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(Effective January 2017)


We apologize in advance for the lengthy nature of these policies. Healthcare has become increasingly complicated, so it is important to the success of your treatment that you review these policies in advance. This allows us to proceed with a shared understanding of the treatment process, and prevent any unwelcome surprises down the line. Thank you in advanced for your attention to these policies, and please feel free to speak to us individually if you have questions or concerns about any of the following items.



I hereby consent to receive mental health treatment from the Family Connections Center, LLC (hereafter referred to as FCC). I understand that my consent is voluntary. I also understand that I do not have to accept any treatment option FCC offers and that I may withdraw my consent at any time.

I accept that working toward change may involve experiencing difficult and intense feelings, some of which may be painful, in order to reach therapy goals. I understand that the changes I make will have an impact on others around me. I accept that such changes can have both positive and negative effects and agree to clarify and evaluate potential effects of changes before undertaking them. On the other hand, therapy has also been shown to have many benefits. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and growth, increased skills for managing stress, improved parenting abilities, and resolutions to specific problems. But, there are no guarantees that this will happen. Psychotherapy requires engagement with the process, and an understand that change can take time.

Timing: Most psychotherapy sessions are between 45-53 minutes long. Most psychopharmacology sessions are between 20-25 minutes. Family's or couple's therapy may be 53 minutes to 1.5 hours, depending on availability and need.

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The time scheduled for your appointment is assigned to you and you alone. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the portion of the fee as described below.

  1. 24-hour cancellation policy for Tuesday-Friday appointments: You will be financially responsible for any sessions cancelled within 24 hours of your appointment.

  2. 72-hour cancellation policy for Monday appointments: You will be financially responsible for any Monday session cancelled within 72 hours of your appointment (e.g. if you have a 9am Monday morning appointment, cancellations need to be made no later than the previous Friday at 9am).

  3. Telehealth sessions: If you are unable to make an appointment due to weather or other urgent matters, please discuss with your provider whether you can have a telehealth session by video.

  4. Rescheduling: If you do need to cancel, please check with your therapist about rescheduling. If your therapist's schedule allows for you to reschedule your appointment in the same week, you will not have to pay the entire cancellation fee, but will still be responsible for the co-pay of the missed session.

We are not able to bill insurance policies for cancelled or missed sessions, so you will be responsible for the full fee of the session, not just the co-pay (or a maximum amount of $150). You are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.

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  1. Full payment is expected at the beginning of each visit, unless prior arrangements have been made.

  2. Payment must be made by check or cash. We are not able to process credit card charges as payment. Please make checks payable to The Family Connections Center, and write the dates of service and therapist's name on the memo line. If you have a Health Savings Account, we can provide you with a receipt that you can then submit to your HSA.

  3. Invoicing: If you do not pay at the time of your session, you will receive a monthly invoice via email for all unpaid fees. A 3% processing fee will be added to any payment that requires invoicing.

  4. Late fee: Outstanding bills that are not paid by the due date on your invoice will incur a late fee of 10% per month.

  5. Outstanding balances: If you are unable to pay a bill by its due date, you may contact your provider in advance to arrange a payment plan. Psychotherapy will be suspended for patient's with accounts outstanding for more than 60 days, until payment has been received. Accounts outstanding for more than 90 days will be terminated and sent to a collections agency. The FCC reserves the right to terminate care for repeated late payments.

  6. Returned checks: Any checks returned to our office are subject to an additional fee of up to $25.00 to cover the bank fees incurred.

  7. Additional services: If you require any additional professional services, such as report writing, home-visits, school-visits, telephone conversations, attendance at meetings or consultations which you have requested, or the time required to perform any other service which you may request, you will be responsible a pro-rated amount of the clinical hourly rate usually reimbursed by your insurance. Insurance usually does not cover these additional services.

  8. Lab Requests: If you need a copy of a laboratory report, please request this from the laboratory that performed these services. We cannot send you a copy of these reports, however you may be able to access them through the Patient Portal. 

  9. Medical Records: You may request a copy of your medical records at any time. The fee is $15 to cover the processing fees.

  10. Transferring Care: In order to assure proper transfer of care to a new provider, we will happily speak with your new provider by phone, or provide them with a summary of your care, upon your request. 

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Financial responsibility: I understand that I am responsible for full payment of all fees for services provided by the FCC regardless of whether there is insurance coverage. If I have insurance, I understand that I am responsible for knowing the specific terms and limits of my insurance coverage, and that I am ultimately responsible for full payment of fees. Furthermore, unless prior arrangements are made, I agree to pay any self-pay fees, copayments, and/or coinsurance amounts at the beginning of each session.

Verifying your benefits: If you have a health insurance policy, it will usually provide some coverage for mental health treatment, but it may not cover the entire cost of your therapy. We can help you verify your benefits, but we would recommend you verify them on your own as well.

