DISCLOSURE & PERMISSION TO TREAT CONTRACT

DISCLOSURE & PERMISSION TO TREAT CONTRACT (including HIPAA & Client's Rights/Responsibilities):

Welcome. Your initial appointment will help me get a better understanding of your situation in order to determine how I might best help you. And it will give you a chance to determine whether my style suits you. You are the customer and you have the right to choose the best therapist for you. Don’t hesitate to ask questions.

Psychotherapy is a way of talking through your problems in order to begin resolving them. You will need to take an active part in psychotherapy by working on, and thinking about, the things you talk about. Counseling has been shown to have many benefits. However, there are no guaranteed results, and at times a session may leave you with uncomfortable feelings. When counseling is effective, it often leads to better relationships, solutions to specific problems, and feeling much less distressed.

PROFESSIONAL DISCLOSURE:

I am a Licensed Clinical Mental Health Counselor (License #068-0000211) and a Board Certified Professional Counselor. I am a member of the American Counseling Association and the Vermont Mental Health Counselors Association.

EDUCATION:

I received a Bachelors Degree from Boston University (1982). I received a Masters of Science in Counseling from the University of Vermont (1992) and have worked with individuals, families, couples and groups since. While at the University of Vermont, I completed an internship at the Multiple Sclerosis Society supervised by Dr. Eric Nichols, Ph.D.

QUALIFICATIONS & EXPERIENCE:

For over 30 years I have been counseling adolescents and adults. For 8 years following my graduation from UVM I worked at the non-profit community agency Spectrum Youth & Family Services. I opened my private practice Familyworks, Ltd. in 2000. In addition to my private practice, over the years I have taught courses in the Graduate Counseling Program at the University of Vermont and have provided workshops and trainings to the general public and other professionals throughout the country. I also supervise post graduates who are working towards their counseling licensure.

SCOPE OF PRACTICE:

I have worked with adolescents and adults, individuals, couples, families and groups for over three decades. I have extensive training in Family Systems Theory, Cognitive Behavioral Therapy, Relational Life Therapy (Terry Real) and Solution Focused Therapy. My areas of clinical concentration include: intimacy and relationship counseling, family therapy, parenting issues, divorce and anxiety.

MY ROLE IN WORKING WITH YOU:

As your counselor, I agree to provide you with a safe, thoughtful, emotionally supportive and respectful relationship where you can explore your beliefs about yourself and your world. My goal is to be authentic in my role as your counselor, to remain interested and curious in your work, to witness your feelings and experiences, to pay close attention, to communicate understanding and to believe in your ability to think and experiment with acting in new ways. My theoretical orientation is based in Person-Centered, Cognitive Behavioral, Relational Life, and Family Systems theories. I work collaboratively with my clients to focus treatment goals, evaluate progress and to decide how often to meet, and when to end treatment.

THE BENEFITS & RISKS OF COUNSELING:

Counseling has been demonstrated to be of benefit for most people and in most situations. Some benefits include relief from feelings that can be debilitating, like depression or anxiety. Just the opportunity to talk things out completely and to be understood, can be beneficial. As a result of counseling, you may be better able to cope with social or family relationships or learn new ways to manage your feelings. Risks may include experiencing uncomfortable feelings or the possibility that some changes may lead to worsening of your problems. You decide how long to be in counseling and when and how you have met your goals. However, if I believe our working together will not benefit you, I will help you with referrals to other counselors or services.

AFTER HOURS EMERGENCIES:

During work hours (Monday through Friday 9-5) or after work hours, if you have a clinical emergency (i.e. risk of suicide or bodily harm to you or another person, trauma, or tragedy, etc.) call my cell phone at 802-233-0162. If you have a life-threatening situation, call 911. 

If I am not immediately available to respond to an emergency, call Crisis Services at (802) 488-7777 or community mental health services in your area. In Chittenden County:

Dept. of Children and Families (802) 863 7370

First Call for Children and Families (802) 488-7777

Adult Crisis (802) 488-6400

Alcohol Crisis Team (802) 488-6425

Domestic Abuse Hotline (802) 658-1996

Franklin County Crisis (802) 524-6554

Addison County Crisis (802) 388-7641

HIPPA: The law, called HIPAA (Health Insurance Portability and Accountability Act) regulates the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. HIPAA requires that I give you a Notice of Privacy Practices. The Notice, attached to the clipboard in my office and also on my website, explains HIPAA’s application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information (see below.) If you would like, I can provide you with a copy of this Notice. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please read and review it carefully.

