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First appointment packet

Christopher Carter, LICSW

339 BOYLSTON STREET, SUITE 900, BOSTON’S BACK BAY

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Christopher Carter, LICSW339 Boylston Street, Boston MA [email protected]

617-444-9391

PRACTICES AND POLICIES

Limits of Confidentiality

In compliance with HIPAA law (see HIPAA Notice of Privacy Practices) and NASW ethics, I will not divulge your personal information to individuals, agencies or other health care providers without your written consent. Information you share in session will be considered strictly confidential except in situations where you are a danger to yourself or others or if I am subpoenaed by an officer of the court for legal proceedings. In addition, I am required by law to report to local protection agencies any suspected or actual incidences of abuse or neglect of a child/dependent, elderly, or disabled person.

Billing

It is your responsibility to pay entire session fee at the beginning or end of each scheduled appointment. I accept payment by cash or check. I do not accept credit cards as a form of payment. Many people find it helpful to prepare check or cash payment prior to their appointment in order to maximize time devoted to therapy.

Fees

Insurance Accepted: Blue Cross/Blue Shield plans. I can often accept out-of-network payments if you have a PPO plan from another insurance company. You will need to contact your insurance company to determine this benefit.

Private Pay rates, to be paid by check or cash only:

o Individual Psychotherapy 45 min $150 o Individual Psychotherapy 60 min $200 o First Session $220 o Couples Therapy 60 min $220o Consultation 60 min $180

Payment is due upon the date services are rendered. If you are using insurance, this means that only your copay is due. If you have a deductible, we can work out a payment plan if necessary. Additional services not listed can be discussed on a case-by-case basis. If you incur a debt with me, copay or deductible, I reserve the option of withholding further appointments until those debts are paid.

Cancellations and Missed Appointments

Please remember to call at least 24 business hours (Monday – Friday) before scheduled appointment time if you need to cancel. If you do not provide 24 hour notice of cancellation or miss a session, you will be responsible for paying half the private pay rate out-of-pocket for the missed appointment prior

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to or at the start of our next meeting in order for treatment to continue. This means that even I you use your insurance, if you miss an appointment or cancel past deadline, you would owe $60. This policy is to honor the treatment agreement, respect professional boundaries and understand that the time that is unused could be going to someone else who needs it.

This policy applies to those using their insurance in addition to those in private pay arrangements.

Contact and Mental Health Emergencies

I have a voicemail box and you may leave a message for me anytime. During regular business hours of 9am to 8pm, I will make every attempt to get back to you, usually within 24 business hours. If you are experiencing an emergency and cannot reach me, please leave me a message and go to your the nearest hospital emergency room. The closest emergency room to my office is at Massachusetts General Hospital at 55 Fruit Street Boston. In addition, Samaritans of Boston operate a 24-hour crisis number at 617-247-0220.

Electronic Communication

I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

If against this recommendation you do happen to communicate therapeutic content via these methods, all existing confidentiality protections will remain equally applicable, your access to all medical information transmitted during these communications will be guaranteed, and copies of this information are available for a reasonable fee, and dissemination of any information from the electronic interaction to researchers, insurers or other entities shall not occur without your consent.

When using information technology in therapy services, potential risks include, but are not limited to the therapist’s inability to make full observations of clinically or therapeutically potentially relevant issues such as your physical condition, speech and tone. Potential consequences thus include the therapist not being aware of what he or she would consider important information that you may not recognize as significant to present verbally the therapist.

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Acknowledgement of Receipt of Practices and Policies

Signage page listed on page 10

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617-444-9391

HIPAA NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. My Pledge Regarding Health Information:

I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.• Give you this notice of my legal duties and privacy practices with respect to health information.• Follow the terms of the notice that is currently in effect.• I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

II. How I May Use And Disclose Health Information About You:

The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the

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coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

III. Certain Uses And Disclosures Require Your Authorization:

1. Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:a. For my use in treating you.b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.c. For my use in defending myself in legal proceedings instituted by you.d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.e. Required by law and the use or disclosure is limited to the requirements of such law.f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.g. Required by a coroner who is performing duties authorized by law.h. Required to help avert a serious threat to the health and safety of others.

2. Marketing Purposes. As a psychotherapist, I will not use or disclose your protected health information for marketing purposes.

3. Sale of PHI. As a psychotherapist, I will not sell your protected health information.

IV. Certain Uses And Disclosures Do Not Require Your Authorization:

Subject to certain limitations in the law, I can use and disclose your protected health information without your Authorization for the following reasons:

1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.

3. For health oversight activities, including audits and investigations.

4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.

5. For law enforcement purposes, including reporting crimes occurring on my premises.

6. To coroners or medical examiners, when such individuals are performing duties authorized by law.

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7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.

8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

9. For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your protected health information in order to comply with workers’ compensation laws.

