custody” not just “physical custody”) must consent to the counseling before a therapist can see the child. In cases of divorce, separation and/or guardianship, appropriate paperwork must be on file with me detailing the parental and/or guardianship arrangement before the child can be seen. In all cases, if a parent or guardian (whether actively involved in a child’s life or otherwise) states they do not wish the child to be seen or to continue in counseling, then counseling service have to be stopped until consent is again established. An exception to this is if there is a court order stating the child is to receive counseling, then a copy of the most current order must be on file for the child to begin. In this situation, the court order supersedes parental rights. Any other situations are handled on a case by case basis.
RECORDS
According to the Health Care Act of 1992, and New Hampshire law, you have a right to review a copy of your file for an appropriate fee. You also have the right to request that I provide a copy of your file to other health care providers with your written authorization. The only portion of your record that I can provide or share is that information which has been generated here. Your clinical records are kept in a safe place for a minimum of seven years for adults and the age of majority (18 years), plus seven years for children. Records will be maintained confidentially in this office in accordance with New Hampshire State Law.
HEALTH INSURANCE/HEALTH SAVINGS ACCOUNTS
With the exception of the Dartmouth Student Group Health Plan and VT Medicaid, I do not work directly with insurance plans. I will provide you with monthly/periodic superbill receipts that you can use to file for reimbursement from your insurance plan, if they offer benefits for out of network providers. If you have a Health Savings Account, may be able to use your HSA credit card (if any) to pay for my services, as I have flagged Julie Püttgen Expressive and Somatic Therapies, PLLC as a healthcare business within Square billing.
DIAGNOSIS
I, as your clinician, will provide a diagnosis if you do not have one, or work with one if you do. Diagnoses can be clinically useful in preparing an effective course of treatment, coordinating care with other health care professionals, and patient self-education. No diagnosis impedes my view of each client as primordially awake, spacious, and kind.
CODES OF ETHICS / PROFESSIONAL BOUNDARIES
Therapists working in the helping professions are required to operate within the professions’ code of ethics. They include but are not limited to the establishing and maintaining of appropriate professional boundaries. A therapist may not become involved in any type of personal relationship with a client i.e. sexually, business, etc. The therapist can serve only one role in the client’s life i.e. cannot be the client’s employer and therapist. Also, the therapist’s role in therapy should be clearly defined. For additional and specific ethical standards, please consult the American Counseling Association Code of Ethics at https://www.counseling.org/resources/ethics.
DISAGREEMENTS / GRIEVANCES
If you feel that you and I, as your therapist, are at an impasse with your case, then I expect you to discuss this with me. The determination to continue services after a conflict will be made on a case-by-case basis. If a healthy relationship cannot be re-established, then I will make a referral and services with me will be discontinued.
In addition to the above, if you feel that your rights have been violated and you wish to make a formal complaint, you are entitled to contact the professional organization and/or licensing board to which I belong. The New Hampshire Board of Mental Health can be reached by calling (603) 271-6762.
CELL PHONES AND TEXTING DURING SESSIONS
In order to support the therapy experience, unless you have talked to me to make arrangements for an emergent call, please silence your phone and refrain from answering calls and/or texting during sessions.
AGRESSION AND/OR THREATS
I, as a clinician, have the right to end a session, phone call, or conversation if I at any time feel threatened or endangered. Consequences of a terminated session will be discussed later if and when safe boundaries have been re-established.
COUNSELOR'S ENDING OF COUNSELING
Counseling can be terminated if I, as a clinician, believe the primary role of the counseling is not for personal growth, development or change. For example (though not limited to this example), counseling can be terminated if the counselor believes a parent has brought a child to counseling in order to build a court case against the other parent.
TERMINATION, CLOSING CASE FILES AND ART WORK
Psychotherapy is a process involving clear communication between client and therapist, who work as a team. Once a treatment plan is established agreed upon, treatment proceeds until the plan is fulfilled. If you wish to terminate before completion of the treatment plan, a final session will be scheduled in order to summarize progress, to discuss any major unresolved issues, or to assist you with transfer to another therapist/provider. Please give seven days’ notice if you plan to terminate before completing your treatment plan. This is particularly important in group psychotherapy, as the treatment process includes the other members in your group.
