Description of Practice:

We believe self-exploration is the key to a healthier, more fulfilling, and more balanced life. Our sole mission atThe Teal Door Counseling Center is to help you achieve your goals. We want to empower you to make positive and lasting change. At The Teal Door, you will get unbiased support, unconditional compassion, and sound guidance. Our licensed multidisciplinary therapists and nurse practitioner - is genuinely interested in understanding your experiences and building on your strengths to work through any challenge.

Therapist-Client Service Agreement:

Welcome to our practice. This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health and Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.

Counseling Services:

Therapy is a relationship where between people work together because of clearly defined rights and responsibilities held by each person. As a client in psychotherapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. We, as your therapist have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.

Your Rights As A Client:

• You have the right to ask questions about any methods used during therapy; if you wish, your therapist will explain her usual approach to you.
• You have the right not to receive therapeutic assistance from this therapist.
• You have the right to end therapy at any time without any moral, legal, or financial obligations other than those already accrued. You have the right to return to therapy.
• Your therapist has the right to dismiss you from the practice.
• You have the right to confidentiality; Within certain limits, information revealed by you during therapy will be kept strictly confidential and will not be revealed to any other person or agency without your written consent.
• You have the right to request restrictions on certain uses and disclosures of your protected health information and receive confidential communications by alternative means.
• You have the right to discuss your treatment, concerns, questions, complaints, or any other matter with your therapist and your therapist welcomes you to do so.
• If you have any concerns of any sort that this office may have somehow compromised your privacy rights, please do not hesitate to speak to your therapist immediately about this matter.

Phone Calls:

When calling during non-business hours, you will always receive a voicemail message. Your therapist will always try to return your call within 48 hours, except for calls made on Friday, Saturday, or Sunday when the call will be returned during business hours, resuming on Monday. In the event of a safety or life-threatening emergency, DO NOT call the office. Call 911 and/or report to your local Emergency Room.

Initial Assessment:

At the initial assessment, the therapist and the client will assess your needs. If the therapist or the client feels that another therapist may be a more efficient fit, the therapist will refer the client to another therapist either within or outside of The Teal Door Counseling Center. Assessment does not stop after the first session, and as information is gathered, the therapist may decide that a referral is in the best interest of the client.

Benefits and Risks:

There are no guarantees of what feelings you will experience or how or when healing will take place. There are no guarantees that any or all of your problems will be remedied by pursuing treatment with The Teal Door Counseling Center.

Efforts to make changes may involve the experience of significant discomfort. You may experience feelings of fear, anger, depression, frustration, and the like. Efforts to improve relationships between family members, marital or romantic partners, and other persons can lead to discomfort or to unanticipated relationship changes. Connections with significant others may be improved and/or disrupted as change occurs.

Clients may also experience strong feelings toward the therapist. It is your therapist's task to help contain these feelings in such a way that you feel safe in the therapeutic relationship. Feelings and behaviors are two different phenomena and it is expected that both therapist and client will not act on inappropriate feelings. Sexually acting out is not ever a possibility in your relationship with your therapist and is unethical.

Hospitalization and Return to Care Policy:

If a client of The Teal Door Counseling Center is hospitalized for a mental health related reason, they must complete an intensive outpatient program (IOP) before resuming services with us. As a private practice, we are considered the lowest level of care and are not equipped to provide the level of support required immediately following hospitalization.

Termination:

Once you have achieved your treatment goals, you and your therapist will collaborate in making the decision to terminate your treatment. Regular participation in therapy is required in order for therapy to be effective. Irregular attendance may be a sign of conflicted feelings about therapy, which can be discussed with your therapist. If a client does not make regular appointments or appointments are regularly missed, the therapy may not be productive.

 

 

Therapist Licensure:

The creation of the Teal Door Counseling Center was driven by our vision to establish a practice rooted in collaboration and continuous clinical support. We recognized a prevailing gap where assistance and oversight ceased upon a clinician achieving full licensure. Acknowledging the pivotal role of a supportive environment, we have implemented a model where all our clinicians, regardless of their seniority, and license, remain under the guidance of a collaborative team. 

As licensed therapists, our scope encompasses a comprehensive range of mental health provisions, encompassing assessment, diagnosis, treatment, and preventive measures.