Most commercial insurance 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. 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 amount for services. This will typically mean that you will be responsible for paying for initial sessions until your deductible has been met. The deductible amount may also need to be met at the start of each calendar year. Some insurance plans have both an in-network and out-of-network deductible.

If we do not accept your insurance, and you have out-of-network benefits, you will be responsible for the deductible, the co-insurance, and the balance between what the insurance covers and our rate. Most out-of-network policies reimburse a “standard and customary” rate. However, if this is lower than our defined rates, you will be balance billed for the difference. Unfortunately, we often do not know what the out-of-network plans will reimburse for certain services until claims have been submitted and processed, so at the time of the service we will bill you the estimated amount you will owe, based on our prior experience with your plan and our verification of your benefits, and then make any adjustments to that amount once we have been paid by your plan.

For some out-of-network plans, such as BCBS PPO, we are not able to bill for out-of-network benefits on your behalf - the member has to submit their receipt on their own behalf. In these cases, you will be responsible for the entirety of the fee at the time of service, and we will provide you with a receipt that you can then submit to your insurance company for reimbursement. Generally, these receipts must be sent with an out-of-network form that can be downloaded from your insurance company's website.

    Important questions to ask your insurance company:

    • Do I have out-of-network benefit? 
    • What is my deductible to see an (in-network or out-of-network) mental health provider?
    • How much have I already paid towards my deductible, and how much do I still owe?
    • Once I meet my deductible, how much will I be responsible for per session?
    • When does my deductible re-start?
    • If I am going to use out-of-network benefits, can the provider submit the claim on my behalf, or do I, the member, need to submit a receipt and get directly reimbursed?

    Insurance or demographic changes: It is your responsibility to let us know if your insurance, address or contact information (including email) changes. We do not accept all insurance plans, so if you are planning a change your insurance, please discuss it with us in advance.

    Billing under parent's insurance: Please be aware that for billing purposes we must identify one individual as the “patient,” and bill their insurance policy, despite the fact that we often work with multiple family members. Due to the nature of our contracts with insurance companies, the person identified will be one of the parents, not the child. Therefore, we generally are not able to accept the child's insurance, if it is different from the parents.

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      Our communications are private and protected by law. Because of laws protecting confidentiality, in most situations your therapist cannot share information about your work without your permission. However, there are certain specific limits to confidentiality. By signing below, you fully understand the following limits:

        1. Staff: In order for FCC to function, my therapist may share some of my protected information with staff for purposes such as scheduling and billing. All administrative staff are trained to protect my privacy and have agreed to be bound by the rules of confidentiality.

        2. Insurance: If you are using your health insurance, you consent that your insurance company can receive certain information about our work. This information usually includes a diagnosis, treatment goals, and a plan for achieving those goals, and in rare cases, notes from sessions. Your therapist cannot refuse to provide this information to your insurance company. If you wish, you may choose to pay privately for treatment in order to avoid any disclosure to your insurance company.

        3. Billing: FCC has a contract with a billing service. As required by HIPAA, FCC has a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. You should receive an additional consent form, specifying the use of protected information by this billing service.

        4. Couples or family therapy: In order for any therapy information or medical records to be released, both members of any couple must provide written authorization. If some individual sessions may help the process of couples or family therapy, what you say in those individual sessions will be considered to be part of the medical record. 

        5. Supervision and consultation: There may be times during your therapy, when in order to support progress toward your goals, your therapist will consult with a colleague or supervisor. Your therapist will do this in a way that minimizes identifying information. All mental health professionals with whom your therapist consults are bound by the rules of confidentiality.

        6. Conferences and Presentations: Therapists at the FCC may present at conferences, speak to professional communities, or publish in professional journals, using ideas or thoughts that arise over the course of your treatment, but in doing so will not reveal any protected information, or details that could be used to identify you.

        7. Legal Proceedings: Generally, if you are involved in legal proceedings, your therapist cannot provide any information about your work together without your permission. There are exceptions and if you anticipate being involved in litigation, you should consult with your attorney to determine whether a court could order your therapist to disclose information.

        8. Lawsuit: If you file a complaint or lawsuit against your therapist, they may disclose relevant information pertaining to you in order to defend himself/herself.

        9. Reporting: If your therapist has reasonable cause to believe that any child under the age of 18 is being (or has been) physically or emotionally harmed in any way (either because of abuse--including sexual abuse--or neglect) the law requires your therapist to file a report with the Massachusetts Department of Children and Families. Your therapist will inform you if he/she finds that he/she must file a report. Similarly, if your therapist has reasonable cause to believe that an elderly person (age 59 or older) or a handicapped person of any age is (or has been) suffering from abuse, the law requires that they file a report with the appropriate authorities.