If I determine your treatment to be no longer in your best interest (or in the case of a child, in your child’s best interest), I reserve the right to initiate the termination of your treatment. Additionally, if I determine your case needs more or different expertise than I am able to provide, I reserve the right to initiate a transfer of your case (to another therapist or another agency) and/or termination of your case.
Case files will be closed if there is no communication from the client for two months after the last attended session unless a special arrangement has been made. Cases can be closed without written notification, if they meet any of the above conditions. Cases can be reopened upon the request of the client if there is a zero balance.
Artwork made as part of sessions belongs to the client and is usually taken home at the end of sessions. Artwork that is not taken by the client will be destroyed when the case is closed unless other arrangements have been made.
Lastly, if at any time you have questions regarding confidentiality, the release of information related to your case, financial responsibility, managed care, or the therapeutic process, please feel free to speak directly with me on these matters.
UNEXPECTED THERAPIST ABSENCE
In the event of my unplanned absence from practice, whether due to injury, illness, death, or any other reason, I maintain a detailed Professional Will with instructions for joint Executors (who are also clinicians bound by confidentiality) to inform you of my status and ensure your continued care in accordance with your needs. Please let me know if you would like the names of my Executors. You authorize my Executors to access your treatment and financial records only in accordance with the terms of my Professional Will, and only in the event that I experience an event that has caused or is likely to cause a significant unplanned absence from practice.
Psychotherapy is a relationship-based process that involves working together in an atmosphere of mutual respect and interest. Through working on previous and current life issues, future dilemmas become more manageable. Success in counseling is based on the participant’s willingness to engage in the process. A participant only gets out of counseling what they are willing to put into counseling. As a healing and growing process, things can get worse before they get better. If that happens, please let me know so a plan can be worked on to help keep you heading towards your therapy goals.
I offer professional, yet personal services and am committed to ethics and confidentiality. The decision to obtain help is courageous and can be difficult. I recognize that it is people’s strength that brings them to work with me.
CLIENTS RIGHTS
I acknowledge and support the client’s rights and responsibilities as they are described in the “NH Mental Health Bill of Rights”.
INTAKES, SCREENINGS, ASSESSMENTS, AND EVALUATIONS
Intakes, screenings, assessments, and evaluations each have a specific goal, process, scope, and implication. These will be reviewed with you as well as any potential consequences for participation in or referral to participate in any of these.
CONFIDENTIALITY
Under New Hampshire law, communication between a client and a licensed psychotherapist are privileged (confidential) and may not be disclosed without the specific authorization of the client. Exceptions to this are the following:
· I, as your therapist, may legally speak to a member of your family or another clinician without your prior consent in case of an emergency.
· If you disclose that you intend to/will harm another person, I will attempt to inform that person, as well as the police.
· If you disclose the physical, sexual, or emotional abuse or neglect of a child, or an elderly or vulnerable adult by you or someone else, I am legally required to notify the appropriate protective services and the police within 72 hours of your disclosure.
· If I have good reason to believe that you are in imminent risk of harming yourself, I will legally break confidentiality and inform an appropriate crisis center, hot line, emergency room, the police, etc. When appropriate, I will explore other options with you.
· If you and your spouse are in couple’s therapy and participate in individual sessions with me, what you disclose in the individual sessions may be considered part of the couple’s therapy. Treatment records of couples’ sessions contain information about each person. Therefore, both clients agree that treatment records will only be released by joint consent. In the event of a disagreement, the records will not be released without a court order.
· Unmarried individuals in couples’ therapy do not have the privilege to the same extent that married individuals have due to the legal status of their relationship. However, each person is asked to maintain the confidence of the other.
· If you are in group therapy, what you share in your group therapy is not considered by law to be privileged. Therefore, it is highly recommended that group members not disclose information shared by other group members. Of course, group facilitators maintain confidentiality.
· If a court order is issued for the release of your records, I will request, but do not need your signed authorization.
· I regularly engage in peer collaboration/case reviews with other clinicians, as a requirement of my continued licensure. All such communications are confidential.