Our distinguished team comprises Licensed Clinical Social Workers (LCSW), Licensed Master Social Workers (LMSW), Licensed Mental Health Counselors (LMHC), and Licensed Marriage and Family Therapists (LMFT), with occasional contributions from university interns, with proper and continual supervision. These professionals are equipped to administer mental health care, spanning assessment, diagnosis, treatment, and preventative interventions.

This form is intended to inform you that your therapist may hold credentials as an LMSW, LMHC, LMFT, or be an intern, all operating under the direct supervision of a Licensed Clinical Social Worker (LCSW). Your well-being remains our paramount focus as we endeavor to deliver proficient and attentive care within a nurturing and collaborative framework.

 

Telehealth Consent and Privacy Acknowledgment

I understand that telehealth involves the use of electronic communications to enable health care services between me and my provider at different locations. I acknowledge and agree to the following:

Consent to Telehealth: I voluntarily consent to receive mental health services via telehealth (video or phone sessions), which may include evaluation, consultation, treatment, and/or education.
Technology Limitations: I understand that there are potential risks associated with telehealth, including but not limited to interruptions, unauthorized access, and technical difficulties. I understand that all reasonable efforts will be made to ensure the confidentiality and security of my information.
Privacy Responsibility: I agree to participate in telehealth sessions from a private, secure, and HIPAA-compliant location to ensure confidentiality and protect my personal health information.

 

Consent for Treatment:
By signing the Informed Consent form, I am stating that I have read and understand these policies and that I agree with all parts of this Informed Consent for The Teal Door Counseling Center.

 

 

Issues in therapy are private and are considered legally protected as privileged information. However, there are exceptions to this confidentiality. These exceptions include, but are not limited to:

• If you threaten to harm yourself or someone else and your therapist believes your threats to be serious, your therapist is obligated to take whatever actions necessary to protect you or others including law enforcement personnel.
• If your therapist has reason to believe that a child, elderly, or handicapped individual is being abused, neglected, exploited, or endangered, your therapist is mandated by New York to report this to the appropriate agency.
• If you are involved or may be in the future involved in litigation of any kind and your mental health becomes an issue before the court, your treatment records may be mandated for disclosure to the court, but only by duly authorized court order.

Our policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled (Notice of Privacy Practices) You have been provided with a copy of that document and we have discussed those issues. Please remember that you may reopen the conversation at any time during our work together.

Professional Records:

We are required to keep appropriate records of the psychological services that we provide. Your records are maintained in a secure location in the office. we keep brief records noting that you were here, your reasons for seeking therapy, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records we receive from other providers, copies of records we send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. These are professional records; they may be misinterpreted and/or upsetting to the untrained readers. For this reason, we recommend that you initially review them with us, or have them forwarded to another mental health professional to discuss the contents. If we refuse your request for access to your records, you have the right to have our decision reviewed by another mental health professional, which we will discuss with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request.

Parents and Minors:

While privacy in therapy is crucial to successful progress, parental involvement can also be essential. It is our policy not to provide treatment to a child under the age of 18 unless she/he agrees that we can share whatever information we consider necessary with a parent. For children 18 years and older we request an agreement between client and the parent allowing us to share general information about treatment progress and attendance, as well as a treatment summary upon completion of therapy. All other communications will require the child's agreement, unless we feel there is a safety concern, in which case we will make every effort to notify the child of our intention to disclose information ahead of time and make every effort to handle any objections that are raised.

Seperated/Divorced Parents:

Typically, a therapist would need consent from one parent and inform the other parent of treatment, but at times this may not be possible. Consent from both parents is not legally required. For example, a parent has the right to refuse treatment for their child. There are a number of parents who refuse their child to be in therapy, vaccinated or use specific medical treatment due to religious beliefs.

Financial Responsibility Agreement:

I understand that I am responsible for all professional services rendered and agree to remit for services at the end of each session. The therapist rendering services reserves the right to raise fees without notice. I have read and understand, agree with and will comply with the above-mentioned fee and payment policies. 

