wilson psychology group, llc

wilson psychology group, llc

intake paperwork
CONFIDENTIALITY, DISCLOSURE, AND INFORMED CONSENT FOR PSYCHOLOGICAL SERVICES

CONSENT FORM

Wilson Psychology Group LLC offers psychological services to patients across the state of Alabama. The licensed psychologist you are meeting with is involved in the group partnership doing business as Wilson Psychology Group LLC.

This psychologist is meeting with you to assist you improve your overall mental and physical health. Our first few appointments will involve an assessment of your needs and establishing goals of treatment. If a different behavioral health professional would better meet your needs, we will assist in locating a provider best suited to help you. Your participation in psychological services is completely voluntary, and if you do not want a psychologist to be member of your team of health care providers, you are free to decline. If you have questions about services offered or provided by the psychologist, you are encouraged to ask them at any time.

In order to understand your needs and improve our services, this psychologist may give you screening measures or questionnaires to complete. If such information was ever presented for program evaluation or research purposes, but the results would never identify you personally.

LIMITS OF CONFIDENTIALITY

We consider privacy of utmost importance and will protect it within the boundaries of the law and professional ethics. For treatment purposes and in order to better serve you, information shared during your sessions may be shared with other Wilson Psychology Group LLC staff. When information is used for these consultation purposes, confidentiality is protected by those involved.

This psychologist will not share identifying information that you discuss during a session with individuals outside of the Wilson Psychology Group LLC treatment team unless you sign a separate written authorization form, with a few important exceptions:

Harm to Self: If you are in imminent danger of serious physical harm to yourself, this psychologist is legally required to call medical or emergency personnel in order to obtain help, protection, and possibly hospitalization for you. This does not mean that because you express feelings and thoughts about harming or killing yourself that your privacy will definitely be compromised. There is an important difference between expressing thoughts/feelings versus acting on them. Only if there is determined to be an imminent danger of serious physical harm to yourself will protective action be taken. If you believe you are in imminent danger of harming yourself, you must seek emergency mental health services at a local hospital or by calling 911.

Harm to Others: Similarly, if you report that you intend to seriously harm another person, by law, we must take action to protect the other person.

Abuse of Children: If there is reasonable suspicion that a child is being neglected, physically abused, sexually abused, subjected to willful cruelty or unjustifiable mental suffering, or exposed to domestic violence in the home, by law, the suspicion must be reported to child protective services or a local law enforcement agency.

Abuse of Elders or Dependent Adults: If there is reasonable suspicion that physical abuse, misuse of physical or chemical restraint, neglect, abandonment, isolation, abduction, or financial abuse is occurring against an elderly (age 65 or older) or dependent adult (i.e., an adult with a mental or physical disability), by law, the suspicion must be reported to the appropriate government agency.

Legal Demands: If legal demands to release information are made (such as a court order), we will make every attempt to inform you before any confidential information is released. You are protected under psychologist-patient privilege law. No information can be provided without your (or your legally-appointed representative’s) written authorization, a court order, or compulsory process (a subpoena) or discovery request from another party to the court proceeding where that party has given you proper notice (when required), has stated valid legal grounds for obtaining the information, and we do not have grounds for objecting under state law (or you have instructed us not to object).

When it is necessary to break confidentiality due to any of these exceptions, we will make a reasonable effort to notify you prior to any disclosures so that we can discuss the disclosure before action is taken, and disclosures will be limited to what is necessary.

ACKNOWLEDGMENT OF INFORMED CONSENT

In signing below you acknowledge that you reviewed all of the information in this document, you have had ample opportunity to discuss it with the psychologist, and you have had your questions answered to your satisfaction. In so doing, you are making an informed decision about meeting with the psychologist and receiving services. Your signature(s) indicates that you voluntarily consent to participate in the evaluation and/or psychotherapy. Your signature(s) does not mean that you have waived any rights.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature of Patient*
Name of Psychologist

First NameLast Name
Date

MonthDayYear
Date
Signature of Psychologist
PROVIDER CONTACT:

Emma Hiatt Wilson, PhD (AL Lic# 2115)

Wilson Psychology Group LLC
1115 Leighton Ave., Ste. 1-A
Anniston, AL 36207

(256) 238-8113 (p)

INFORMED CONSENT FOR TREATMENT

I affirm that prior to becoming a patient of Wilson Psychology Group, LLC, I have been provided sufficient information to understand the professional identity of the provider(s), general scope of treatment, the ethical and legal limits of confidentiality, as well as the potential risks and benefits and alternatives treatments available. This information has been presented in non-technical terms which allows me to have a full understanding of the informed consent of treatment with provider(s) of Wilson Psychology Group, LLC.