· Any information related to substance abuse or HIV or any other STD will only be released after that category is acknowledged on the release form by the signer initializing that particular action.
· Once information is sent outside this office, I cannot control and am no longer responsible for its use and dissemination.
· Any recorded message left on my clinical voicemail – (802) 727 0494 – is confidential, and may also be used as evidence in a civil or criminal proceeding, if this use is compelled by an overriding statute, ordered by a court with the appropriate jurisdiction, or permission is granted to do so by the client, the client’s guardian, designee, surviving trustee or parent.
· I take reasonable steps to ensure the confidentiality of all my clients. However, I cannot protect information once it leaves the building by phone, email, regular mail, or is picked up by a client or a person the client authorized.
· All Mental Health Counseling cases are subject to review by relevant state licensing Boards at any time.
SPECIAL CONCERNS WITH REGARDS TO MINORS AND CONFIDENTIALITY
• Although communications between a client and a licensed psychotherapist are confidential, parents of a minor child (even non-custodial parents) have a right to access the counselor and authorize release of information. If this is a concern, please discuss it with me BEFORE beginning treatment. I find there is less resistance to the counseling when all parties consent to the counseling and participate to the extent that the court allows.
· In cases of a minor, the child is the client and their communications are confidential. Thus, any communications from anyone other than the client are not considered protected and can be shared with other parties involved in the case. These communications can also become part of the notes and thus could be seen by outside parties if the notes were requested to be released.
· According to Berg vs. Berg, a minor’s notes can be released with the written consent of both parents or with a court order.
• If the client is an adolescent, the content of the therapy session will be considered confidential unless there is reason to believe that the adolescent is a danger to themself or other people. These risky behaviors may or may not include drug use, risky sexual behaviors, illegal activities, etc.
• It is important to the success of the therapy that a safe place is set up for the child and that all involve agree to honor the therapeutic space. Conflicts among the adults in the child’s life adversely impact the child and counteract any positive gains made by therapy. It is often suggested that parents and/or guardians seek their own individual counseling to help manage those inter-relational stresses. On occasions, conflicts among parents due to bringing the child to counseling or because of court proceeding can become so strong that it is actually more detrimental to the child to attend counseling because of the immense tension between the parents. Children are megaphones for the conflicts in the family and in these situations, I reserve the right to withdraw from the case in order to decrease issues of stress between the parents.
• Non-biological parents and/or guardian must have documentation from the court or a release from both parents that they can be informed of information pertaining to minors, set up appointments, pick up the minor, etc. Releases can be written to limit access to certain information if desired (i.e. one could limit information to setting up appointments but not treatment planning).
• In the State of New Hampshire, either parent can bring a child to counseling and either parent can take a child out of counseling. Thus, I seek to have both parents sign the informed consent, meet with the counselor, ask questions, provide information, learn how to help their child, etc. Where a parent is not involved in a child’s life, then a letter from the other parent or guardian and/or a court document is needed stating the situation. Where custody and decision-making have been given to one parent by the court, the non-custodial parent still has “parental rights” meaning they have the right to know what is going on with their child…even if they do not have the right to make decisions for that child.
CONFIDENTIALITY AND THE WAITING ROOM
This waiting room is a common area in which I, as a clinician, am committed to partnering with you to maintain your confidentiality. To do so I request that:
· All client(s), parent(s), guardian(s)agree to wait to talk with the clinician about concerns or updates until we are in the session room
· Parents ask to update me about their child at the beginning of the session and then proceed to the session room for the discussion
· All agree that the session ends at the door of the counseling room
· All agree to hold phone conversations outside the waiting room
· All maintain awareness of any information they choose to share with other people in the waiting room
· All parents/guardians agree that are to stay in the waiting room unless a specific arrangement has been made with the clinician
CUSTODY AND RELEASES
This Informed Consent Form is a consent for treatment. In the case of a minor, any and all people who have legal decision-making authority for the child (meaning “legal custody” not just “physical custody”) must consent to the counseling before a therapist can see the child. In cases of divorce, separation and/or guardianship, appropriate paperwork must be on file with me detailing the parental and/or guardianship arrangement before the child can be seen. In all cases, if a parent or guardian (whether actively involved in a child’s life or otherwise) states they do not wish the child to be seen or to continue in counseling, then counseling service have to be stopped until consent is again established. An exception to this is if there is a court order stating the child is to receive counseling, then a copy of the most current order must be on file for the child to begin. In this situation, the court order supersedes parental rights. Any other situations are handled on a case by case basis.
