Patient Information
Date:
SSN
Address:
Home Phone:
Can a message be left at your Home Phone number?
YES NO
Work Phone:
Work Phone Extension
Can a message be left at your Home Phone number?
YES NO
Cell Phone:
Can a message be left at your Home Phone number?
YES NO
Email
Okay to use Email?
YES NO
Gender
Female Male
Please Enter Your Age
Referred By:
In Case of Emergency, Contact:
Relationship
Phone
Consent for Treatment Services for a Minor
Is the patient a minor?
YES NO
Date:
Confidentiality Statement
Some important issues regarding confidentiality need to be understood as we begin our work together. Please review this material carefully so that we may discuss any questions or concerns.
In general, law protects the confidentiality of all communications between a patient and treatment provider, and I can only release information about our work to others with your written permission. However, there are a few exceptions.
In most judicial proceedings you have the right to prevent me from testifying. However, in child custody proceedings, adoption proceedings, and proceedings in which your emotional condition is an important element, a judge may require my testimony if it is determined that resolution of the issues before the court requires it. If you are involved in litigation, or are anticipating litigation, and you choose to include your mental or emotional state as part of the litigation, I may have to reveal part or all of your treatment or evaluation records.
If you are called as a witness in criminal proceedings, opposing counsel may have limited access to your treatment records. My testimony may also be ordered in other cases including legal proceedings related to psychiatric hospitalization, malpractice and disciplinary proceedings, court-ordered psychological evaluations, and certain legal cases following the death of a client.
In addition, there are some circumstances when I am required to breach confidentiality without a patient’s permission. This occurs if I suspect the neglect or abuse of a minor, in which case I must file a report with the appropriate state agency. If, in my professional judgment, I believe that a patient is threatening serious harm to another, I am required to take protective action, which may include notifying the police, warning the intended victim, or seeking the client’s hospitalization. If a client threatens harm to him/herself, I may be required to pursue hospitalization.
The intent of these requirements is that a treatment provider has both a legal and ethical responsibility to take action to protect endangered individuals from harm when his or her professional judgment indicates that such danger exists.
There are several other matters concerning confidentiality:
1. I may occasionally find it helpful or necessary to consult about a case with another professional. In these consultations I make every effort to avoid revealing the identity of the client. The consultant is also legally bound to maintain confidentiality. If I feel that it would be helpful to refer you to another professional for consultation then, with your permission, I will discuss your case with him/her.
2. I am required to maintain complete treatment records. Patients are entitled to receive a copy of these records, unless I believe the information would be emotionally damaging and, in such cases, the records must be made available to the patient’s appropriate designee. Patients will be charged an appropriate fee for preparation.
3. If you use third party reimbursement, I am required to provide the insurer with a clinical diagnosis and sometimes a treatment plan or summary.
4. If you are under 18 years of age, please be aware that while the specific content of our communications is confidential, your parents have a right to receive general information on the progress of treatment.
5. I may occasionally use a fax machine in communication with other agencies. I will only release information that you have authorized me to release and I do send faxes with a cover sheet that includes a confidentiality statement, but this does not insure that the fax is received in the proper place or handled in a confidential matter once it is received. You may pick up and hand deliver documents to agencies if you wish. I will also mail documents by request.
6. I will reply to email messages sent to me and I will make an effort to limit the type of information discussed in these messages, but it is important to stress that email is not a confidential mode of communication and should not be utilized if you require a higher degree of security.
I have read the above and fully understand the limits of confidentiality in this relationship and the circumstances in which confidential communications may need to be breached.
Date:
Fee Schedule and Payment Agreement
Initial Evaluation
This includes the initial session, review of records, report preparation, correspondence with referring providers, schools, or other agencies as requested, and administrative time establishing file.
Fee: $250
Individual Psychotherapy
30 minute session
Fee: $125
45-60 minute session
Fee: $200
Family Therapy
45-60 minute session
Fee: $225
90 minute session
Fee: $350
Phone Consultation
First 10 minutes: No Charge
Every 15 minutes thereafter: $50
Generation of Specifically Requested Report
Per hour of effort: $200
Fee Agreement
I understand that the fees as stated above are payable at the time of each session. I agree to accept financial responsibility for any missed appointments with less than 24 hours’ notice. The missed appointment fee is the full fee of the appointment missed, and I understand that this is not billable to my insurance company. I have carefully read all the terms stated above, and I have had an opportunity to discuss any questions. I fully understand all the areas covered and accept these terms.
Date:
Outpatient Services Contract
Thank you for seeking my services. This document contains important information about my professional services and business policies. Please read it carefully and ask any questions you may have. When you sign this document, it will represent an agreement between us.
PSYCHOLOGICAL SERVICES
I specialize in evidence-based treatments for eating disorders, such as family-based treatment (FBT) and cognitive-behavioral therapy (CBT). “Evidence-based” means that these treatments have been proven to work in controlled research studies. However, they do not work for everyone and I cannot guarantee outcomes.
I do not do inpatient work at any hospital, so my practice is limited to outpatients only. If you feel you need more intensive treatment beyond outpatient treatment, I will facilitate a referral to another provider who is able to meet this need.
