Makeda Bostwick LPC Pa License: PC009454

Biopsychosocial History & Assessment Adult Self-Report

Financial Agreement and Authorization to Charge Credit Card

Practice Policies

In Case of an Emergency

For Disclosure of Mental Health Treatment Information

Consent for Telehealth Consultation

Notice of Privacy Practices

Informed Consent for Psychotherapy

Office Policies & Agreement for Psychotherapy Services

Biopsychosocial History & Assessment

Adult Self-Report
Name:
Date of Birth:

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Marital Status:
Home Address:
Mobile Number:
Insurance Carrier:

ABOUT YOUR CONCERNS

Please check all the items below that you currently experience or having difficulty, and feel free to add any others at
the bottom under “Other concerns or issues.” You may add details as needed to clarify.

Abortion Grieving, mourning Physical problems

Abuse - emotional Guilt PMS
Abuse - neglect Headaches, pains Poor self-care
Abuse - sexual Health, illness Pornography use
Adoption Hearing voices Procrastination
Aggression Hostility Relationship problems
Alcohol Use Hyperactivity Relaxation
Ambition Impulsive spending Re-marriage
Anger Impulsiveness Risk-taking
Anxiety Incest Sadness
Arguing Indecision School problems
Attention problems Inferiority feelings Self-abuse (burning)
Career concerns Infertility Self-abuse (cutting)
Childhood issues Inhibitions Self-abuse (other)
Children – care of Interpersonal conflicts Self-abuse (scratching)
Children - custody Irresponsibility Self-abuse (pulling hair out)
Children - management Irritability Self-centeredness
Choices I’ve made Judgment problems Self-control
Chronic pain Laziness Self-esteem
Codependence Legal matters, charges, suits Self-neglect, poor self-care
Communication Loneliness Separation
Compulsive spending Loss of control Sexual addiction
Confusion Losses Sexual conflicts
Constant conflicts Loss of interest in activities Sexual desire differences
Crying Loss of interest in sex Shyness
Deaths Low energy Smoking
Debt Low frustration tolerance Spirituality
Decision making Low income Step-parenting
Dependence Low mood Stress
Depression Marital conflict Stress-management
Distractibility Marital distance Suspiciousness
Divorce, separation Marital infidelity/affairs Temper problems

Domestic violence Medical concerns Tension / stress

Drug abuse – over the counter Memory problems Thought disorganization
Drug abuse - prescription Menopause Threats of violence
Drug abuse – street drugs Menstrual problems Tiredness
Drug abuse - alcohol Mixed feelings Tobacco use
Education Mood swings Unhappiness
Employment – lack of Motivation Violence
Employment - overdoing Mourning Violence – victim of crime
Employment problems Nail-biting Weight and diet issues

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 Employment - termination Nervousness Withdrawal - isolating
Emptiness Nightmares Work problems
Exhaustion Obsessions, compulsions Worry all the time
Failure Outbursts Other concerns or issues:
Fatigue, low energy Oversensitive to criticism
Fears, phobia Oversensitive to rejection
Feelings of helplessness/hopeless Overweight
Financial troubles Panic or anxiety attacks
Friendship problems Parenting
Gambling Perfectionism
Gender identity Pessimism
Goals not being met Phobias

I would appreciate learning more about you and your perspective on your life. Please describe, in detail, why you
checked the above items. Tell me about your challenges, strengths, your needs and any family or community
support you have in your life:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

What goals would you like to accomplish in treatment:

1. ___________________________________________________________________________

2. ___________________________________________________________________________

3. ___________________________________________________________________________

4. ___________________________________________________________________________

Are you currently taking illegal drugs? No Yes If so, what?

How long have you used this drug? Frequency of use? How much?

Are you drinking Alcohol? No Yes Frequency of use?

How long have you used alcohol? How much?

Describe how your use has affected your family or friends (what are their perceptions of your use):

Describe any changes in your use patterns:

Describe how your use has affected your family or friends (what are their perceptions of your use):

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Have you ever wanted to stop but feel you cannot?