RECORDS
According to the Health Care Act of 1992, and New Hampshire law, you have a right to review a copy of your file for an appropriate fee. You also have the right to request that I provide a copy of your file to other health care providers with your written authorization. The only portion of your record that I can provide or share is that information which has been generated here. Your clinical records are kept in a safe place for a minimum of seven years for adults and the age of majority (18 years), plus seven years for children. Records will be maintained confidentially in this office in accordance with New Hampshire State Law.
HEALTH INSURANCE/HEALTH SAVINGS ACCOUNTS
With the exception of the Dartmouth Student Group Health Plan and VT Medicaid, I do not work directly with insurance plans. I will provide you with monthly/periodic superbill receipts that you can use to file for reimbursement from your insurance plan, if they offer benefits for out of network providers. If you have a Health Savings Account, may be able to use your HSA credit card (if any) to pay for my services, as I have flagged Julie Püttgen Expressive and Somatic Therapies, PLLC as a healthcare business within Square billing.
DIAGNOSIS
I, as your clinician, will provide a diagnosis if you do not have one, or work with one if you do. Diagnoses can be clinically useful in preparing an effective course of treatment, coordinating care with other health care professionals, and patient self-education. No diagnosis impedes my view of each client as primordially awake, spacious, and kind.
CODES OF ETHICS / PROFESSIONAL BOUNDARIES
Therapists working in the helping professions are required to operate within the professions’ code of ethics. They include but are not limited to the establishing and maintaining of appropriate professional boundaries. A therapist may not become involved in any type of personal relationship with a client i.e. sexually, business, etc. The therapist can serve only one role in the client’s life i.e. cannot be the client’s employer and therapist. Also, the therapist’s role in therapy should be clearly defined. For additional and specific ethical standards, please consult the American Counseling Association Code of Ethics at https://www.counseling.org/resources/ethics.
DISAGREEMENTS / GRIEVANCES
If you feel that you and I, as your therapist, are at an impasse with your case, then I expect you to discuss this with me. The determination to continue services after a conflict will be made on a case-by-case basis. If a healthy relationship cannot be re-established, then I will make a referral and services with me will be discontinued.
In addition to the above, if you feel that your rights have been violated and you wish to make a formal complaint, you are entitled to contact the professional organization and/or licensing board to which I belong. The New Hampshire Board of Mental Health can be reached by calling (603) 271-6762.
CELL PHONES AND TEXTING DURING SESSIONS
In order to support the therapy experience, unless you have talked to me to make arrangements for an emergent call, please silence your phone and refrain from answering calls and/or texting during sessions.
AGRESSION AND/OR THREATS
I, as a clinician, have the right to end a session, phone call, or conversation if I at any time feel threatened or endangered. Consequences of a terminated session will be discussed later if and when safe boundaries have been re-established.
COUNSELOR'S ENDING OF COUNSELING
Counseling can be terminated if I, as a clinician, believe the primary role of the counseling is not for personal growth, development or change. For example (though not limited to this example), counseling can be terminated if the counselor believes a parent has brought a child to counseling in order to build a court case against the other parent.
TERMINATION, CLOSING CASE FILES AND ART WORK
Psychotherapy is a process involving clear communication between client and therapist, who work as a team. Once a treatment plan is established agreed upon, treatment proceeds until the plan is fulfilled. If you wish to terminate before completion of the treatment plan, a final session will be scheduled in order to summarize progress, to discuss any major unresolved issues, or to assist you with transfer to another therapist/provider. Please give seven days’ notice if you plan to terminate before completing your treatment plan. This is particularly important in group psychotherapy, as the treatment process includes the other members in your group.