At this point in time, I declare I am competent to make my own personal decisions to engage and to participate in psychological/behavioral health care treatment, such as, but not limited to the following: psychotherapy, neuropsychological assessment, and/or psychological testing. I understand that services will be administered by providers at Wilson Psychology Group, LLC. Accordingly, this is a decision I am making voluntarily, and I have not been subjected to influence or duress in the pursuit of treatment. I understand treatment is not mandatory, and if I chose to discontinue treatment, that decision should not impact my medical or other mental health care in any way.

In summary, my signature below affirms my informed and voluntary consent to receive treatment. I am aware that I can revoke this consent and discontinue treatment at
any time.
Patient of Responsible Party*
Date*

MonthDayYear
Date
Parent Signature if Patient is a Minor
Date

MonthDayYear
Date
Witness Signature
Date

MonthDayYear
Date

Patient Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Patient Preferred Name and/or Pronouns
Social Security Number*
Gender
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer
Occupation
Referred By:

Contact Information
Email*
example@example.com
Home Phone Number
Please enter a valid phone number.
Mobile Phone Number*
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Best number to reach you at:
In the event of an emergency, please contact:*

First NameLast Name
Home Phone Number*
Please enter a valid phone number.
Mobile Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
May Wilson Psychology Group, LLC communicate with you by text?

YesNo
If so, provide contact number where you would like to receive a text?
If you have an answering machine, may we leave a message including the provider's name?

YesNo

Responsible Party

Who will pay for services not covered by insurance? This MUST be completed in full.
Person Responsible for Payment*

First NameLast Name
Relationship to Patient*
Date of Birth*

MonthDayYear
Date
Social Security Number*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Mobile Phone Number*
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Insurance Information

Please fill out this information COMPLETELY. Incomplete forms cannot be processed for insurance. This is required for compliance with the Health Insurance Portability and Accountability Act (HIPAA), therefore, ALL information must be filled-out. If you do not have insurance, please indicate “N/A” in any blanks.
Primary*
Policy Holder Name*

First NameLast Name
Relation to Patient*
Employer of Policy Holder
Contract Number*
Group Number*
Social Security Number of Policy Holder*
Date of Birth of Policy Holder*

MonthDayYear
Date
Date Policy Effective

MonthDayYear
Date
Deductible Amount $
Co-pay Amount $
Secondary
Policy Holder Name

First NameLast Name
Relation to Patient
Employer of Policy Holder
Contract Number
Group Number
Social Security Number of Policy Holder
Date of Birth of Policy Holder

MonthDayYear
Date
Date Policy Effective

MonthDayYear
Date
Deductible Amount $
Co-pay Amount $
FINANCIAL ARRANGEMENTS: For your convenience, we offer the following methods of payment. Please check the option your prefer:

Credit Card (Visa/MasterCard)Personal CheckCashPayPal/CashApp/Venmo/Apple Pay

I UNDERSTAND AND AGREE THAT, REGARDLESS OF MY INSURANCE STATUS, I AM ULTIMATELY RESPONSIBLE FOR THE BALANCE ON MY ACCOUNT FOR ANY PROFESSIONAL SERVICES RENDERED. I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I WILL NOTIFY WILSON PSYCHOLOGY GROUP, LLC, OF ANY CHANGES TO MY PERSONAL, CONTACT, OR INSURANCE INFORMATION. I FURTHER UNDERSTAND THAT BY PRESENTING MY INSURANCE CARD, I AM AUTHORIZING WILSON PSYCHOLOGY GROUP, LLC, TO BILL MY INSURANCE, AND I AM GIVING WILSON PSYCHOLOGY GROUP, LLC, MY CONSENT TO SUPPLY ANY INFORMATION REGARDING VISITS WITH MY PROVIDER TO MY INSURANCE COMPANY FOR BILLING AND REIMBURSEMENT PURPOSES.