Psychological History:

Have you ever taken medication for anxiety, depression, sleep, or other emotional conditions? Yes or No
If yes, what and when:
___________________________________________________________________________________________

Have you ever been in counseling or psychotherapy before? Yes or No

If yes, where and when:
___________________________________________________________________________________________

Have you had any past hospitalizations for emotional problems? Yes or No
If yes, when and where:
___________________________________________________________________________________________

Have you ever intentionally hurt yourself or made a suicide attempt? Yes or No
If yes, explain how and when:
___________________________________________________________________________________________

Who is your primary care physician:

___________________________________________________________________________________________

Are you taking any prescribed medications? Yes or No

Name of medication Dosage and Frequency Reason Physician

___________________________________________________________________________________________
___________________________________________________________________________________________

Family History:

Is there a history of depression, anxiety, alcoholism, or other mental health conditions in your family?
Yes or No If yes, who?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

Have you ever experienced any emotional, physical, or sexual abuse? Yes No
If yes, please explain:
___________________________________________________________________________________________
___________________________________________________________________________________________

Have you ever been accused of assaulting or inappropriately touching someone? Yes No
If yes, please explain who / when:

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___________________________________________________________________________________________

Does the use of alcohol or drugs by someone close to you contribute to your problems? Yes No
If yes, please explain:
___________________________________________________________________________________________

Did you grow up in a home in which a parent abused alcohol or drugs?

Yes No If yes, please explain:
___________________________________________________________________________________________

Signature: _____________________________________ Date: __________________________

Financial Agreement and Authorization to Charge Credit Card

 Co-payments are due at the time of service.

 Insurance policies are contracts between you and your insurance company. I file these claims as a courtesy
and try to help with problems, but you may need to resolve those beyond my control. You will be charged
for any insurance claims that are not paid within 30 days of the date of service.
 If I am not covered by your insurance company, full payment is due when services are provided.
 Phone conversations are not covered by insurance and are charged at a prorated fee based on $100/ hour.
 Any appointments scheduled but not kept, as well as any appointments cancelled within 24 hours of
scheduled time will be charged a fee of $100. This is not covered by your insurance company.
 You are discouraged from requesting my participation in legal proceedings. If you become involved in
legal proceedings and do request my participation, you will be expected to pay for all of my professional
time, including preparation and transportation costs, even if I am called to testify by another party. The rate
for this participation is $220 per hour, including preparation time, time away from my office, and all related
correspondence with third parties, with a retainer fee of $1500 due in advance. You also acknowledge that
any testimony may not be in your favor, as I can only testify to facts and professional opinion.
 If you request a written letter, treatment summary, etc., you will be charged a pro-rated fee based on $100
per hour, with a minimum fee of $25 per document.
 If you request your records, you will be charged the associated fees per the PA State Code for Medical
Records Charges.
 I authorize Makeda Bostwick LPC to submit claims for psychotherapy sessions to the insurance policy that

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 I have presented.
 I authorize Makeda Bostwick LPC to charge the card entered in this client portal for co-payments,
coinsurance, deductibles. full session fee if self-pay, and for late cancellations or no-shows. I may change
this authorization at any time by providing a written statement to the practice. All transactions will be
documented and available for me to review.
 I understand that if my credit card does not accept a charge, I will immediately make the payment to the
practice.
 I understand that I may cancel this authorization at any time, but by doing so, I acknowledge that the
balance owed will be due & paid in full.
 I acknowledge that credit card transactions could be linked to Protected Health Information.

Credit Card Information: Expiration date:

Name (as it appears on your card): 3-digit CVV Code (located on the back of your
card:
16-digit card number:
Zip code:
Card type (i.e. Visa, Mastercard, Flex Spending
Card):

Client Signature: ________________________________ Date: ____________

PRACTICE POLICIES

APPOINTMENTS AND CANCELLATIONS The standard meeting time for psychotherapy is 50 minutes.
Sessions may at times be shorter due to a client’s insurance coverage or tolerance level. Requests to change the 50-
minute session needs to be discussed with the therapist in order for time to be scheduled in advance.