        10. Harm to self or others: Finally, if you let your therapist know that you intend to harm yourself or intend to harm another person and your therapist believes the risk is real, they may be required to break confidentiality by contacting the police, alerting the intended victim, contacting a family member, or seeking your hospitalization without consent. Your therapists will make every reasonable effort based on their clinical impression to accommodate your preferences and input to establish a mutually agreed upon plan in these circumstances.

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        The preferred means of communicating with your therapists is by calling their office telephone.

        Phone: If a therapists is not available to answer the telephone, you may leave a message on their confidential voicemail and they will return your call as soon as possible, but it may take a day or two for non-urgent matters. If you do not hear back from your therapist or you feel you have an urgent clinical matter that cannot wait for a return call, you can call your therapist's cell phone number, which will be left on their voicemail message. If your therapist is on vacation or sick, the number of the covering provider will be left on their voicemail message. Please do not use your therapist's cell phone number for matters that can wait until your therapists returns to the office. 

        Emergency: In case of an emergency please call 911, go to your local emergency room, or call crisis services. Crisis services number for Hampshire County is 413-586-5555. If you are in a different county, you can find the correct number at https://www.csoinc.org/?page_id=195.

        Email and texting:

        1. Practice Fusion Patient Portal: Your therapist's preference is that you contact him/her by phone. If after discussing it with your therapist, you would like to use email to contact your therapist, you can send secure messages to her/him through the Practice Fusion Patient Portal. Your therapist can send you an invitation to join the Practice Fusion Patient Portal. You will need to click on the email invitation and sign in (creating a log-in and password), and then can use the “Messaging” tab to communicate securely with your therapist. Please limit communication over email to non-clinical matters, such as scheduling. Your therapist will only check and respond to this email account during their regular working hours. The patient portal also allows you to check the time and date of any up-coming appointments.  
        2. Other email and texting: We cannot assure that emails or texts sent through any other media are secure. If you choose to contact your therapist by text or email outside of the Patient Portal, you are doing so with the full understanding that your therapist cannot guarantee the safety and security of that communication, despite FCC taking all possible action to protect your privacy. Emails occasionally disappear or are delayed, so be aware that your therapist may never receive an email that you send. So, for example, if you cancel a session through an email account other than the Patient Portal, you will also need to leave a phone message as well notifying your therapist of the cancellation. If you do choose to contact your therapist by text or email that does not go through the Patient Portal, they will not be able to respond to you by this method, and will respond by phone or through Practice Fusion. Your therapist will respond to all communication on the next business day they are in the office. So, for all urgent matters that need attention more immediately, you must call (not text or email) them on their cell phone number.

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        If you anticipate becoming involved in a court case, we recommend that you discuss this with us in person. As mental health practitioners we can not comment or recommend legal actions, and do not get involved in legal decision making. If required, we can provide a summary letter of our diagnostic impressions and verification of the mental health services we have provided, however, we do not provide judgements on legal matters such as custody, fostering, adoption, living arrangements, disability benefits, divorce, etc. If your case requires your therapists participation in any way, you will be expected to pay for the professional time required, even if another party compels your therapist to testify.

        Information discussed in couples and family therapy is for therapeutic purposes and is not intended for use in any legal proceedings involving the couple. You agree not to subpoena your therapist to testify for or against any party or to provide records in a court action.

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        1. For accounts outstanding for more than 60 days, care will be suspended until payment is received, and care may be terminated if this happens more than once.

        2. For accounts outstanding more than 90 days, your care will be terminated, and we will send your account to a collections agency.

        3. If we have not met within six months, your case will be closed, unless otherwise discussed.

        4. If despite three attempts to contact you, we have not been able to schedule a follow-up appointment, your case will be closed until further arrangements are made.

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        1. Psychiatric care at the Family Connections Center is only provided to adult patients who are also receiving on-going psychotherapy at the center.

        2. If your therapy ends at the FCC for any reason, your psychiatric care will be terminated at the same time. As such, if you will continue to need psychiatric care after ending therapy at the FCC, you and your therapist will need to make plans in advance for follow-up care.

        3. We do not have a child psychiatrist on staff, and therefore do not prescribe medication for children.

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        If you have any concerns with what is happening in therapy, or feel dissatisfied in any way, we encourage you to talk with your therapists so they can respond. Such comments will be taken seriously and handled with care and respect. Moreover, they are part of the process of your therapist coming to understanding more about you and your needs. You may also end therapy at any time, and/or request a referral to another therapist at FCC or elsewhere. This will not be held against you in anyway and you may decide you would like to return to therapy at a later date. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion or national origin. You have the right to ask questions about any aspects of your treatment and about your therapist's specific training and approach.

        Your signature below indicates that you have read this Agreement and the Notice of Privacy Practices and agree to their terms.


        Signature of Patient or Personal Representative


        Printed Name of Patient or Personal Representative


        Date ________________


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