I understand that I or my responsible party is responsible for my bill, not my insurance company. If my insurance does not pay in a timely manner, I will pay the bill in full

I, the undersigned, hereby agree to pay all amounts and changes for services rendered by Wilson Psychology Group, LLC, no later than thirty (30) days of the rendering of said services, unless other specific written arrangements are made. In the event of default in the payment of said services, I waive, as to the debt, all rights of exemptions and laws of Alabama, or of any other state, as to personal property, and agree to pay all costs of collection or repeated attempts to collect or secure said indebtedness, including all reasonable legal/attorney fees. Please initial and sign below:
Please check all and sign below*

I understand that I will be receiving appointment reminders at any phone number I submit to Wilson Psychology Group, LLCI understand that unless a scheduled appointment is cancelled at least twenty-four (24) hours in advance, insurance companies do not reimburse missed appointments, and I will be charged for the time reserved.I authorize release of medications information requested by my insurer that is necessary to process my claims and request payment to Wilson Psychology Group, LLC.I understand that if my balance is not paid within 90 days, that my account, including all financial records associated with my account, may be turned over to an outside agency for resolution.
Patient or Responsible Party*
Date*

MonthDayYear
Date
Parent Signature if Patient is a Minor
Date

MonthDayYear
Date
Witness Signature
Date

MonthDayYear
Date

Patient or Responsible Party*
Please read carefully the following notice:

On the Patient Information Sheet, ALL BLANK AREAS MUST BE COMPLETED PRIOR TO BEING SEEN BY THE PROVIDER. This includes social security numbers for any child that is an established patient. If information is missing, your insurance CANNOT be filed without this information. If you do not have all the information available to you, you will be asked to pay in full until such information is provided for insurance filing. This is a requirement of the Health Insurance Portability and Accountability Act (HIPAA)—federal law with which all health service providers must remain in full compliance.

I have read and understand this information (please sign below):
Date*

MonthDayYear
Date
Parent Signature if Patient is a Minor
Date

MonthDayYear
Date
Witness Signature
Date

MonthDayYear
Date

Questions Concerning Your Billing

NEW PATIENTS

If you wish your sessions to be billed to your insurance, you must present your insurance card and provide your social security number. Insurance cannot be filed without this information.

Our billing agent is contracted through our electronic health record, athenahealth, and the payment portal is located at https://www.quickpayportal.com. Your insurance will typically be filed within a few days of your visit. However, your insurance company requires a processing time of approximately 4 to 6 weeks before payment is received by the billing agent. If you wish to know if your insurance company has paid for your visits, how much your insurer has paid, or whether you have a credit owed or balance due, you will need to contact athenahealth via the patient portal.

OLD PATIENTS

If you have any questions regarding your balance due or credit, please contact athenahealth through the patient portal. If you are due a refund, please allow a 4-week processing time.

If you are a patient who has not been seen in 2 years or more, or there are any updates required to maintain the accuracy of your Patient Information Sheet, you will need to fill out all new forms so that we may update your file.

If you will not be returning as a patient and have any questions regarding your account, please contact athenahealth.

Patient Name*

First NameLast Name
Date*

MonthDayYear
Date
I give Wilson Psychology Group, LLC, staff, and electronic health record and billing company my permission to speak with the following people about any health and billing issues that arise. By signing this document, I give those people permission to discuss any health information and/or billing information (account inquiry, insurance claims, account balances, etc.) with owners or employees of Wilson Psychology Group, LLC and/or the billing contact via your athenahealth patient portal.
Name*

First NameLast Name
Relation to Patient*
Leave a message on answering machine:

YesNo
Name

First NameLast Name
Relation to Patient
Leave a message on answering machine:

YesNo
Patient or Responsible Party*
Date*

MonthDayYear
Date
Parent Signature if Patient is a Minor
Date

MonthDayYear
Date
Witness Signature
Date

MonthDayYear
Date

Date*

MonthDayYear
Date
Cancellation Policy - Acknowledgement

Please read and sign if you agree to abide by this policy.

* When necessary, patients must cancel appointments at least 24 hours before the previously-scheduled appointment time. *

Please note exceptions:

1. All Monday appointments must be canceled before 9:00 a.m. on the FRIDAY

prior to the previously-scheduled appointment.

2. If your appointment is scheduled at the day following a holiday or office closing, you must cancel before 9:00 a.m. on the previous working/business day.

YOU are financially responsible for the time Wilson Psychology Group reserved for you, even if you cannot attend the appointment, unless Wilson Psychology Group, LLC, is notified in advance.

Insurance companies will not reimburse your provider for your missed appointment.

Wilson Psychology Group values the time spent with you, and this policy honors the time set aside for both you and your provider.
Patient or Responsible Party*
Parent Signature if Patient is a Minor
Date

MonthDayYear
Date
Witness Signature
Date

MonthDayYear
Date

POLICY OF CONFIDENTIALITY

Wilson Psychology Group, LLC’s, policy on confidentiality is consistent with that of the Alabama Board of Examiners in Psychology as well as with the official position of the American Psychological Association’s Ethical Principles of Psychologists.