10. Appointment reminders and health related benefits or services. I may use and disclose your protected health information to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

V. Certain Uses and Disclosures Require You To Have The Opportunity To Object:

1. Disclosures to family, friends, or others. I may provide your protected health information to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

VI. You Have The Following Rights With Respect To Your Protected Health Information (PHI):

1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain protected health information for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.

2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

3. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.

4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.

5. The Right to Receive a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter

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time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.

6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.

7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

This notice went into effect on August 16th, 2018.

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Acknowledgement of Receipt of Privacy Notice


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617-444-9391

CONSENT TO TREAT AGREEMENT

I acknowledge that I have fully discussed with Christopher Carter, LICSW (henceforth “therapist”) the various aspects of psychotherapy. The nature of the treatment has been described, including the extent, its possible side effects, and possible alternative forms of treatment. I understand I may withdraw from treatment at any time but if I decide to do this I will discuss my plan with my psychotherapist before acting on it.

My therapist has further discussed with me scheduling policies, fees to be charged, payment procedures, policies regarding missed or canceled appointments, emergency procedures, holidays and vacations, matters relating to insurance, and, if applicable, preauthorization and utilization review issues.

I have read the documents provided and fully understand procedures and policies, the nature of treatment, the alternatives to this treatment, the limits of confidentiality and the circumstances in which confidential communications may need to be breached.

I have been given the opportunity to ask questions regarding my psychotherapist's education and training, areas of special interest or training, and types of psychotherapy utilized by the therapist.

I understand that I may request copies of any policies or administrative documents.

I agree and consent to psychotherapy with the above-mentioned therapist.

Private Pay option only: The agreed upon fee is currently $___________ per session to be paid at the time of each appointment. I understand that this may be negotiated in the future.

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Acknowledgement of Receipt of Consent to Treat Agreement


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Please give the following pages back to your therapist after completion

Acknowledgement of Receipt of:

1. HIPAA Notice of Privacy Practices2. Practices & Policies3. Consent to Treat Agreement

By signing below, I certify that I have received, understand and agree to the stipulations within the aforementioned notices (HIPAA Notice of Privacy Practices, Practices and

Policies and Consent to Treat Agreement).

I have been informed of my rights under the HIPPA act and I consent to treatment with this provider under these guidelines.

___________________________________________________________ __________________Client Signature Date

___________________________________________________________Printed Name

___________________________________________________________ _________________Therapist Signature Date

_Christopher M Carter LICSW_________________________Printed Name

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617-444-9391

FACE SHEET

Demographic Information

Full Name: _____________________________________ DOB: ______________ Age: _______

Address: ______________________________________

__________________________________________________

Phone #: _______________________________

Email: __________________________________

Emergency Contact and #: ______________________________________________________________________

Referral source: __________________________________________________________________________________

If Student, list school: ____________________________________________________________________________

If Employed, list employer: _____________________________________________________________________

Primary Care Physician and contact information: __________________________________________

I consent to permit communication between my therapist and my primary care (sign ROI) I decline permission to communicate with my primary care

Psychiatrist and contact information: _________________________________________________________

I consent to permit communication between my therapist and my psychiatrist (sign ROI) I decline permission to communicate with my psychiatrist

Payment Information (if not yet provided to your therapist)

Private Pay Insurance (list info below if not previously given)

Insurance & policy #: Insurance phone #:

Policy Holder: Policy Holder DOB:

Policy Holder employer: Policy Holder phone #:

Secondary Insurance (if applicable):

Electronic communication preferences

I would like to be able to schedule and cancel sessions using electronic communication (text and email) and I permit my therapist to initiate communication of administrative matters using these means.

I decline use of electronic communication of administrative matters with my therapist.

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New Patient Self-Report Questionnaire To the best of your ability, answer the following questions as fully as possible.

PERSONAL DEMOGRAPHICS (you may write “Skip”)

Where born/Where raised: Culture/ethnicity/sex orientation:

Employment/Occupation: Education:

Resources/sources of support: Spirituality/religion:

Leisure/Recreation interests: Past or present legal issues:

Who do you consider your family?

MENTAL HEALTH HISTORY

Have you ever been in psychotherapy? If yes, explain. Briefly note any significant events in your life:

Any history of Psychiatric medication? If yes, explain.

Any family members with substance abuse histories?

Ever been Psychiatrically hospitalized? If yes, explain.

These are the people I’d like you to speak with regarding my care (if applicable):

Any family members with mental health histories?

PHQ-9 SELF-ASSESSMENT

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Client: _____________________________________ Date: ____________ Over the past two weeks how often have you been bothered by any of the following problems? Please check the box that best describes your feelings.