If I determine your treatment to be no longer in your best interest (or in the case of a child, in your child’s best interest), I reserve the right to initiate the termination of your treatment. Additionally, if I determine your case needs more or different expertise than I am able to provide, I reserve the right to initiate a transfer of your case (to another therapist or another agency) and/or termination of your case.
Case files will be closed if there is no communication from the client for two months after the last attended session unless a special arrangement has been made. Cases can be closed without written notification, if they meet any of the above conditions. Cases can be reopened upon the request of the client if there is a zero balance.
Artwork made as part of sessions belongs to the client and is usually taken home at the end of sessions. Artwork that is not taken by the client will be destroyed when the case is closed unless other arrangements have been made.
Lastly, if at any time you have questions regarding confidentiality, the release of information related to your case, financial responsibility, managed care, or the therapeutic process, please feel free to speak directly with me on these matters.
UNEXPECTED THERAPIST ABSENCE
In the event of my unplanned absence from practice, whether due to injury, illness, death, or any other reason, I maintain a detailed Professional Will with instructions for joint Executors (who are also clinicians bound by confidentiality) to inform you of my status and ensure your continued care in accordance with your needs. Please let me know if you would like the names of my Executors. You authorize my Executors to access your treatment and financial records only in accordance with the terms of my Professional Will, and only in the event that I experience an event that has caused or is likely to cause a significant unplanned absence from practice.
Financial Policies
FINANCIAL POLICIES
The client’s fee, per 50-minute therapy session, will be established at the onset of treatment and will be understood as the Financial Agreement. Payment is due at the time of service. Each client is required to have a credit card on file with me through Square. I will charge invoices that are more than 30 days overdue to the card on file. In cases where 30 days have elapsed and payment through the card on file fails, I will send the client a final notice via USPS Certified Mail, requesting immediate payment. I reserve the right to refer delinquent accounts to a third-party credit agency. I reserve the right to suspend or cease treatment for clients with delinquent accounts.
BILLING
The amount paid by the client (or client’s parent(s)/guardian(s)) directly is referred to as the Fee.
RESPONSIBILITY
The client (or client’s parent(s)/guardian(s)) is responsible for the entire payment of the charge.
With parents who are separated, one parent will be the designated payee to the account. Split billing to the parents is not done. However, I am happy to provide both parents with a copy of the financial statements as needed.
ATTENDANCE
The scheduling of an appointment construes the making of a contract with the therapist of time for money. This contract assumes either attendance or timely notice of cancellation of the appointment. Timely notification is considered 24 hours in advance of the appointment but please notify me as soon as you are aware you cannot make an appointment. Calling well in advance allows the possibility of my using that time slot for care of another client.
CANCELLATION/NO-SHOW POLICY
· Each client is eligible for one free no-show/cancellation during the course of our therapeutic relationship, in acknowledgment that emergencies happen & we all make mistakes.
· For subsequent cancellations made 24 hours or less before appointment time, I will charge a full session fee.
· If I have space available, and we can reschedule your appointment within the same week, no fee will apply.
· If you cancel more than 24 hours ahead of time, no fee will apply.
· For snow/winter weather, Zoom will substitute for any scheduled in-person session.
CONSEQUENCES OF MISSED SESSIONS
When cancellations made the day of an appointment and/or no shows together add up to three or more, I see this as a sign that the client is not interested or invested in the counseling process. At this point, I reserve the right to place the client on a same-day call list or terminate counseling, with a referral to other resources. A client placed on the same day call list will need to call each day they are available to see if I have an opening that day. If there is an opening, the client will be able to schedule. If no appointment is available that day, then the client will need to call the next time they are able to see if there is an opening. Once a client has called, made an appointment and followed through on the appointment three consecutive times, they will be able to schedule appointments in advanced as normal.
SICKNESSES AND CONTAGIONS
If you or a member of your family has a sickness, contagion, infestation or such (i.e. strep throat, flu, cold, covid, MRSA, fever, lice, bed bugs, etc.), please call to reschedule your appointment. Please cancel as soon as you know you are not able to make the session. Cancellations made the day of an appointment will still be charged the same-day cancellation fee. Determination to waive the consequence will be determined by me. In most cases, clients are aware of their symptoms the day before a session and should call then to avoid any consequences of same day cancellations. Please see Cancellation Policy.