Wilson Psychology Group maintains strictest confidentiality of all information disclosed during diagnostic, evaluative, and therapeutic appointments. Access to records can be granted to others only with the expressed written consent of the patient. However, there are legal limits to confidentiality in the delivery of psychiatric services, and it is important that the patient understand when legal breaches of confidentiality are necessary and agree to these exceptions prior to being seen by Wilson Psychology Group.

Limits of Confidentiality

1. When failing to reveal information could result in serious, physical bodily harm or imminent danger to the patient or others. In this scenario, priority must be given to protecting individuals’ lives over maintaining confidentiality.

2. When there exists reasonable concern for the safety of a minor, elderly adult, or dependent adult. In such circumstances, a report is written and sent to the Department of Human Resources (DHR) of the county in which harm may have occurred within 24 hours.

3. When insurance coverage requests release of records. Whenever feasible, this is always facilitated with the patient’s written consent.

4. When courts subpoena information for litigation in child custody, divorce proceedings, or when the patient informs the court of their own mental health condition, which may call for the provider to disclose information related to session notes, psychodiagnostic evaluation, neuropsychological assessment or testing, or other expert testimony.

5. When couples and/or families are seen in evaluation or therapy together, the content of those sessions cannot be considered confidential (except under specific legal circumstances dictated by the adjudicator). The providers and employees of Wilson Psychology Group, LLC, have no control over either partner or any member of the family disclosing the content of joint sessions.

6. When a patient decides to enter group therapy, the patient will be reminded that while the provider will continue to refrain from the disclosure of personal information about a patient, the provider cannot guarantee all members of the group will always maintain confidentiality.

POLICY OF CONFIDENTIALITY

I have read the policy concerning the practice of confidentiality outlined by Wilson Psychology Group, LLC, and I understand and agree to the limits of confidentiality outlined on the previous page.
Patient or Responsible Party*
Date*

MonthDayYear
Date
Parent Signature if Patient is a Minor
Date

MonthDayYear
Date
Witness Signature
Date

MonthDayYear
Date

Notice of Privacy Policies

This notice describes how health information concerning you may be used and disclosed and how you may get access to this information. Please review it carefully. The privacy of your health information is important to us.

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this notice while it remains in effect. This notice takes effect (02/20/2021), and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this notice and make the new notice available upon request.

You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

TREATMENT: We may use or disclose your health information to a physician or healthcare provider providing treatment to you.

PAYMENT: We may use and disclose your health information to obtain payment for service we provide to you.

HEALTHCARE OPERATIONS: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Notice of Privacy Policies (cont’d)

YOUR AUTHORIZATION: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use of disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason, except those described in this notice.

TO YOUR FAMILY AND FRIENDS: We must disclose your health information to you, as described in the Patient Rights section of this notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help you with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

PERSONS INVOLVED IN CARE: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, the prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses of disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up forms of health information.

REQUIRED BY LAW: We may use or disclose your health information when we are required to do so by law.

ABUSE OR NEGLECT: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health and safety of others.

NATIONAL SECURITY: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having custody of protected health information of inmate or patient under certain circumstances.

Notice of Privacy Policies (cont’d)

APPOINTMENT REMINDERS: We may use or disclose your health information to provide

you with appointment reminders (such as voicemail messages, postal mail, or text/SMS).

PATIENT RIGHTS

ACCESS: You have the right to look at or obtain copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. If you request copies we will charge you $0.15 for each page, $12.00 per hour for staff time to locate and copy your health information, and the cost of postage, if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee).

DISCLOSURE ACCOUNTING: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

RESTRICTION: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in emergency).

ALTERNATIVE COMMUNICATIONS: You have the right to request that we communicate with you about your health information by alternative means or alternative locations. YOU MUST MAKE YOUR REQUEST IN WRITING OR RECORDED MESSAGE. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

AMENDMENT: Youhavetherighttorequestthatweamendyourhealthinformation.(Your request must be in writing and it must explain why the information should be amended). We may deny your request under certain circumstances.