Insurance:

It is sometimes difficult to determine exactly how much mental health coverage is available. Managed Health Care Plans such as HMO's and PPO's often require advanced authorization, without which they may refuse to provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person's usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. You should also be aware that most insurance companies require you to authorize us to provide them with a clinical diagnosis. (Diagnoses are technical terms that describe the nature of your problems and whether they are short-term or long-term problems. All diagnosis come from a book entitled the DSMV. There is a copy in our office and we will be glad to let you see it to learn more about your diagnosis, if applicable Sometimes we have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases This information will become part of the insurance companies claim to keep such information confidential, we have no control over what they do with it once it is in their hands, In some cases, they may share the information with a national medical information databank. We will provide you with a copy of any report we submit if you request it.

By signing this Agreement, you agree that I can provide requested information to your carrier if you plan to pay with insurance.

In addition, if you plan to use your insurance, authorization from the insurance company may be required before they will cover therapy services. If you did not obtain authorization and it is required, you may be responsible for full payment of the fee. Many policies leave a percentage of the fee (which is called co- insurance) or a flat dollar amount (referred to as a co-payment) to be covered by the patient. Either amount is to be paid at the time of the visit by check, credit card, or cash. In addition, some insurance companies also have a deductible, which is an out-of-pocket amount that must be paid by the patient before the insurance companies are willing to begin paying any number of services. This will typically mean that you will be responsible to pay for the initial sessions with us until your deductible has been met; the deductible amount may also need to be met at the start of each calendar year. Once we have all of the information about your insurance coverage, we will discuss what we can reasonably expect to accomplish with the benefits that are available and what will happen if coverage ends before you feel ready to end your sessions. It is important to remember that you always have the right to pay for our services yourself to avoid the problems described above, unless prohibited by our provider contract.

Contacting Us:

We are often not immediately available by telephone. We do not answer our phone when we are with clients or otherwise unavailable. At these times, you may leave a message on my confidential voice mail and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters. If, for any number of unseen reasons, you do not hear from us or we are unable to reach you, and you feel you cannot wait for a return call or if you feel unable to keep yourself safe, go to your local hospital Emergency Room or call 911 and ask to speak to the mental health worker on call. We will make every attempt to inform you in advance of planned absences, and provide you with the name and phone number of the mental health professional covering our practice.

Other Rights:

If you are unhappy with what is happening in therapy, we hope you will talk to us so that we can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that we refer you to another therapist or practice and are free to end therapy at any time. You have the right to considerate, safe, and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment.

A copy of this consent will be given upon request

18 Miller Road|Mahopac, NY 10541

As required by the Privacy and Regulations Promulgated Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

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

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payments or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information, that may identify you and that relates to your past, present or future physical or mental health or condition and related services.

Uses and Disclosures of Protected Health Information: Your protected health information may be used and disclosed by our organization, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the organization, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, you protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for equipment or supplies coverage may require that your relevant protected health information be disclosed to the health plan to obtain approval for coverage.

Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of our organization. These activities include, but are not limited to, quality assessment activities, employee revie activities, accreditation activities, and conducting or arranging for other business activities. For example, we may disclose you protected health information to accrediting agencies as part of an accreditation survey. We may also call you by name while you are at our facility.

We may use or disclose your protected health information in the following situations without your authorization: As Require by Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Dru Administration requirements, Legal Proceedings, Law Enforcement, Criminal Activity, Inmates, Military Activity, National Security and Worker's Compensation. Required uses and Disclosures: Under the law, we must make disclosures to you and when require by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other Permitted and Required Uses and Disclosures Will Be Made Only with Your Consent, Authorization, or Opportunity to Object, unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that your physician or this organization has taken an action in reliance on the use or disclosure indicated in the authorization

Your Rights: Following is a statement of your rights with respect to your protected health information.

You have the right to request a restriction of your protected health information: This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Our organization is not required to agree to a restriction that you may request. If our organization believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, e.g., electronically.

You may have the right to have our organization amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any of your protected health information. 

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information, if you have any questions concerning or objections to this form, please ask to speak with our President in person or by phone at 232-714-2426.

Associated companies with whom we may do business, such as an answering service or delivery service, are given only enough information to provide the necessary service to you. No medical information is provided.

18 Miller Road|Mahopac, NY 10541

At our practice, we are dedicated to maintaining an efficient appointment scheduling system for the optimal benefit of all our patients. Your cooperation in adhering to the following appointment policy is greatly appreciated.