PAYMENTS & COLLECTIONS
Clients or families/guardians are expected to pay their bill at each session they attend. I accept personal checks, cash, and credit cards (through Square). Counseling will be suspended if the client's account is not current.
Session fees are billed through Square. Missed appointments and cancellations without 24 hours’ notice carry a full session fee. Please see Cancellation Policy.
Letter writing (including updates, reports, evaluations, etc) for court, DCYF, probation officers and other people (outside of normal billing) is charged at $40 per quarter hour increments.
Phone conversations longer than 10 minutes are charged at $40 per quarter hour increments and will be billed in addition to session fees. The payment is the responsibility of the client.
Groups, programs, other therapies, trainings and other offerings are offered with various fees.
Collection Agencies can be used to collect outstanding bills. Information needed to collect past due amounts can be shared with the collection agency.
The client’s fee, per 50-minute therapy session, will be established at the onset of treatment and will be understood as the Financial Agreement. Payment is due at the time of service. Each client is required to have a credit card on file with me through Square. I will charge invoices that are more than 30 days overdue to the card on file. In cases where 30 days have elapsed and payment through the card on file fails, I will send the client a final notice via USPS Certified Mail, requesting immediate payment. I reserve the right to refer delinquent accounts to a third-party credit agency. I reserve the right to suspend or cease treatment for clients with delinquent accounts.
BILLING
The amount paid by the client (or client’s parent(s)/guardian(s)) directly is referred to as the Fee.
RESPONSIBILITY
The client (or client’s parent(s)/guardian(s)) is responsible for the entire payment of the charge.
With parents who are separated, one parent will be the designated payee to the account. Split billing to the parents is not done. However, I am happy to provide both parents with a copy of the financial statements as needed.
ATTENDANCE
The scheduling of an appointment construes the making of a contract with the therapist of time for money. This contract assumes either attendance or timely notice of cancellation of the appointment. Timely notification is considered 24 hours in advance of the appointment but please notify me as soon as you are aware you cannot make an appointment. Calling well in advance allows the possibility of my using that time slot for care of another client.
CANCELLATION/NO-SHOW POLICY
· Each client is eligible for one free no-show/cancellation during the course of our therapeutic relationship, in acknowledgment that emergencies happen & we all make mistakes.
· For subsequent cancellations made 24 hours or less before appointment time, I will charge a full session fee.
· If I have space available, and we can reschedule your appointment within the same week, no fee will apply.
· If you cancel more than 24 hours ahead of time, no fee will apply.
· For snow/winter weather, Zoom will substitute for any scheduled in-person session.
CONSEQUENCES OF MISSED SESSIONS
When cancellations made the day of an appointment and/or no shows together add up to three or more, I see this as a sign that the client is not interested or invested in the counseling process. At this point, I reserve the right to place the client on a same-day call list or terminate counseling, with a referral to other resources. A client placed on the same day call list will need to call each day they are available to see if I have an opening that day. If there is an opening, the client will be able to schedule. If no appointment is available that day, then the client will need to call the next time they are able to see if there is an opening. Once a client has called, made an appointment and followed through on the appointment three consecutive times, they will be able to schedule appointments in advanced as normal.
SICKNESSES AND CONTAGIONS
If you or a member of your family has a sickness, contagion, infestation or such (i.e. strep throat, flu, cold, covid, MRSA, fever, lice, bed bugs, etc.), please call to reschedule your appointment. Please cancel as soon as you know you are not able to make the session. Cancellations made the day of an appointment will still be charged the same-day cancellation fee. Determination to waive the consequence will be determined by me. In most cases, clients are aware of their symptoms the day before a session and should call then to avoid any consequences of same day cancellations. Please see Cancellation Policy.
PAYMENTS & COLLECTIONS
Clients or families/guardians are expected to pay their bill at each session they attend. I accept personal checks, cash, and credit cards (through Square). Counseling will be suspended if the client's account is not current.