Notice of Privacy Policies - Acknowledgement

I HAVE READ AND UNDERSTAND THE POLICY GIVEN TO ME AND AGREE TO THE TERMS HEREIN.
Patient or Responsible Party*
Date*

MonthDayYear
Date
Parent Signature if Patient is a Minor
Date

MonthDayYear
Date
Witness Signature
Date

MonthDayYear
Date

Payment & Fees

Fee Schedule

PAYMENT FOR SERVICES IS DUE IN FULL AT THE TIME OF YOUR VISIT. If insurance is being filed, we will collect in full until we receive the correct co-payment amount. We accept Visa, MasterCard, personal checks, cash, and mobile payments through an authenticated provider (e.g., PayPal, Cash App, Venmo, ApplePay).

The fee schedule and out-of-pocket cost of each service is as follows:

Initial Session of Individual Psychotherapy for All Patients: $200.00

Subsequent/Follow-up Sessions for All Patients: $150.00

Psychiatric Diagnostic Evaluation (single session): $200.00

Subsequent Sessions of Psychiatric Diagnostic Evaluation: $150.00

Psychological Testing for Adults, Adolescents, or Children: $180.00

Feedback Session following Psychological Testing: $150.00

Written Report of Results of Psychiatric Diagnostic Evaluation: $100.00

Group Therapy: $80.00

Couples Counseling Session: $180.00

Initial Session

The first visit involves a psychiatric diagnostic evaluation and biopsychosocial clinical interview to enable the clinician to develop an adequate understanding of the patient’s chief concern, personal and social history, medical and mental health background, and goals of individual therapy, if indicated. This session lasts approximately 45-60 minutes. If the diagnostic evaluation takes longer than the initial session, any future sessions required to complete the evaluation will be charged the same rate as any other subsequent/follow-up session. If a written report is required or requested, an additional $100.00 will be charged. Report-writing fees are not typically reimbursed by insurance panels, unless neuropsychological testing as conducted.

Psychological Testing and Feedback Session

When neuropsychological testing or other assessment is conducted during the initial session, Wilson Psychology Group will schedule a feedback or follow-up session to review the test results with the patient in detail. Treatment recommendations are made at this time, as well as any referral for medical treatment. If a written report of test results, diagnostic framework, and treatment recommendations is created, the provider will review the report at the time of the feedback session. No written report will be provided without a feedback session, which enables the provider to explain the results in detail and provides an opportunity for the patient to ask questions about relevant findings and next steps for treatment.

Couples Counseling

When patients coming for couples’ therapy, the initial interview is to gather information on the couple and their current family context. Wilson Psychology Group will then schedule individual sessions with each individual independently, for which each patient is charged the standard subsequent session fee and then makes recommendations for treatment relative to each individual, as well as the relationship. Each of these visits carries a separate service fee (see rates listed).

Payment & Fees

Fee Schedule

PAYMENT FOR SERVICES IS DUE IN FULL AT THE TIME OF YOUR VISIT. If insurance is being filed, we will collect in full until we receive the correct co-payment amount. We accept Visa, MasterCard, personal checks, cash, and mobile payments through an authenticated provider (e.g., PayPal, Cash App, Venmo, ApplePay).

The fee schedule and out-of-pocket cost of each service is as follows:

Initial Session of Individual Psychotherapy for All Patients: $200.00

Subsequent/Follow-up Sessions for All Patients: $150.00

Psychiatric Diagnostic Evaluation (single session): $200.00

Subsequent Sessions of Psychiatric Diagnostic Evaluation: $150.00

Psychological Testing for Adults, Adolescents, or Children: $180.00

Feedback Session following Psychological Testing: $150.00

Written Report of Results of Psychiatric Diagnostic Evaluation: $100.00

Group Therapy: $80.00

Couples Counseling Session: $180.00

Initial Session

The first visit involves a psychiatric diagnostic evaluation and biopsychosocial clinical interview to enable the clinician to develop an adequate understanding of the patient’s chief concern, personal and social history, medical and mental health background, and goals of individual therapy, if indicated. This session lasts approximately 45-60 minutes. If the diagnostic evaluation takes longer than the initial session, any future sessions required to complete the evaluation will be charged the same rate as any other subsequent/follow-up session. If a written report is required or requested, an additional $100.00 will be charged. Report-writing fees are not typically reimbursed by insurance panels, unless neuropsychological testing as conducted.

Psychological Testing and Feedback Session

When neuropsychological testing or other assessment is conducted during the initial session, Wilson Psychology Group will schedule a feedback or follow-up session to review the test results with the patient in detail. Treatment recommendations are made at this time, as well as any referral for medical treatment. If a written report of test results, diagnostic framework, and treatment recommendations is created, the provider will review the report at the time of the feedback session. No written report will be provided without a feedback session, which enables the provider to explain the results in detail and provides an opportunity for the patient to ask questions about relevant findings and next steps for treatment.

