Forms

Confidentiality by law and professional ethics, your sessions are strictly confidential. Generally, no information will be shared with anyone without your written permission. If you are seeing another therapist or health professional it may be necessary for me to contact that person so that we can coordinate our efforts. If this is necessary I will ask for your permission. In addition, some insurance companies require periodic updates. I will only provide this information with your permission. There are however, a number of exceptions to this confidentiality policy.

If I am ordered by the court to testify or release records.

If you are a victim or perpetrator of child abuse, I am required by law to report this to the authorities responsible for investigating child abuse.

If you are a victim or perpetrator of elder or dependent adult abuse, I am required by law to report this to Adult Protective Services or other appropriate authorities.

If you threaten harm to yourself, someone else or the property of others, I may be required to call the police and warn the potential victim or take other reasonable steps to prevent the threaten harm.

Fees: My fee is $170.00 for an individual and $200 for a family hour session. You are expected to pay for your session at the end of each session. Insurance clients: co-payments are expected to be paid at each session.

Unpaid balances: Payments received more than thirty days after the date due are subject to 19.8 annual percentage service charge calculated on a monthly rate of 1.65% of the remaining balance. Delinquent bills will be turned over to a collection agency. The patient is responsible for the original bill, service charges, collection fees as well as any legal costs that are incurred as a result of the collection process.

Insurance: I accept insurance for services rendered. You need to provide me with all your insurance information, so I am able to submit a bill to your insurance company. Please let me know of any changes with your insurance.

Cancellations: You will be charged my whole fee for all cancelled and rescheduled appointments with the exception noted below. You may call my answering service 24 hours a day, seven days a week to cancel an appointment within 24 hours of your appointment or send an email.

After Hours Emergencies: I am not available after my usual business hours for emergencies I do check my messages during weekdays between 9:00 AM and 6:00 PM and I am usually available to speak with you on the telephone (or schedule a time we can talk). Leave a message on my answering machine (301-385-8257). For after-hours emergencies or if you need immediate assistance call 911, your medical group or your primary care physician. For mental health crisis, contact the National Suicide and Mental Health Prevention at 988 and/or text Crisis Textline at 741741.

Terminating Treatment: You have the right to terminate or take a break from your treatment at any time without my permission or agreement. However, if you do decide to exercise this option, I encourage you to talk with me about the reason for your decision in a counseling session so that we can bring sufficient closure to our work together. In our final session we can discuss your progress thus far and explore ways in which you can continue to utilize the skills and knowledge that you have gained through your therapy. We can also discuss any referrals that you may require at that time.

Please sign this form and keep a copy for yourself for future reference. Should you have any questions at any time, please ask.

I/we have read, understand and agree to the information and policies described in this patient information form.

I, ____________________________, the undersigned, acknowledge that I have agreed to communication with Gwenn H. Herman by means of electronic media, including email, facsimiles, cellphone's, Skype, Yahoo Voice and Google Voice. I understand that my communications with Gwenn H. Herman by such means are relatively easy to access by unauthorized persons, which may compromise their privacy and confidentiality. I further understand that emails may be part of my medical records and are not to be used for emergencies.

I understand the nature and extent of the potential risks involved with communication by means of these forms of electronic media as described above and I am nevertheless voluntarily agreeing to such use and assuming the risks associated with the use of such media in my communications with Gwenn H. Herman. I further understand that if I wish to cease communications with Gwenn H. Herman by any such means, I may do so at any time by sending Gwenn H. Herman a written notice of my desire to limit or avoid the use of such means of communication in the future.

I, ______________________________, hereby authorize, Gwenn Herman, to disclose information and records obtained in the course of my diagnosis and/or treatment to: _____________________________.

__________ Pertinent medical and/or psychiatric information relevant to
diagnosis and treatment

This disclosure of information and records authorized herein is required (by the receiving party) for the following purpose: _____________________________________________

The specific uses and limitations on the types of medical information to be disclosed are as follows:
_____________________________________________

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This authorization will expire one year from date of signature. I understand that I have a right to receive a copy of this authorization. I also understand that this authorization may be revoked by me, in writing, at any time, except to the extent that action has already been taken.