A $25.00 service charge will be charged for any checks returned for any reason for special handling.

Cancellations/no shows that occur less than 24 hours before the scheduled session will be subject to a $100.00 fee.
This is not covered by insurance. This is necessary because a time commitment is made to you and is held
exclusively for you. If you are late for a session, you may lose some of that session time. Your therapist will make
every effort to re-schedule you within the same week when possible.

Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the entire fee of $100 if
cancellation is less than 24 hours.

If cancellations become habitual, your therapist reserves the right to discharge you from therapy with a referral for
other therapists who can treat you.

TELEPHONE ACCESSIBILITY If you need to contact me between sessions, please leave a message on my voice
mail. I am often not immediately available; however, I will attempt to return your call within 24 hours. When I am
unavailable, my telephone is answered by voicemail that I monitor frequently. I will make every effort to return your
call within two days, except for weekends and holidays. If you are difficult to reach, please inform me of sometimes
when you will be available. If you are unable to reach me and feel that you cannot wait for me to return your call,
contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. In
addition, Crisis Services is available 24 hours per day to immediately address your needs. Crisis Services can
be reached at 814-456-2014.

IN THE EVENT THAT YOU ARE OUT OF TOWN, SICK OR NEED ADDITIONAL SUPPORT,
TELEHEALTH SESSIONS ARE AVAILABLE.

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SOCIAL MEDIA AND TELECOMMUNICATION Due to the importance of your confidentiality and the
importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients
on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these
sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our
therapeutic relationship. If you have questions about this, please bring them up when we meet, and we can talk more
about it.

ELECTRONIC COMMUNICATION I cannot ensure the confidentiality of any form of communication through
electronic media, including text messages. If you prefer to communicate via email or text messaging for issues
regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot
guarantee immediate response and request that you do not use these methods of communication to discuss
therapeutic content and/or request assistance for emergencies. While I take every precaution to protect client
confidentiality, if you choose to communicate with your therapist and/or practice via text, email, or other electronic
methods, you accept the associated privacy risks.

It is the policy of Makeda Bostwick LPC to engage in texting and emails between therapist and client only for
scheduling purposes.

If you have an immediate and significant clinical concern that involves safety, including thoughts of suicide, you
should call Crisis Services (814-456-2014), call 911, or visit the nearest emergency room. After taking this
immediate action, your therapist can be notified via telephone message so she/ he can follow-up with you and other
providers.

If you choose to send me a text or email regarding a safety concern, you acknowledge:

· that this is a break with office policy

· that your therapist may not receive the message in a timely manner

· that you may be discharged from treatment and given referrals for other providers

If you have a clinical concern that does not involve safety and is not an immediate concern, you can send me a
message in the secure, HIPAA compliant client portal. Each client has a unique user ID and password that was
established upon intake. I will make every effort to reply to your message in a timely manner.

RECORDING

Audio or video recording in any part of the building is strictly prohibited and will result in termination of therapy
with a referral. If you need to take notes during your session, please ask for pen and a notepad.

MINORS If you are a minor, your parents may be legally entitled to some information about your therapy. I will
discuss with you and your parents what information is appropriate for them to receive and which issues are more
appropriately kept confidential.

TERMINATION Ending relationships can be difficult. Therefore, it is important to have a termination process in
order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the
treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine
that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the
therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is
terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists
to treat you. You may also choose someone on your own or from another referral source.

Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made
in advance, for legal and ethical reasons, I must consider the professional relationship discontinued. In this
circumstance, you may contact our office for appropriate referrals.

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STANDARD RATES:

For your information, this section lists the fees for the most common services offered. There may be times where
other services may be provided (including but not limited to letters, summaries of treatment and/or legal/court
issues).