Couples Counseling

When patients coming for couples’ therapy, the initial interview is to gather information on the couple and their current family context. Wilson Psychology Group will then schedule individual sessions with each individual independently, for which each patient is charged the standard subsequent session fee and then makes recommendations for treatment relative to each individual, as well as the relationship. Each of these visits carries a separate service fee (see rates listed).

Exchange of Information between Physicians

You must sign a release of information form in order for us to release your records to another professional or to obtain your records from another professional. The records are not the property of the patient (Alabama Code Law 34262). The patient may not have the records or testing protocols. Portions of the record can be copied for the client.

Confidentiality is strictly maintained. There are limits to this confidentiality and they must be agreed upon before engaging the service with Wilson Psychology Group. These are explained in a form given to you prior to your first session. You are always encouraged to ask questions about limits of confidentiality as they arise in treatment. Please note that no recording devices are allowed in therapy session; and teletherapy sessions are never to be reordered, by patient for provider.

Wilson Psychology Group, LLC remains its own entity and is not a partner with any other mental health professional who works within or outside of this office. While clinical information regarding patients may be shared among providers who work directly for Wilson Psychology Group, LLC, no clinical or PHI is shared between other mental health professionals or entities, unless the client signs an appropriate release of information.

Legal Procedures

PAYMENT FOR EXPERT WITNESS FOR DEPOSITION AND COURT TESTIMONY IS REQUIRED IN ADVANCE. Wilson Psychology Group, LLC cannot provide this service on credit due to costs associated with court preparation, as well as the cancellation of any previously-scheduled appointments. For legal cases, a $1,000.00 per person retainer is required for legal preparation, collateral contacts and testimony. The court testimony fee is $1,000.00 for a half day. Roundtrip mileage for out of town appearances incurs a charge of $.35 cents per mile. If more than one day is required, the fee is $175.00 per hour.

Wilson Psychology Group may be called to court cases. Usually, this will not be an inconvenience, but occasionally, patient time may be interrupted due to being on an “on call” basis by a court subpoena, or if there is a patient or personal emergency. She apologizes for any inconvenience this may cause.

Wilson Psychology Group requires a copy of a credit card on file to be used for any appointment fees, co-pays or missed appointment fees.

Notice of Payment & Fee - Acknowledgement
I, blanks*, have read, understand, and agree to the details related to payment and fees associated with services described in this form.
Patient or Responsible Party*
Date*

MonthDayYear
Date
Parent Signature if Patient is a Minor
Date

MonthDayYear
Date
Witness Signature
Date

MonthDayYear
Date

Informed Consent for Telepsychology

This Informed Consent for Telepsychology contains important information focusing on doing psychotherapy using the phone or the Internet. Please read this carefully, and let me know if you have any questions. When you sign this document, it will represent an agreement between us.

Benefits and Risks of Telepsychology

Telepsychology refers to providing psychotherapy services remotely using telecommunications technologies, such as video conferencing or telephone. One of the benefits of telepsychology is that the patient and provider can engage in services without being in the same physical location. This can be helpful in ensuring continuity of care if the patient or provider moves to a different location, takes an extended (in-state2) vacation, or is otherwise unable to continue to meet in person. It is also more convenient and takes less time. Telepsychology, however, requires technical competence on both parts to be effective and helpful. While there are benefits to telepsychology, there are also some differences between in-person psychotherapy and telepsychology, as well as some risks. The risks of telepsychology are described below.

Risks to confidentiality

Because telepsychology sessions take place outside the psychologist’s private office, there is potential for other people to overhear sessions when the patient is not in a private location during the session. Wilson Psychology Group will take reasonable steps to ensure your privacy, but it is important the patient finds a private place for the session, where interruptions can be kept to a minimum. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in the session only when no other individuals are present, and no one can overhear the conversation.

Issues related to technology

There are many ways that technology issues may impact the delivery of telepsychology. For example, technology may stop working or be disconnected during a session, other people might be able to get access to our private conversation, or stored data may be accessed by unauthorized people or companies.