Session fees are billed through Square. Missed appointments and cancellations without 24 hours’ notice carry a full session fee. Please see Cancellation Policy.
Letter writing (including updates, reports, evaluations, etc) for court, DCYF, probation officers and other people (outside of normal billing) is charged at $40 per quarter hour increments.
Phone conversations longer than 10 minutes are charged at $40 per quarter hour increments and will be billed in addition to session fees. The payment is the responsibility of the client.
Groups, programs, other therapies, trainings and other offerings are offered with various fees.
Collection Agencies can be used to collect outstanding bills. Information needed to collect past due amounts can be shared with the collection agency.
Client Consent for Use and/or Disclosure of Protected Health Information
1. I understand that my Protected Health Information (PHI) is protected under the provisions of HIPAA, the Health Insurance Portability and Accountability Act (HIPAA).
2. I understand, agree, and consent that appointment reminders and other necessary correspondence will be sent to me via phone, text, email, or paper mail by the Provider.
3. I understand that, given security concerns over the potential for unwanted PHI disclosure, email/text correspondence between the Provider and myself is to be restricted to simple scheduling matters. For more complex matters, phone and paper mail are the appropriate modes of communication.
4. The Provider may use and/or disclose my PHI (which includes information about my health or condition and the treatment provided to me) in order for the Provider to treat me and obtain payment for the treatment, as necessary for the Provider to conduct her specific health care operation.
5. I understand that I have a right to request that the Provider restrict how my PHI is used and/or disclosed to carry out treatment, payment, and/or health care operations. However, I understand that the Provider is not required to agree to any restrictions that I have requested. If the Provider agrees to a requested restriction, then the restriction is binding on the Provider.
6. I understand that this Consent is valid for seven years. I further understand that I have the right to revoke this Consent, in writing, at any time for all future transactions, with the understanding that any such revocation shall not apply to the extent that the Provider has already taken action in reliance on this Consent.
7. I understand that if I revoke this consent at any time, the Provider has the right to refuse to treat me.
8. I understand that if I do not sign this Consent, then the Provider will not treat me.
2. I understand, agree, and consent that appointment reminders and other necessary correspondence will be sent to me via phone, text, email, or paper mail by the Provider.
3. I understand that, given security concerns over the potential for unwanted PHI disclosure, email/text correspondence between the Provider and myself is to be restricted to simple scheduling matters. For more complex matters, phone and paper mail are the appropriate modes of communication.
4. The Provider may use and/or disclose my PHI (which includes information about my health or condition and the treatment provided to me) in order for the Provider to treat me and obtain payment for the treatment, as necessary for the Provider to conduct her specific health care operation.
5. I understand that I have a right to request that the Provider restrict how my PHI is used and/or disclosed to carry out treatment, payment, and/or health care operations. However, I understand that the Provider is not required to agree to any restrictions that I have requested. If the Provider agrees to a requested restriction, then the restriction is binding on the Provider.
6. I understand that this Consent is valid for seven years. I further understand that I have the right to revoke this Consent, in writing, at any time for all future transactions, with the understanding that any such revocation shall not apply to the extent that the Provider has already taken action in reliance on this Consent.
7. I understand that if I revoke this consent at any time, the Provider has the right to refuse to treat me.
8. I understand that if I do not sign this Consent, then the Provider will not treat me.
Right to Treatment Waiver & Informed Consent
I understand that psychotherapy is a form of medical treatment. I further understand that the purpose of this treatment is to improve my (or my child’s) health and/or relationships. However, I realize that it is possible that disruptions in my (or my child’s) health or relationships may occur during the treatment process, and I agree that I will discuss the nature and frequency of these disruptions if they occur.
I have read the outline and this statement in full and have had sufficient time to be sure that I considered it carefully. I have asked questions about any sections that I did not understand fully, or that I had concerns about.
I consent to the use of a diagnosis and to release information necessary to complete the treatment plan.
I agree to be responsible in a timely manner for payment of charges related to my/my child’s therapy, group sessions and/or other services provided by the Provider. I understand that these services are not covered by insurance.