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. For psychotherapists this requires little change from the practice of confidentiality that has been required of our profession prior to HIPAA. In general, the HIPAA Act gives you, the client or patient, significant new rights to understand and control how your health care information is used. HIPAA provides penalties for covered entities that misuse personal health information.

As required by HIPAA, I have prepared this explanation of how I am required to maintain the privacy of your health information and how I may use and disclose your health information. Please note that, for the practice of psychology, these HIPAA requirements compliment rather than add any significant change to our normal and usual practice as regards record keeping and confidentiality. I may use and disclose your medical records only for each of the following purposes: treatment, payment and healthcare operations.

Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would be performing psychotherapy in this office, or making a referral to another health care provider for additional evaluation or treatment.

Payment means such activities as obtaining reimbursement services, confirming insurance coverage, billing or collection activities, and utilization review for managed care coverage and approval and/or at the request of a third party payer for your treatment (your insurance company). An example of this would be sending a bill for your psychotherapy visit to your insurance company, or telephonically, by mail, or by fax, sending the necessary clinical information for your insurance company to approve more sessions for coverage for you.

I may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that might be requested by or is of interest to you. The scheduling software I use (Booksy.com) may send you invitations to review my practice. Just ignore the requests if you do not want to leave a review.

Any other uses and disclosures will be made only with your written authorization.

You may revoke such authorization in writing and I am required to honor and abide by that written request, except to the extent that I have already taken actions relying on your prior written authorization to take such actions.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer or to me:

The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. (I am, however, not required to agree to a requested restriction if Vermont law or Federal law indicates that to do so would be a violation of Duty to Warn Statutes of person or property, violation of mandated reporting of known abuse of a minor or child, or violation of mandated reporting of known abuse of an elderly or incapacitated person. As a psychotherapy client you own the privilege of confidentiality, and no information, including your presence in therapy or the fact that you are a patient, will be disclosed without your specific written permission in a release of information request. Psychotherapy has traditionally always been more restricted in its mandated legal and ethical protection of your protected health information. HIPAA regulations do not affect any previous safeguards to your privacy as a patient, except in certain cases to strengthen them. The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternate locations. The right to inspect and copy your protected health information. The right to amend your protected health information. The right to receive an accounting of disclosures of protected health information. The right to obtain a paper copy of this notice upon request.

I am required by law to maintain the privacy of your protected heath information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

This notice is effective as of July 2006 and I am required to abide by the terms of the Notice of Privacy Practices currently in effect. I reserve the right to change the terms of my Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that I maintain. I will post and you may request a written copy of a revised Notice of Privacy Practices from this office. You have recourse if you feel that your privacy protections have been violated. You have the right to file written complaint with my office, the Department of Health and Human Services, or the Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of my office. I will not retaliate against you in any fashion for filing a complaint.  Please speak with me or contact my office for more information. For more information about HIPAA or to file a complaint, please write to or contact:

The U.S. Department of Health and Human Services, Office of Civil Rights, 200 Independence Avenue, S.W. Washington, D.C. 20201(202) 619-0257 or Toll Free: 1-877-696-6775

FEES, HEALTH INSURANCE, AND MANAGED CARE 

The fee for the initial 45-60 minute consultation is $175. Each additional individual, couple, or family session is $150.  In some special circumstances, we may negotiate a lower fee, determined by your ability to pay.  

After 1/1/25 my fees will be as follows:

Initial Consultation: $200

Individual 45-60 minutes: $175

Couples 45-60 minutes: $175

Couples 90-120 minutes: $325

Any telephone consultation or email which requires more than 10 minutes of my time, may be pro-rated at my standard hourly rate for professional services. Although health insurance may aid in payment, you alone are responsible for paying for your appointments. If you cancel without giving 24 hours notice, you must pay for the time you have reserved. Insurance companies do not pay for missed appointments. The fee for a missed appointment is $150.)

Feel free to ask me any questions that you have concerning payment arrangements. Under a managed care plan, the insurance company periodically requires me to submit your diagnosis, progress, and treatment plan to their reviewer, who then determines if further treatment is medically necessary. I want you to know that if you have a managed care insurance plan, this information will be released to the reviewers. If you don’t want me to release this information, you can choose not to use your insurance coverage and pay for my services yourself at the time of each visit. 