PAYMENT
Please note that I practice under the umbrella of a Limited Liability Company, or LLC. As such, all professional dealings with me are legally dealings with Dr. Renee Rienecke, LLC, and all checks should be made out to Dr. Renee Rienecke, LLC. I am the sole practitioner of the LLC, as well as manager and owner. I have no other employees, so I handle all issues directly.
Payment in full is expected at the time of service. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due.
Please note that the full fee for services will be charged for all missed appointments unless the appointment is cancelled 24 hours in advance (unless there is a documentable emergency or medical illness).
INSURANCE
I do not accept insurance, but I can provide you with the necessary receipts for you to submit to your insurance company, if you choose. It is important that you review your benefits for out of network coverage.
CONTACTING ME
I check my messages frequently and return calls left during business hours as soon as I can. The quickest way to reach me is by email, if you feel comfortable doing so. I do not respond to text messages.
In the case of a serious psychiatric emergency, and you’re unable to reach me, you should proceed to an emergency room at a local hospital, or call 911 for assistance. I do not carry a pager.
Thank you for allowing me the opportunity to work with you!
Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.
Date:
Consent for Telehealth Treatment
1. I understand that my psychologist, Dr. Renee D. Rienecke, recommends engaging in telehealth services with me to provide treatment.
2. I understand that this is out of necessity and an abundance of caution and has originated due to the Coronavirus (Covid-19) pandemic. This will continue until such time that we are able to meet in person, or could continue, depending on the particular circumstance.
3. I understand that telehealth treatment has potential benefits including, but not limited to, easier access to care.
4. I understand that telehealth has been found to be effective in treating a wide range of disorders, and there are potential benefits including, but not limited to, easier access to care. I understand, however, there is no guarantee that all treatment of all patients will be effective.
5. I understand that it is my obligation to notify my psychologist of my location at the beginning of each treatment session. If for some reason, I change locations during the session, it is my obligation to notify my psychologist of the change in location.
6. I understand that it is my obligation to notify my psychologist of any other persons in the location, either on or off camera, who can hear or see the session. I understand that I am responsible to ensure privacy at my location. I will notify my psychologist at the outset of each session and am aware that confidential information may be discussed.
7. I understand that it is my obligation to ensure that any virtual assistant artificial intelligence devices, including but not limited to Alexa or Echo, will be disabled or will not be in the location where information can be heard.
8. I agree that I will not record either through audio or video any of the session, unless I notify my psychologist and this is agreed upon.
9. I understand there are potential risks to using telehealth technology, including but not limited to, interruptions, unauthorized access, and technical difficulties. I understand some of these technological challenges include issues with software, hardware, and internet connection which may result in interruption.
10. I understand that my psychologist is not responsible for any technological problems of which my psychologist has no control over. I further understand that my psychologist does not guarantee that technology will be available or work as expected.
11. I understand that I am responsible for information security on my device, including but not limited to, computer, tablet, or phone, and in my own location.
12. I understand that my psychologist or I (or, if applicable, my guardian or conservator), can discontinue the telehealth consult/visit if it is determined by either me or my psychologist that the videoconferencing connections or protections are not adequate for the situation.
13. I have had a conversation with my psychologist, during which time I have had the opportunity to ask questions concerning services via telehealth. My questions have been answered, and the risks, benefits, and any practical alternatives have been discussed with me.
14. Doxy is the technology service we will use to conduct telehealth videoconferencing appointments. My psychologist has discussed the use of this platform. Prior to each session, I will receive an email link to enter the “waiting room” until the session begins. There are no passwords or log in required.
By signing this document, I acknowledge:
1. Doxy is NOT an emergency service. In the event of an emergency, I will use a phone to call 911 and/or another appropriate emergency contact.
2. I recognize that my psychologist may need to notify emergency personnel in the event he/she feels there is a safety concern, including but not limited to, a risk to myself/others or my psychologist is concerned that immediate medical attention is needed.
3. Though my psychologist and I may be in virtual contact through telehealth services, neither Doxy nor my psychologist provides any medical or emergency or urgent healthcare services or advice. I understand should medical services be required, I will contact my physician. If emergency services are needed, I understand I should call 911.
4. Doxy facilitates videoconferencing and this technology platform is not, itself, a source of healthcare, medical advice, or care.
5. I understand that the same fee rates apply for telehealth as apply for in-person treatment.
6. During these times of the impact of Coronavirus (Covid-19) my psychologist may not have access to all of my medical/treatment records. My psychologist has made reasonable efforts to obtain records, but I understand and agree this may not be reasonably possible.
7. To maintain confidentiality, I will not share my telehealth appointment link or information with anyone not authorized to attend the session.
8. I understand that either I or my psychologist can discontinue the telehealth services if those services do not appear to benefit me therapeutically or for other reasons which will be explained to me. I understand there may be no other treatment alternative available. I have read and understand the information provided above regarding telehealth, have discussed it with my psychologist, and I hereby give informed consent to the use of telehealth.
Date:
Additional Forms
Please fill out the ROI form and the Permission to Collect Payment Form on SpringSource's website under "Forms." Thank you.