We diligently remind all patients of their upcoming appointments and value your commitment to the same.

If you find yourself unable to keep your scheduled appointment, we kindly request that you contact your therapist a minimum of 24 hours in advance. This allows us to reschedule your appointment and accommodate other patients in need of timely care.

Failure to cancel or reschedule your appointment with at least 24 hours’ notice may result in a no-show fee of $75.00, which will be charged to the credit card on file. Please be aware that this fee is not covered by insurance and will be processed within 24 hours of the missed appointment.

By providing your signature below, you acknowledge receipt of this notice and demonstrate your understanding of our practice policy. Your cooperation is crucial in ensuring the seamless functioning of our scheduling system and the timely provision of care to all our valued patients.

18 Miller Road|Mahopac, NY 10541

1. I understand that I am responsible to notify The Teal Door Counseling Center of any changesto my insurance. I am responsible for the payment of each session if I am not covered by my insurance.

If you have a deductible, a payment for your session will be taken until your deductible is met.

 

4. I understand that my therapy session is an allotted time slot. I understand that if I am late to my appointment, I will not be able to extend my session. I understand that I will be charged a NO- SHOW fee of $75.00 if I fail to show for my appointment or fail to give 24 hour notice for a cancellation. 

 

5. I have recieved the crisis prevention hotline numbers.

By signing this, I am agreeing to the above stated terms and stipulations regarding the services I receive from the therapist.

18 Miller Road|Mahopac, NY 10541

We appreciate the opportunity to provide mental health services to you or your loved one. In an effort to maintaintransparency, and ensure clarity in our financial arrangements, we want to inform you of certain fees associated with ourservices that are not covered by insurance.

General Letter Fee: Diagnostic, School related, Companion Pet Letter	$50 (Letters will be issued at clinicians’ discretion)
No Show or Late Cancel Fee	$75
Medication Management No Show or Late Cancel Fee	$100
Collateral Service Fee: Participation in meetings, conferences, IEP meetings	$50 per 15 minutes
Legal Fees: Responding to subpoena, testimony, all other legal related work for client or third party	$300 per hour
Legal Letter Fee	$100
Record Request Fee	.75 cents per page

Completion of FMLA, disability paperwork, or letters of support will only be considered after the client has engaged in atleast 12 therapy sessions with their therapist. We reserve the right to decline completing any paperwork if, after ourassessment, we do not believe we can adequately support it based on the information presented during therapy sessions.

For those seeking letters of support, we request that you reach out to your therapist directly to discuss your specificrequirements. Additionally, if you are requesting records, we ask for your understanding and cooperation in allowing 14days for processing. This time frame ensures that we can maintain the quality and confidentiality of the information being provided.

In special situations, clients have the option to schedule phone sessions or consultations to address specific needs. Forinstance, a parent may seek to engage in a session involving their child’s services. These sessions will be billed aspsychotherapy/family sessions and submitted to insurance. For sliding scale clients, the regular session rate will apply.

Legal services will not be performed unless required by a subpoena. This includes court appearances, depositions, phonecalls with attorneys, and any other records required. These services are not billable to your insurance company and mustbe paid before services are rendered. For attendance at, or participation in court proceedings, including preparation andtravel time, the fee is $300 per hour. A minimum retainer of $1,000 is required to be paid no later than 1 week prior to thescheduled court date. This retainer is non-refundable.For therapy services directly court-ordered or entered into as part of an ongoing lawsuit, the fee is $300 per hour. Thisincludes the time required to complete documentation for court purposes.We believe in transparency with our legal fees. We will discuss the specifics of the fee agreement with you prior toscheduling your appointment.

Upon request, or when scheduling your appointment, we provide good faith estimates of anticipated fees in accordancewith the No Surprise Act (Section 2799B-6 of the Public Health Service Act)

At the Teal Door Counseling Center, we have a policy of keeping your credit or debit card onfile for convenient payment. As healthcare dynamics evolve, more responsibility is placed onthe patient, and having a guarantee of payment on file is crucial. Compliance with this practicepolicy is a requirement for receiving services.

While we still accept cash or check payments, a card on file is mandatory. Payment is expectedat the time of service. During your initial appointment with your therapist, please provide yourcredit card. This information will be securely stored in a gateway.