I agree to undertake therapy with Julie Püttgen Expressive and Somatic Therapies, PLLC, or if I am the parent or legal guardian of a minor child beginning treatment, the child may undergo therapy with Julie Püttgen Expressive and Somatic Therapies, PLLC.
I understand that medications are not prescribed by this Provider. For clients needing/wanting medications, the Provider is willing to work in conjunction with the client and the client’s physician for the best of the client. A signed release form will be needed for communication with client’s physician, staff and office. For clients who do not have a primary care physician, recommendations can be made but I understand that I am responsible for my own well-being and maintenance thereof.
I understand that Julie Püttgen Expressive and SomaticTherapies, PLLC reserves the right to service cases which fit their organization, structure, expertise, and mission.
I agree to enter treatment. I have been informed about my rights as a client, I have had the opportunity to discuss these rights, and I understand them at this time. I understand the privacy procedures and limitations and have had an opportunity to discuss them. I understand that if, at any time, I have questions regarding these rights, I can and should speak to my therapist about my concerns.
This agreement is continuing and binding until disallowed by one or both parties.
I have read the outline and this statement in full and have had sufficient time to be sure that I considered it carefully. I have asked questions about any sections that I did not understand fully, or that I had concerns about.
I consent to the use of a diagnosis and to release information necessary to complete the treatment plan.
I agree to be responsible in a timely manner for payment of charges related to my/my child’s therapy, group sessions and/or other services provided by the Provider. I understand that these services are not covered by insurance.
I agree to undertake therapy with Julie Püttgen Expressive and Somatic Therapies, PLLC, or if I am the parent or legal guardian of a minor child beginning treatment, the child may undergo therapy with Julie Püttgen Expressive and Somatic Therapies, PLLC.
I understand that medications are not prescribed by this Provider. For clients needing/wanting medications, the Provider is willing to work in conjunction with the client and the client’s physician for the best of the client. A signed release form will be needed for communication with client’s physician, staff and office. For clients who do not have a primary care physician, recommendations can be made but I understand that I am responsible for my own well-being and maintenance thereof.
I understand that Julie Püttgen Expressive and SomaticTherapies, PLLC reserves the right to service cases which fit their organization, structure, expertise, and mission.
I agree to enter treatment. I have been informed about my rights as a client, I have had the opportunity to discuss these rights, and I understand them at this time. I understand the privacy procedures and limitations and have had an opportunity to discuss them. I understand that if, at any time, I have questions regarding these rights, I can and should speak to my therapist about my concerns.
This agreement is continuing and binding until disallowed by one or both parties.
Fee Agreement
I have agreed with Julie Püttgen Expressive and Somatic Therapies, PLLC that
I understand payment for session is due at time of service.
- my private-pay session fee will be $150 per session, OR
- I am a current VT Medicaid member, OR
- I am a current Dartmouth Student Group Health Plan member and my co-pay will be $30 per session, OR
- my private-pay sliding-scale session fee will be $_____ per session (please specify in the Acknowledgments and Signatures field below).
I understand payment for session is due at time of service.
Cancellation Policy
- Each client is eligible for one free no-show/same-day cancellation during the course of their therapeutic relationship with Julie Püttgen Expressive and Somatic Therapies, PLLC, in acknowledgment that emergencies happen and we all make mistakes.
- For subsequent cancellations with less than 24 hours’ notice before appointment time, client will pay a full session fee.
- VT Medicaid clients are exempt from the above requirement.
- For DSGHP clients, the cancellation fee is $150: a $30 copay, plus the $120 usually paid by insurance.
- If Julie Püttgen Expressive and Somatic Therapies, PLLC has space available, and it is possible to reschedule an appointment within the same week, no fee will apply.
- If the client cancels more than 24 hours ahead of time, no fee will apply.
- In case 2 or more canceled or rescheduled regular appointments within the space of any one calendar month, Julie Püttgen Expressive and Somatic Therapies, PLLC reserves the right to place client on a “will call” scheduling basis.
- In case of snow/winter weather that prohibits travel, Zoom will substitute for any scheduled in-person session.
- Scheduling arrangements, including cancellations, are to be made via email to [email protected].