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All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client’s) written permission, except where disclosure is required by law.  Most of the provisions explaining when the law requires disclosure were described to you in the notice of privacy practices that you received with this form.

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; and where a client presents a danger to self, to others, to property, or is gravely disabled (for more details see also notice of privacy practices form).

Disclosure may be required pursuant to a legal proceeding.  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 insert name of psychotherapist. In couple and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. Ms. Swope will use clinical judgment when revealing such information.  Ms. Swope will not release records to any outside party unless so authorized to do so by all adult family members who were part of the treatment.

If there is an emergency during our work together, or in the future after termination, where Donna Swope, LCSW-C becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, she will do whatever she 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, she may also contact the police, hospital, or the person whose name you have provided on the biographical sheet.

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 so instruct Ms. Swope only the minimum necessary information will be communicated to the carrier. Unless authorized by you explicitly, the psychotherapy notes will not be disclosed to your insurance carrier.

Ms. Swope has no control or knowledge over what insurance companies do with the information she submits 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 eligibility to obtain health or life insurance. The risk stems from the fact that mental health information is entered into insurance companies’ computers and soon will also be reported to the Congress-approved 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 have been reported to have been sold, stolen, or accessed by enforcement agencies; therefore, you are in a vulnerable position.

It is very important to be aware that e-mail and cell phone (also cordless phones) communication can be relatively easily accessed by unauthorized people and, hence, the privacy and confidentiality of such communication can be easily compromised.  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.  Faxes can be sent erroneously to the wrong address.  Please notify Ms. Swope at the beginning of treatment if you decide to avoid or limit in any way the use of any or all of the above-mentioned communication devices.  Please do not use e-mail or faxes in emergency situations.

Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters that 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 Ms. Swope to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.

Ms. Swope consults as needed with other professionals regarding her clients; however, the client’s name or other identifying information is never mentioned.  The client’s identity remains completely anonymous, and confidentiality is fully maintained.

Considering all of the above exclusions, if it is still appropriate, upon your request, Ms. Swope will release information to any agency/person you specify unless she concludes that releasing such information might be harmful in any way.

If you need to contact Ms. Swope between sessions, please leave a message in her confidential voicemail box (301) 739-6630 ext. 1 and your call will be returned as soon as possible. Ms. Swope checks her messages a few times a day (but not during the nighttime), unless she is out of town.  Ms. Swope checks her messages less frequently on weekends and holidays.  If an emergency situation arises, please indicate it clearly in your message.  If you need to talk to someone right away, you can call Ms. Swope at (240) 527-9896 or 24-hour crisis line (301) 662-2255 or the Police (911)

Clients are expected to pay the standard fee of $100 per 50-minute session at the end of each session or at the end of the month unless other arrangements have been made.  Telephone conversations, site visits, report writing and reading, consultation with other professionals, release of information, reading records, longer sessions, travel time, and so forth, will be charged at the same rate, unless indicated and agreed otherwise.  Please notify Ms. Swope if any problem arises 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 clients and not to the insurance companies.  Unless agreed upon differently, Ms. Swope will provide you with a copy of your receipt on a per session basis, which you can then submit to your insurance company for reimbursement if you so choose.

Ms. Swope is currently in the paneling process to become a provider with a select number of insurance companies. Should Ms. Swope become paneled with the clients insurance company, the client agrees to pay the co-pay amount specified by the insurance company at the end of each session and the clients insurance companies will be billed directly by the transitions LLC office manager /medical billing specialist.

If any check received by the client is in default, Ms. Swope will charge the cost of the processing fee incurred by her bank and request payment of the same amount of the original check by cash or money order.  This payment must be made prior to the beginning of the next scheduled session.

As was indicated in the section “Health Insurance and 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 that are the focus of psychotherapy are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage.  If there is any problem with my charges, my billing, your insurance, or any other money-related point, please bring it to my attention.  I will do the same with you.  Such problems can interfere greatly with our work.  They must be worked out openly and quickly.

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 precondition of, the initiation of arbitration.  The mediator shall be a neutral third party chosen by agreement of Ms. Swope and client(s).  The cost of such mediation, if any, shall be split equally, unless otherwise agreed.  In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Washington County, Hagerstown, MD. in accordance with the rules of the American Arbitration Association, that 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, Ms. Swope can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitrator will determine that sum.

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. Ms. Swope 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 your experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, and so forth, or experiencing anxiety, depression, insomnia, and so forth. Ms. Swope may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that 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 a decision that is positive for one family member is viewed quite negatively by another family member. 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, Ms. Swope is likely to draw on various psychological approaches according, in part, to the problem that is being treated and her assessment of what will best benefit you. These approaches include behavioral, cognitive-behavioral, psychodynamic, existential, system/family, psycho-educational, awareness-oriented, supportive, stress management / reduction, guided imagery and hypnosis (for trauma only).

Within a reasonable period of time after the initiation of treatment Ms. Swope will discuss with you (client) his/her working understanding of the problem, treatment plan, therapeutic objectives, and 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, Ms. Swope’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 Ms. Swope does not provide, he has an ethical obligation to assist you in obtaining those treatments.

As set forth above, after the first couple of meetings, Donna Stevenson Swope, LCSW-C will assess if she can be of benefit to you. Ms. Swope does not accept clients who, in her opinion, she cannot help.  In such a case, she will give you a number of referrals that you can contact.  If at any point during psychotherapy, Ms. Swope assesses that she is not effective in helping you reach the therapeutic goals, she is obliged to discuss it with you and, if appropriate, to terminate treatment.  In such a case, she would give you a number of referrals that may be of help to you. If you request it and authorize it in writing, Ms. Swope 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, Ms. Swope will assist you in finding someone qualified, and, if she has your written consent, she 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, Ms. Swope will offer to provide you with names of other qualified professionals whose services you might prefer.  The client agrees to one final appointment for receiving the aforementioned and clinical recommendations.

Not all dual relationships are unethical or avoidable. Therapy never involves sexual or any other dual relationship that impairs Ms. Swope’s objectivity, clinical judgment, or therapeutic effectiveness or can be exploitative in nature. Ms. Swope will assess carefully before entering into nonsexual and non-exploitative dual relationships with clients. Hagerstown is a small community and many clients know each other and Ms. Swope  from the community. Consequently, you may bump into someone you know in the waiting room or out in the community. Ms. Swope will never acknowledge working therapeutically with anyone without his/her written permission.  Many clients choose Ms. Swope as their therapist because they knew her before they entered into therapy with her and/or are aware of her stance on the topic.  Nevertheless, Ms. Swope will discuss with you, her client(s), the often-existing complexities, potential benefits, and difficulties that may be involved in such relationships.  Dual or multiple relationships can enhance therapeutic effectiveness but can also detract from it and often it is impossible to know that ahead of time.  It is your, the client’s, responsibility to communicate to Ms. Swope if the dual relationship becomes uncomfortable for you in any way. Ms. Swope will always listen carefully and respond accordingly to your feedback. Ms. Swope will discontinue the dual relationship if she finds it interfering with the effectiveness of the therapeutic process or the welfare of the client and, of course, you can do the same at any time.

Since scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours’ (1 days’) notice is required for rescheduling 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.