We conduct a weekly review of your account and process any outstanding balances to yourcredit card, unless alternative arrangements have been previously agreed upon.

By signing below, you authorize The Teal Door Counseling Center to charge no-show fees,copays, and/or therapy sessions to the credit or debit card you provide.

*Please include a family member you would like included in your billing communication*

(Clients over the age of 18 should include their guardian)

Client Information

Authorization Details

I authorize The Teal Door Counseling Center to disclose the following financial information to the person(s) named below. This authorization does not permit the release of any clinical or treatment-related information.

Scope of Information to be Disclosed

I understand that the following financial information may be shared with the person(s) listed above:

• Billing statements and account balances
• Insurance claims and reimbursement details
• Payment history and payment arrangements
• Dates of service
• Other information related to the financial aspects of services provided

Right to Revoke

I understand that I have the right to revoke this authorization at any time by providing written notice to The Teal Door Counseling Center. I understand that any information disclosed prior to the revocation of this authorization will not be affected.

 

Acknowledgment and Signature

I understand that I am not required to sign this authorization form. I also understand that refusing to sign this form will not affect my ability to obtain treatment or services from The Teal Door Counseling Center. I understand that information disclosed under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by privacy regulations

Please utilize this list in case of an emergency 

Crisis Prevention

• Crisis Prevention Response Unit: 914-925-5959
• Crisis text line: text “start” 741-741
• NYC well: text “well” 65173
• Safe alternatives for self-harm information: 1-800-366-8288   
• New York HOPEline: 1-877-846-7369

Domestic Violence

• My Sister’s Place: 1-800-298-7233
• Hopes Door: 1-888-438-8700                                                
• National Domestic Violence Hotline: 1-800-799-7233          
• National Teen Dating Abuse Hotline: 1-866-331-9474            
• Love Is Respect: 1-866-331-9474

Suicide Prevention Hotlines

• 1-800-273-8255
• 1-800-272-TALK (8255)                                                          
• 1-800-784-2433
• Boys Town: 1-800-448-3000

Child Abuse and Bullying

• Child Abuse Hotline: 1-800-422-4453                                    
• Bullying Prevention Center: 1-800-537-2237

Hospital Psychiatric Emergency Numbers

• Four Winds Hospital: 1-800-528-6624
• NY Presbyterian Hospital: 1-888-694-5700                        
• Northern Westchester Hospital: 914-666-1036              
• Westchester Medical Center: 914-493-7075
• Phelps Memorial Hospital Center: 914-366-2222                      
• St. Joseph’s Medical Center: 914-378-7471                              
• White Plains Hospital: 914-681-0600                                            
• St. Vincent’s Hospital: 914-967-6500
   

Mahopac Police Department: 845-628-1300

Yorktown Police Department: 914-962-4141

 

Substance Abuse Help

• Alliance For Safe Kids: 914-736-1450              
• www.stopoverdose.org
• Drug Crisis In Our Backyard: 845-842-1212                          
• Partners In Prevention: 914-277-5582
• National Center For Addiction: 212-841-5200                                      
• 24/7 NYS Drug Abuse Hotline: 1-877-846-7369  
• Report underage drinking: 1-800-UNDER21                   
• National Institute On Drugs Abuse For Teens:
  • 1- 800-622-HELP (4357)

Support Groups

• Al-Anon/Alateen Meetings:
• www.westchesterputnamalanon.org Nar-Anon Meetings:
• www.nar-anon.com
• AA: www.nyintergroup.com
• Families Anonymous: 847-294-5877

Teen Support

• Teen Helpline: 1-800-TLC-TEEN
• Text 4 Teens Helpline: 845-391-1000

Eating Disorders

• National Eating Disorders Association: 1-800-931-2237

Safe Place

• National Safe Place: Text SAFE to your location 69866
• Runaway Safe House For Teens: 845-279-2588

Rape and Sexual Assault

• National Sexual Assault Hotline/ RAIN: 1-800-656-4673 or 212-227-3000

LGBT

• LGBT Hotline: 1-888-843-4564
• Parents Families Friends and Allies of LGBT: 914-468-4636
   

18 Miller Road|Mahopac, NY 10541