Not at AllSeveral

Days

More than half the days

Nearly every

day

1. Little interest or pleasure in doing things

2. Feeling down, depressed or hopeless

3. Trouble falling or staying asleep, or sleeping too much

4. Feeling tired or having little energy

5. Poor appetite or overeating

6. Feeling bad about yourself – that you are a failure or have let you or your family down

7.Trouble concentrating on things, such as reading the newspaper or watching television

8.

Moving or speaking so slowly that other people may have noticed? Or the opposite – being so fidgety or restless that you have been moving around more than usual

9. Thoughts that you would be better off dead or of hurting yourself in some way

If you checked off any problems, please circle how difficult these problems have made it for you to do your work, take care of things at home, or get along with other people.

(Circle one) Not at all difficult A little difficult Very difficult Extremely difficult

In the past two years have you felt depressed or sad most days, even if you felt okay sometimes? (Circle one) Yes No

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ABBREVIATED BAM-R

Client: _____________________________________ Date: ____________

In the past 30 days…

1. How has your physical health been?

Excellent Very Good Good Fair Poor

2. How many nights did you have trouble falling asleep or staying asleep? _______

3. How many days have you felt depressed, anxious, angry or very upset throughout most of the day?

____

4. How many days did you drink ANY alcohol? _______ (if 0, skip to #6)

5. How many days did you have at least 5 drinks (for men) or at least 4 drinks (for women)? _______

6. How many days did you use any illegal or street drugs or abuse any medications? ______

7. How many days did you abuse or overuse any of the following drugs (even if prescribed):

a. Marijuana/weed: ________

b. Benzos or downers: ________

c. Cocaine or crack: ________

d. Stimulants: _________

e. Opiates: __________

f. Inhalants: _________

g. Other drugs: ________

8. How much were you bothered by cravings or urges to drink alcohol or use drugs?

Not at all Slightly Moderately Considerably

Extremely

9. How much have you been bothered by arguments or problems getting along with any family

members or friends? Not at all Slightly Moderately

Considerably Extremely12

ADVERSE CHILDHOOD EXPERIENCES (ACE) QUESTIONNAIRE

Client: _____________________________________ Date: ____________

During your first 18 years of life…

1. Did a parent or other adult in the household often swear at you, insult you, put you down, or

humiliate you?

OR Yes - No

Act in a way that made you afraid that you might be physically hurt?

2. Did a parent or other adult in the household often push, grab, slap, or throw something at you?

OR Yes - No

Ever hit you so hard that you had marks or were injured?

3. Did an adult or person at least 5 years older than you ever touch or fondle you or have you touch

their body in a sexual way?

OR Yes - No

Try to or actually have oral, anal, or vaginal sex with you?

4. Did you often feel that no one in your family loved you or thought you were important or special?

OR Yes - No

Your family didn’t look out for each other, feel close to each other, or support each other?

5. Did you often feel that you didn’t have enough to eat, had to wear dirty clothes, and had no one to

protect you?

OR Yes - No

Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

6. Were your parents ever separated or divorced?

Yes - No

7. Was your mother or stepmother often pushed, grabbed, slapped, or had something thrown at her?

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OR

Sometimes/often kicked, bitten, hit with a fist, or hit with something hard?

OR

Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

Yes - No

8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?

Yes - No

9. Was a household member depressed or mentally ill or did a household member attempt suicide?

Yes - No

10. Did a household member go to prison?

Yes - No

Total YES answers: _______ This is your ACE Score

https://acestoohigh.com/got-your-ace-score/

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The form on the next page is optional and useful if you would like me to have contact with anybody else in your life, either personal or another health provider.

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Authorization for Use or Disclosure of Protected Health Information

1. I hereby authorize to use and/or disclose the[Name of Health Care Provider]

protected health information described below to .[Name of Individual]

2. Authorization for Release of Information□ to

covering the period of health care from□ all past, present and future periods:OR

a. □ I authorize the release of my complete health record (including records relatingto mental health care, communicable diseases, HIV or AIDS, and treatment of alcohol/drug abuse).

OR

b. □ I authorize the release of my complete health record with the exception of the following information:

□□□□

Mental health recordsCommunicable diseases (including HIV and AIDS) Alcohol/drug abuse treatmentOther (please specify):

3. This medical information may be used by the person I authorize to receive this information formedical treatment or consultation, billing or claims payment, or other purposes as I may direct.

4. This authorization shall be in force and effect until , at which time this[Date or Event]authorization expires.

5. I understand that I have the right to revoke this authorization, in writing, at any time. Iunderstand that a revocation is not effective to the extent that any person or entityhas already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

6. I understand that my treatment, payment, enrollment or eligibility for benefits will not beconditioned on whether I sign this authorization.

7. I understand that information used or disclosed pursuant to this authorization may be disclosedby the recipient and may no longer be protected by federal or state law.

Signature of Patient or Personal Representative Date

Print Name of Patient or Personal Representative Relationship to Patient

Christopher Carter LICSW


617-444-9391

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