-Initial Evaluation: $100.00

-Individual Therapy: $100.00

-Individual Therapy (30-45 minutes) $50.00-75.00

-Couple Therapy: $100.00

-Late Cancel (after the 2nd time/non-emergency): $100.00

-No Show $100.00

-Monthly Late Fee \*(outstanding balances only) \*$25.00

________________________________________________________________________________________
Client Signature Date

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 In Case of an Emergency

If you have a mental health emergency, I encourage you not to wait for communication back from me, but do one or
more of the following:

- Call 911

- Call Lifeline at (800) 273-8255 (National Suicide Prevention/Crisis Lifeline)

- Go to the emergency room of your choice

Emergency procedures specific to Telehealth services

There are additional procedures that we need to have in place specific to Telehealth services. These are for your
safety in case of an emergency and are as follows:

You understand that if you are having suicidal or homicidal thoughts, experiencing psychotic symptoms, or in a
crisis that we cannot solve remotely, I may determine that you need a higher level of care and Telehealth services
are not appropriate. I require an Emergency Contact Person (ECP) who I may contact on your behalf in a life-
threatening emergency only. Please enter this person's name and contact information below.

Either you or I will verify that your ECP is willing and able to go to your location in the event of an emergency.
Additionally, if either you, your ECP, or I determine necessary, the ECP agrees take you to a hospital. Your
signature at the end of this document indicates that you understand I will only contact this individual in the extreme
circumstances stated above.

Please list your Emergency Contact Person here:

ECP (Emergency Contact person): Phone:

You agree to inform me of the address where you are at the beginning of every session. You agree to inform me of
the nearest mental health hospital to your primary location that you prefer to go to in the event of a mental health
emergency.

Please list this hospital and contact number here:

Hospital: Phone:

You agree to inform me of the nearest police department to your primary location that you prefer to go to in the
event of an emergency.

Please list this police department and contact number here:

Police Department: Phone:

Client Signature: ____________________________ Date: __________________

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 For Disclosure of Mental Health Treatment Information

I, _______________________________, whose Date of Birth is ___________________, authorize Makeda Bostwick LPC

to disclose to and/or obtain from:

the following information:

Description of Information to be Disclosed

(Patient/Client should initial each item to be disclosed)

_____ Assessment ______Nursing/Medical Information

_____ Diagnosis _____ Educational Information
_____ Psychosocial Evaluation _____ Discharge/Transfer Summary
_____ Psychological Evaluation _____ Continuing Care Plan
_____ Psychiatric Evaluation _____ Progress in Treatment
_____ Treatment Plan or Summary _____ Demographic Information
_____ Current Treatment Update ______Other_______________________
_____ Medication Management Information ______Other_______________________
_____ Presence/Participation in Treatment

Purpose
This information may be used or disclosed in connection with mental health treatment, payment, or healthcare operations.

If the purpose is other than as specified above, please specify:

____________________________________________________________________________________________________
____________________________________________________________________________________________________
________________________

Revocation
I understand that I have a right to revoke this authorization, in writing, at any time by sending written notification to Makeda
Bostwick LPC at 141 Randall Ave Ste #2, Girard, Pa 16417 or by verbal notification in person.
I further understand that a revocation of the authorization is not effective to the extent that action has been taken in reliance
on the authorization.

Expiration
Unless sooner revoked, this authorization expires on the following date: _______________ or as otherwise indicated:
____________________________________________________________________________________________________
_________

Conditions
I further understand that Makeda Bostwick LPC will not condition my treatment
on whether I give authorization for the requested disclosure. However, it has been explained to me that failure to sign this
authorization may have the following consequences: ___Impedes coordination of care____

Form of Disclosure
Unless you have specifically requested in writing that the disclosure be made in a certain format, we reserve the right to
disclose information as permitted by this authorization in any manner that we deem to be appropriate and consistent with
applicable law, including, but not limited to, verbally, in paper format or electronically.

Redisclosure

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I understand that there is the potential that the protected health information that is disclosed pursuant to this authorization
may be redisclosed by the recipient and the protected health information will no longer be protected by the HIPAA privacy
regulations, unless a State law applies that is stricter than HIPAA and provides additional privacy protections.

I will be given a copy of this authorization for my records.