All accounts are payable in full within 30 days after billing. I reserve the right to collect any unpaid balance due to me. If you are not making regular monthly payments on the account balance, I may use a collection agency or take legal action to secure payment, as authorized by state or federal law, and the collections action will become a part of your credit record. You will be notified in writing before I take action to collect. I reserve the right to terminate treatment and refer you elsewhere for continued care if the unpaid balance exceeds $300.00. 

IMPORTANT: By entering into a counseling agreement with Barbara Boutsikaris, you understand that Barbara Boutsikaris and/or her records/files will not be available for any court proceedings or hearings and you agree not subpoena Barbara Boutsikaris or her records/files.

Your Responsibilities:

1. You have the responsibility to provide me with complete and accurate information that will ensure the creation of a useful and individualized plan of care.

2. You have the responsibility to take an active part in your treatment process and to come to sessions without being under the influence of alcohol or any non-prescribed drugs.

3. You have the responsibility to pay any co-payment owed at the close of each session.  Payment for service is an important issue, in part because in counseling clarity of relationships and responsibilities is often a goal of treatment.

4. If you have health insurance, you are responsible for verifying your insurance coverage, deductibles, reimbursement rates, co-payments, and getting your initial authorization, if needed.

5. You have the responsibility to keep all scheduled appointments and to be no more than 15 minutes late. If you are more than 15 minutes late it doesn’t allow for enough time to get into the work and, therefore, I reserve the right to cancel your appointment. If you are not able to attend your appointment, you have the responsibility to call/text ahead no less than 24 hours ahead of your scheduled appointment to cancel your appointment and/or reschedule. 

An appointment is a commitment to our work and a contract between us to be present and on time. I will make our sessions a priority and ask you to do the same to keep missed sessions to a minimum. Rarely, and usually because of an emergency, I may not be able to start on time. For this I ask your understanding and assure you that you will receive the full time at the time of your session or at another time. Your session time is reserved for you and a canceled appointment is an interruption in your work. Therefore, unless there is an emergency or sickness, if you miss an appointment, are more than 15 minutes late, or cancel with less than 24 hours notice, you will be responsible for the cancelation fee of $100, which can not be billed to your insurance.

6. I understand my rights and responsibilities above and that if I am more than 15 minutes late, cancel less than 24 hours in advance, or no show I will be charged $100 which must be paid before my next appointment. 

Your Rights:

1. You have the right to services regardless of race, religion, sex, ethnic background, age sexual orientation, disability, ability to pay, HIV status, or any other non-clinical reason.

2. You have the right to be treated with courtesy, dignity, respect, and in a language you understand.

3. You have the right to receive confidential services. Your records are protected under the Federal Confidentiality Regulations and cannot be disclosed without your written consent unless otherwise provided for in the regulations. If you do give your written consent, you should know that you can revoke this consent at any time except to the extent that action has already been taken on it. By law, there are two situations in which I must tell others some of what you tell me: (1) When I believe you immediately intend to harm yourself or another person, or (2) when I believe a child, elder, or disabled adult has been, or will be, abused or neglected.

4. If you are under 18, your parent or guardians have a right to know, in general terms, about what happens in our sessions. Insurance companies receive only the dates of our appointments, my charges, and a diagnosis. On some occasions, insurance companies ask for more detailed information about your symptoms, diagnosis and my treatment methods. My policy is to provide the minimum information necessary to obtain payment and will inform you if this should occur.

5. You have the right to review your records, to make additions or corrections, and to obtain copies for other professionals or yourself. However, reading records, or having someone else read them, is a significant issue and I will want to explore this thoroughly before making the records available.

6. You have the right to receive information necessary to give informed consent prior to being involved in activities which include the use of audio or video tape recorders.

7. You have the right to clear professional and ethical boundaries within our therapeutic relationship. I cannot see you socially outside our sessions, or enter into a business or other relationship with you besides this therapeutic one. If we should run into each other outside of my office, I will follow your lead in order to protect your privacy and avoid confusion about the boundaries of our relationship.