1 Joint Task Force for the Development of Telepsychology Guidelines for Psychologists (2013). Guidelines for the practice of telepsychology. American Psychologist, 68, 791-800. Retrieved from https://www.apa.org/ pubs/journals/features/amp-a0035001.pdf

2 It is important to note that Dr. Emma Wilson is currently licensed to treat patients in Alabama, therefore, telepsychology sessions cannot be conducted if the patient is physically out-of-state, even temporarily. Patients should inform Dr. Wilson if they plan to leave the state. Sessions may resume when the patient returns to Alabama, where Dr. Wilson holds a license to practice. If there are no plans to return, Dr. Emma Wilson will attempt to refer the patient to a provider licensed in the state in which services will be rendered.

Crisis management and intervention

Usually, Wilson Psychology Group will not engage in telepsychology with patients who are currently in-crisis or require high levels of support and intervention. Before engaging in telepsychology, the patient and provider will develop an emergency response plan to address potential crisis situations that may arise during the course of telepsychology sessions.

Appropriateness of Telepsychology

The provider may determine that telepsychology is no longer the appropriate form of treatment for a patient. We will discuss options of engaging in in-person counseling or referrals to another professional in your location who can provide appropriate services.

Efficacy of telepsychology

Most research shows that telepsychology is about as effective as in-person psychotherapy. However, some providers (and patients) feel something is lost by not being in the same room or “face-to-face.” For example, there is debate about a provider’s ability to fully understand non-verbal information when providing telepsychology.

Electronic Communications

The patient and provider will together determine which kind of telepsychology service to use. This may require certain computer or cell phone systems to use telepsychology services. The patient is solely responsible for the cost of any necessary equipment, accessories, or software to take part in telepsychology.

In an effort to protect patient privacy, Wilson Psychology Group will only use email communication and text messaging in rare instances. In order to provide timely responses and avoid missing patient calls, any and all communication should go through the primary phone line of Wilson Psychology Group, LLC (256-238-8113). This includes scheduling and rescheduling of appointments, billing and payment-related matters, and other administrative issues. You are always welcome to request a returned phone call from Wilson Psychology Group, but please consider that telephone consultations (of at least 5-7 minutes in duration), written documentation or letters to other agencies, preparation for testimony in court or in deposition, and attending meetings with other agencies, and, at the request of the patient, consultation with medical providers. These services are all charged and billed at a prorated amount based on the cost of an individual session.

Wilson Psychology Group cannot guarantee the confidentiality of any information communicated by email or text. Therefore, no clinical information is discussed by email or text unless truly exceptional and/or extenuating circumstances exist. Furthermore, Dr. Wilson cannot typically respond quickly to email or text, so these methods of communication should never be used in case of an emergency.

Treatment is most effective when clinical discussions occur at your regularly scheduled sessions. If an urgent issue arises, please contact the main phone number for Wilson Psychology Group, LLC (256-238-8113), and the provider or office staff will make every effort to return your call within 24 hours, except on weekends and holidays. If you are unable to reach Dr. Emma Wilson and do not feel you can wait for a call back, Wilson Psychology Group advises contacting the your family physician or going to the nearest emergency room and requesting to speak with the psychologist or psychiatrist on-call. If we will be unavailable for an extended period of time, Wilson Psychology Group will make every effort to notify you ahead of time, and if necessary, determine a plan of care that can be employed during the provider’s absence.
Confidentiality

Psychologists have a legal and ethical responsibility to put forth their best efforts to protect all communications that are a part of telepsychology. However, given the nature of electronic communications technologies, providers cannot realistically guarantee that our communications will always be kept confidential or that other people will never gain access to our communications. Wilson Psychology Group attempts to use updated encryption methods, password- protected systems, firewalls, and back-up records to maintain patient privacy, but the potential risk that electronic communications may be compromised, unsecured, or accessed by others remains pertinent to the discussion of telepsychology. It is recommended that the patient should also take reasonable steps to ensure the security of communications between provider and patient (e.g., using a secure network for telepsychology sessions, ensuring the patient is alone or out-of-earshot of other individuals, and maintaining passwords to protect the security of the device you use for telepsychology).

The extent of confidentiality and the exceptions to confidentiality that was outlined in the Confidentiality, Disclosure, and Informed Consent for Psychological Services still apply in telepsychology. Please let me know if you have any questions about exceptions to confidentiality.

