Office Policies and General Information Agreement
When Disclosure Is Required By Law: Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent or elder abuse or neglect; where a client presents a danger to self, to others, to property or is gravely disabled or when client’s family members communicate to Dr. David that the client presents a danger to others.
When Disclosure May Be Required: Disclosure may be required pursuant to a legal proceeding by or against you. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by Dr. David. In couple and family therapy, or when different family members are seen individually, even over a period of time, confidentiality and privilege do not apply between the couple or among family members, unless otherwise agreed upon. Dr. David will use his clinical judgment when revealing such information. Dr. David will not release records to any outside party unless he is authorized to do so by all adult family members who were part of the treatment. Emergencies: If there is an emergency during our work together, or in the future after termination where Dr. David becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, he will do whatever he can, within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose he may also contact the person whose name you have provided on the biographical sheet.
Health Insurance & Confidentiality of Records: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. If you instruct Dr. David, only the minimum necessary information will be communicated to the carrier. Dr. David has no control or knowledge over what insurance companies do with the information submitted or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy or to future capacity to obtain health or life insurance or even a job. The risk stems from the fact that mental health information is likely to be entered into insurance companies’ computers and is likely to be reported to the National Medical Data Bank. Accessibility to companies’ computers or to the National Medical Data Bank database is always in question as computers are inherently vulnerable to break-ins and unauthorized access. Medical data has also been reported to be legally accessed by enforcement and other agencies, which also puts you in a vulnerable position.
Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) nor your attorney, nor anyone else acting on your behalf will call on Dr. David to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested unless otherwise agreed upon.
Consultation: Dr. David consults regularly with other professionals regarding his clients; however, clients’ identity remains completely anonymous, and confidentiality is fully maintained.
E-Mails, Cell Phones, Computers and Faxes: It is very important to be aware that computers and e-‐‑mail and cell phone communication can be relatively easily accessed by unauthorized people and, hence, can compromise the privacy and confidentiality of such communication. E-mails in particular are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e-mails that go through them. Additionally, Dr. David’s e-mails are not encrypted. Faxes can easily be sent erroneously to the wrong address. Dr. David’.s computers are equipped with a firewall, a virus protection and a password and he also backs up all confidential information from his computers onto a backup drive. The backup drive is stored securely off-site. Please notify Dr. David if you decide to avoid or limit, in any way, the use of any or all communication devises, such as e-mail, cell phone or fax. Please do not use e-mail or faxes for emergencies.
Records and Your Right to Review Them: Both the law and the standards of my profession require that I keep appropriate treatment records. As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when Dr. David assesses that releasing such information might be harmful in any way. In such a case Dr. David will provide the records to an appropriate and legitimate mental health professional of your choice.
* Considering all of the above exclusions, if it is still appropriate, upon your request, Dr. David will release information to any agency/person you specify unless Dr. David assesses that releasing such information might be harmful in any way.
Telephone & Emergency Procedures: If you need to contact Dr. David between sessions, please leave a message on the answering service (323) 401-0493 and your call will be returned as soon as possible. Dr. David checks his messages a few times during the daytime only, unless he is out of town. If an emergency situation arises, indicate it clearly in your message, and if you need to talk to someone right away, you can call the Suicide Hotline (24-hour crisis line) at (310) 391-1253, the Police (911), or the Emergency Room at UCLA Hospital and Medical Center (Info Number 310-825-4321). Please do not use e-mail or faxes for emergencies.
Payments & Insurance Reimbursement: Clients are expected to pay the standard fee of $250 per therapy hour session [a therapy hour is generally fifty (50) minutes in duration] at the end of each session, unless other arrangements have been made or unless the patient is a Medicare patient (Medicare allowable rate will be billed through Medicare). Telephone conversations that last longer than 15 minutes, site visits, report writing and reading, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed upon otherwise. Please notify Dr. David if any problems arise during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that professional services are rendered and charged to the client and not to the insurance company. Unless agreed upon differently, Dr. David will provide you with a copy of your receipt on a monthly basis, which you can then submit to your insurance company for reimbursement, if you so choose. As was indicated in the section Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems dealt with in psychotherapy are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage.
Mediation & Arbitration: All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of Dr. David and client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed upon. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement shall be submitted to and settled by binding arbitration in Los Angeles, CA in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, Dr. David can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceeding shall be entitled to recover a reasonable sum as and for attorneys fees. In the case of arbitration the arbitrator will determine that sum.
The Process of Therapy/Evaluation and Scope of Practice: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty and openness in order to change your thoughts, feelings and/or behavior. Dr. David will ask for your feedback and views on your therapy, its progress and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc, or experiencing anxiety, depression, insomnia, etc. Dr. David may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about or handling situations. This can cause you to feel very upset, angry, depressed, challenged or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing or relationships. Sometimes, another family member views a decision that is positive for one family member quite negatively. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy Dr. David is likely to draw on various psychological approaches according, in part, to the problem that is being treated and his assessment of what will best benefit you. These approaches include, but are not limited to, behavioral, cognitive-‐‑behavioral, cognitive, psychodynamic, existential, system/family, developmental (adult, child, family), humanistic or psycho-‐‑educational. Dr. David provides neither custody evaluation recommendation nor medication or prescription recommendation nor legal advice, as these activities do not fall within his scope of practice.
Discussion of Treatment Plan: Within a reasonable period of time after the initiation of treatment Dr. David will discuss with you (client) his working understanding of the problem, treatment plan, therapeutic objectives and his view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, Dr. David’s expertise in employing them or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits. If you could benefit from any treatment that Dr. David does not provide, he has an ethical obligation to assist you in obtaining those treatments.
Termination: As set forth above, after the first couple of meetings Dr. David will assess if he can be of benefit to you. Dr. David does not accept clients who, in his opinion, he cannot help. In such a case he will give you a number of referrals, who you can contact. If at any point during psychotherapy, Dr. David assesses that he is not effective in helping you reach the therapeutic goals, he is obligated to discuss it with you and, if appropriate, to terminate treatment. In such a case he would give you a number of referrals that may be of help to you. If you request it and authorize it in writing, Dr. David will talk to the psychotherapist of your choice in order to help with the transition. If at any time you want another professional’s opinion or wish to consult with another therapist, Dr. David will assist you in finding someone qualified, and if he has your written consent, he will provide her or him with the essential information needed. You have the right to terminate therapy at any time. If you choose to do so, Dr. David will offer to provide you with names of other qualified professionals whose services you might prefer.
Dual Relationships: Not all dual relationships are unethical or avoidable. Therapy never involves sexual or any other dual relationship that impairs Dr. David’s objectivity, clinical judgment or therapeutic effectiveness or that can be exploitive in nature. Dr. David will carefully assess before entering into non-sexual and non-exploitative dual relationships with clients. It is possible that you may bump into someone you know in the waiting room or into Dr. David out in the community. Dr. David will never acknowledge working with anyone without his or her written permission.
Cancellation: Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours (1 full day) notice is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification. Most insurance companies do not reimburse for missed sessions.