8. You have the right to question any aspect of your treatment and to voice your opinions, recommendations or grievances without the fear of restraint, interference, coercion, discrimination or reprisal. If you are dissatisfied for any reason, please raise your concerns immediately. If you feel that you have been treated unfairly or unethically and cannot resolve this problem with me, you can contact the Vermont Office of the Secretary of State. Their number is 802-828-2363. For more information about this process, see a copy of the Client Grievance Procedures (on clipboard in the waiting room of my office).

9. You have the right to emergency services by calling either 911, Adult Crisis at 802-488-6425 or First Call for Children and Families at 802-864-7777. You can reach me in an emergency by calling my cell phone: 802-233-0162.

INFORMED CONSENT

CONFIDENTIALITY:

Your psychotherapy services and records are confidential, however, limits to this confidentiality do exist and include: minors or other persons with a legal guardian (information may be released to the legal guardian), imminent danger to self (e.g. suicide risk), danger to others, suspicion of abuse or neglect toward a child or vulnerable adult, or/and under court order. If you have signed a release with an insurer, the insurer may request such information as diagnosis, treatment plan, and general course of treatment. However, it is important to note that some insurers may request release of more detailed or sensitive information. Please discuss with me any concerns you may have about such disclosure. I may occasionally find it helpful to consult with other professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The consultant is also legally bound to keep the information confidential.

CONSENT TO TREATMENT: 

I understand that my participation in therapy is completely voluntary, and that I may terminate treatment at any time. The goals of my treatment have been agreed upon with my provider. I understand that I may negotiate changes in these goals at any time. There are possible advantages and disadvantages of participating in psychotherapy and a positive outcome is not guaranteed. During the process of therapy you could face and work through difficult emotions, fears, or experiences. Therapy might also have unanticipated relationship consequences. For instance, some persons undergoing individual therapy may find their growth through the therapeutic process, sometimes to the point of yielding a relationship break-up. Therapy may occur in an outdoor setting as appropriate. A dog may be on the premises. In the unlikely event that the animal may cause damage or personal harm, Barbara Boutsikaris and Familyworks, Ltd. will not be held liable.

General Notice

I have a legal and ethical responsibility to make my best efforts to protect all communications that are part of our psychotherapy sessions. I have chosen to use YungSidekick note-taking system for psychotherapy as part of my effort to provide the best care to my clients. It provides me with an automatically generated transcript and summarization of our sessions. YungSidekick’s system is HIPAA compliant and uses up-to-date encryption methods, firewalls, and backup systems to help keep your information private and secure. You are consenting for me to record our sessions using YungSidekick’s system.

Details:

Recordings of our sessions will be transcribed and summarised by YungSidekick HIPAA-compliant technology. YungSidekick doesn’t store the recordings and client personal information. I may choose to keep the summarised notes as part of your confidential medical record. YungSidekick only keeps anonymized data to help improve the tool. As with any technology, there are certain risks and benefits, which I will list here:

Risks:

All technology contains a risk of confidential information being disclosed.  You can ensure the security of our communications by only using trusted secure networks for psychotherapy sessions and having passwords to protect the device you use for psychotherapy. YungSidekick mitigates this risk by ensuring up-to-date technological security and storing the data with as little identifying information as possible. YungSidekick Researchers will have access to your de-personalized transcripts (transcript content with removed names, emails, and other identifying information).   The system may contain unknown bias in the way it generates the session summary and presents clinical information. This risk is mitigated by your therapist’s commitment to review and modify the note as needed using their clinical expertise.

Benefits: 

The technology allows the therapist to focus more of their attention on therapy. Removes the need for taking notes or trying to remember information during and after the session.  YungSidekick reduces the therapist's workload and may help with compassion fatigue. The technology may provide additional clinical insights for the therapist which helps improve outcomes in the therapeutic process. 

By signing this consent, you are agreeing to allow Barbara Boutsikaris to use the YungSidekick software.  

CLIENT DISCLOSURE & CONSENT CONFIRMATION:

My signature acknowledges that I have been offered a copy of the Professional Qualifications and Experience of Barbara Boutsikaris, MS LCMHC a statement of after-hours availability, as well as a listing of actions that constitute unprofessional conduct according to Vermont statutes (above). I have also been informed of the methods for making a consumer inquiry or filing a complaint with the Office of Professional Regulation. In addition, I have reviewed copies of an informed consent statement, HIPAA, and permission to release information to the client’s primary care physician. This information was given to me no later than my third office visit.