Emergencies and Technology

This provider will work with patients to develop a plan for dealing with crisis situations and/or technology failures while providing telepsychology services. Safety plans typically include a discussion of how crisis/emergency situations will be addressed through local resources (such as a visit to the local ER or possible hospitalization), and plans may include resources intended to facilitate continued living in the community. Resources include crisis hotlines such as the National Suicide Prevention Hotline [(800) 273-8255], a service available nationwide, 24 hours per day; as well as spending quality time any natural, trusted supports identified by the patient; engaging in enjoyed activities; or practicing stress management techniques. Dr. Wilson will typically confirm the patient’s physical location at the onset of the telepsychology session (in case of emergency); explain how to address technology failures during sessions and in crisis situations; and/or obtain the patient’s consent to contact an emergency contact in case of emergency, including the clinician’s inability to contact, connect-with, or otherwise locate the patient. If the patient’s safety remains in question, a welfare check will be requested from local law enforcement.

Assessing and evaluating threats and other emergencies can be different when conducting telepsychology when compared with traditional in-person therapy. To address some of these challenges, we will create an emergency plan before engaging in telepsychology services. Wilson Psychology Group will ask you to identify an emergency contact person who is near your location and the individual I will contact in the event of a crisis or emergency to assist in addressing the situation. I will ask that you sign a separate authorization/release of information form that will allow me to call your emergency contact, as needed, during a crisis or emergency, assuming the provider is acting in good faith and with the patient’s safety at the forefront of his or her mind.

If the session is interrupted for any reason, such as a failure of technology, and you are having an emergency, do not call me back; instead, call 911 or go to your nearest emergency room. Please contact me after you have obtained emergency services, and you are safe.

If the session is interrupted and you are not having an emergency, disconnect from the session and I will wait 1-2 minutes and then attempt to reconnect with you via the telepsychology platform on which we had been conducting our telepsychology session. If you do not receive a call back within two (2) minutes, then simply call me back at the main office phone number (256-238-8113).

Confidentiality

Psychologists have a legal and ethical responsibility to put forth their best efforts to protect all communications that are a part of telepsychology. However, given the nature of electronic communications technologies, providers cannot realistically guarantee that our communications will always be kept confidential or that other people will never gain access to our communications. Wilson Psychology Group attempts to use updated encryption methods, password- protected systems, firewalls, and back-up records to maintain patient privacy, but the potential risk that electronic communications may be compromised, unsecured, or accessed by others remains pertinent to the discussion of telepsychology. It is recommended that the patient should also take reasonable steps to ensure the security of communications between provider and patient (e.g., using a secure network for telepsychology sessions, ensuring the patient is alone or out-of-earshot of other individuals, and maintaining passwords to protect the security of the device you use for telepsychology).

The extent of confidentiality and the exceptions to confidentiality that was outlined in the Confidentiality, Disclosure, and Informed Consent for Psychological Services still apply in telepsychology. Please let me know if you have any questions about exceptions to confidentiality.

Emergencies and Technology

This provider will work with patients to develop a plan for dealing with crisis situations and/or technology failures while providing telepsychology services. Safety plans typically include a discussion of how crisis/emergency situations will be addressed through local resources (such as a visit to the local ER or possible hospitalization), and plans may include resources intended to facilitate continued living in the community. Resources include crisis hotlines such as the National Suicide Prevention Hotline [(800) 273-8255], a service available nationwide, 24 hours per day; as well as spending quality time any natural, trusted supports identified by the patient; engaging in enjoyed activities; or practicing stress management techniques. Dr. Wilson will typically confirm the patient’s physical location at the onset of the telepsychology session (in case of emergency); explain how to address technology failures during sessions and in crisis situations; and/or obtain the patient’s consent to contact an emergency contact in case of emergency, including the clinician’s inability to contact, connect-with, or otherwise locate the patient. If the patient’s safety remains in question, a welfare check will be requested from local law enforcement.

Assessing and evaluating threats and other emergencies can be different when conducting telepsychology when compared with traditional in-person therapy. To address some of these challenges, we will create an emergency plan before engaging in telepsychology services. Dr. Emma Wilson will ask you to identify an emergency contact person who is near your location and the individual I will contact in the event of a crisis or emergency to assist in addressing the situation. I will ask that you sign a separate authorization/release of information form that will allow me to call your emergency contact, as needed, during a crisis or emergency, assuming the provider is acting in good faith and with the patient’s safety at the forefront of his or her mind.

If the session is interrupted for any reason, such as a failure of technology, and you are having an emergency, do not call me back; instead, call 911 or go to your nearest emergency room. Please contact me after you have obtained emergency services, and you are safe.

If the session is interrupted and you are not having an emergency, disconnect from the session and I will wait 1-2 minutes and then attempt to reconnect with you via the telepsychology platform on which we had been conducting our telepsychology session. If you do not receive a call back within two (2) minutes, then simply call me back at the main office phone number (256-238-8113).
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