Please read the following policies. Keep one copy of this document for your records.

You are required to pay your annual out-of-network or in-network deductible at the beginning of your plan’s calendar year. After your out-of-network or in-network deductible has been satisfied, you are responsible for the co-pay or co-insurance amount set by their insurance carrier. Any non-covered services are your financial responsibility.

Co-payments, co-insurance, non-covered services and/or deductibles are your responsibility and are due at the time services are rendered. In the event that payment for a performed service is denied by your insurance carrier, it is your responsibility to pursue action with them, as the policy is a legal contract between you and your insurance company.

NHWS is a teaching clinic so on occasion student interns from various colleges may accompany the group facilitator, observe group sessions, and have sight of your child’s notes. A background check through each respective institution is conducted for each student intern. NHWS periodically allows volunteers to assist in the clinic. They may be in the treatment area with your child under the supervision of the group facilitator. Each volunteer has HIPAA privacy instructions. Volunteers are in place to learn, to assist the group facilitator and to work for the benefit of patient care. Volunteers are not employees of NHWS and cannot assist you with billing, scheduling, medical or insurance information.

In general, the privacy of all communication between a patient and a psychologist is protected by law. In most situations, we can only release information about your child’s treatment to others with your written permission. But there are a few exceptions.

In most legal proceeding you have the right to prevent me from providing any information about your child’s treatment. In some proceedings involving child custody and those in which your child’s emotional condition is an important issue, a judge may order my testimony if he/she determines that issues demand it.

There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a patient’s treatment. For example, if I believe that a child, elderly person, or disabled person is being abused, I may be required to file a report with the appropriate state agency.

If I believe that a patient is threatening serious bodily harm to another, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If the patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection.

These situations have rarely occurred in my practice. If a similar situation occurs, I will make every effort to fully discuss it with you before taking any action.

I may occasionally find it helpful to consult other professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The consultant is also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together.

The laws and standards of our profession request us to keep treatment records. You are entitled to receive a copy of your child’s records, or a summary can be prepared for you instead. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your child’s records, we recommend that you review them with your child’ therapist so that he/she can discuss the content. You will be charged an appropriate fee for any professional time spent preparing, copying, and mailing your child’s records. Payment is required before records are sent or picked up. Record requests are typically able to be handled within 2 weeks of the request.

Your signature below validates your initials on each of the clinic polices described above.

By selecting the "Send" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. By selecting "Send" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature, and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting agreement between you and New Horizons Wellness Services, LLC. You are also confirming that you are the responsible party authorized to enter into this Agreement.