_____________________________________________________________________________
Signature of Patient Date
_____________________________________________________________________________
Signature of Parent, Guardian, or Personal Representative Date

If you are signing as a personal representative of an individual, please describe your authority to act for this individual
(power of attorney, healthcare surrogate, etc.).

_____Check here if patient/client refuses to sign authorization

_____________________________________________________________________________
Signature of Staff Witness Date

CONSENT FOR TELEHEALTH CONSULTATION

1. I understand that my health care provider wishes me to engage in a telehealth consultation.

2. My health care provider explained to me how the video conferencing technology that will be used to affect
such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will
not be in the same room as my provider.
3. I understand that a telehealth consultation has potential benefits including easier access to care and the
convenience of meeting from a location of my choosing.

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 4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and
technical difficulties. I understand that my health care provider or I can discontinue the telehealth
consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
5. I have had a direct conversation with my provider, during which I had the opportunity to ask questions in
regard to this procedure. My questions have been answered and the risks, benefits and any practical
alternatives have been discussed with me in a language in which I understand.

CONSENT TO USE THE TELEHEALTH BY A HIPPA COMPLIANT PLATFORM

Telehealth by HIPPA compliant platform is the technology service we will use to conduct telehealth
videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this
document, I acknowledge:

1. Telehealth is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
2. Though my provider and I may be in direct, virtual contact through the Telehealth Service, Telehealth
Service will not be used to provide any medical or healthcare services or advice including, but not limited
to, emergency or urgent medical services.
3. The Telehealth, HIPPA compliant service facilitates videoconferencing and is not responsible for the
delivery of any healthcare, medical advice, or care.
4. I do not assume that my provider has access to any or all the technical information in the Telehealth,
HIPPA compliant platform service – or that such information is current, accurate or up to date. I will not
rely on my health care provider to have any of this information in the Telehealth, HIPPA compliant
platform service.
5. To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to
attend the appointment.

By signing this form, I certify:

 That I have read or had this form read and/or had this form explained to me.
 That I fully understand its contents including the risks and benefits of the procedure(s).
 That I have been given ample opportunity to ask questions and that any questions have been answered to
my satisfaction.

Client Signature: ________________________________ Date: ____________

NOTICE OF PRIVACY PRACTICES

I. MY PLEDGE REGARDING HEALTH INFORMATION: I understand that health information about you and
your health care is personal. I am committed to protecting health information about you. I create a record of the care
and services you receive from me. I need this record to provide you with quality care and to comply with certain
legal requirements. This notice applies to all the records of your care generated by this mental health care practice.
This notice will tell you about the ways in which I may use and disclose health information about you. I also
describe your rights to the health information I keep about you and describe certain obligations I have regarding the
use and disclosure of your health information. I am required by law to:

 Make sure that protected health information (“PHI”) that identifies you are kept private.
 Give you this notice of my legal duties and privacy practices with respect to health information.
 Follow the terms of the notice that is currently in effect.
 I can change the terms of this Notice, and such changes will apply to all information I have about you. The
new Notice will be available upon request, in my office, and on my website.

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II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: The following categories
describe different ways that I use and disclose health information. For each category of uses or disclosures I will
explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed.
However, all the ways I am permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers
who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health
information without the patient’s written authorization, to carry out the health care provider’s own treatment,
payment or health care operations. I may also disclose your protected health information for the treatment activities
of any health care provider. This too can be done without your written authorization. For example, if a clinician
were to consult with another licensed health care provider about your condition, we would be permitted to use and
disclose your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis
and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other
health care providers need access to the full record and/or full and complete information in order to provide quality
care. The word “treatment” includes, among other things, the coordination and management of health care providers
with a third party, consultations between health care providers and referrals of a patient for health care from one
health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or
administrative order. I may also disclose health information about your child in response to a subpoena, discovery
request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell
you about the request or to obtain an order protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

1. Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use
or disclosure of such notes requires your Authorization unless the use or disclosure is:

a. For my use in treating you.

b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint,
family, or individual counseling or therapy.

c. For my use in defending myself in legal proceedings instituted by you.

d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.

e. Required by law and the use or disclosure is limited to the requirements of such law.

f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.

g. Required by a coroner who is performing duties authorized by law.

h. Required to help avert a serious threat to the health and safety of others.

2. Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.

3. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to
certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

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1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the
relevant requirements of such law.

2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or
reducing a serious threat to anyone’s health or safety.

3. For health oversight activities, including audits and investigations.

4. For judicial and administrative proceedings, including responding to a court or administrative order, although my
preference is to obtain an Authorization from you before doing so.

5. For law enforcement purposes, including reporting crimes occurring on my premises.

6. To coroners or medical examiners, when such individuals are performing duties authorized by law.

7. For research purposes, including studying and comparing the mental health of patients who received one form of
therapy versus those who received another form of therapy for the same condition.

8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the
President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the
safety of those working within or housed in correctional institutions.

9. For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may
provide your PHI in order to comply with workers’ compensation laws.

10. Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to
remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment
alternatives, or other health care services or benefits that I offer.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that
you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The
opportunity to consent may be obtained retroactively in emergency situations.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or
disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your
request, and I may say “no” if I believe it would affect your health care.

2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request
restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI
pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

3. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for
example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.

4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an
electronic or paper copy of your medical record and other information that I have about you. I will provide you with
a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your
written request, and I may charge a reasonable, cost-based fee for doing so.

5. The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I
have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you
provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of
receiving your request. The list I will give you will include disclosures made in the last six years unless you request

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a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I
will charge you a reasonable cost-based fee for each additional request.

6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of
important information is missing from your PHI, you have the right to request that I correct the existing information
or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of
receiving your request.

7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice,
and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via
e-mail, you also have the right to request a paper copy of it.

EFFECTIVE DATE OF THIS NOTICE

This notice will go into effect after completion of your intake session/same day.

Acknowledgement of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding
the use and disclosure of your protected health information. By checking the box below, you are acknowledging that
you have received a copy of HIPAA Notice of Privacy Practices.

Client Signature: _____________________________ Date: ______________

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 Informed Consent for Psychotherapy
General Information

The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is
important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This
consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate
that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.

The Therapeutic Process

You have taken an incredibly positive step by deciding to seek therapy. The outcome of your treatment depends largely on your
willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events
and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are
no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my
absolute best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.

Confidentiality

The session content and all relevant materials to your treatment will be held confidential unless you request in writing to have all
or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of
confidentiality exist and are itemized below:

1. If a client threatens or attempts to commit suicide or otherwise conducts him/herself in a manner in which there is a substantial
risk of incurring serious bodily harm.

2. If a client threatens grave bodily harm or death to another person.

3. If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of
physical, emotional, or sexual abuse of children under the age of 18 years.

4. Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

5. Suspected neglect of the parties named in items #3 and # 4.

6. If a court of law issues a legitimate subpoena for information stated on the subpoena.

7. If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an
expert’s report to an attorney.

Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for
you. Information about you may be shared in this context without using your name.

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and
confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me
first, I will be more than happy to speak briefly with you but feel it appropriate not to engage in any lengthy discussions in public
or outside of the therapy office.

Client Signature: ____________________________ Date: __________________

Office Policies & Agreement for Psychotherapy Services

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Welcome to my practice. Your first visit to a new therapist is especially important, and you may have many
questions. This letter is to introduce myself and give you information to help you decide whether we can work
together. Please take time to read it carefully and let me know if you have any questions or need more information.
When you sign this document, it will represent an agreement between us.
Qualifications

I received my masters in 2013 from Capella University. I work from an integrative perspective and rely on a broad
range of techniques, including psychodynamic, narrative/logotherapy, cognitive-behavioral, and emotion-focused
interventions. I bring certain expertise to our collaboration while you bring self-knowledge, the ability to learn from
your life experiences, and a vision of what you want your life to be. I enjoy working with a diverse range of
individuals and others in relationships.

The Process of Therapy/Evaluation

During our first meetings, I will assess whether I can be of benefit to you. I do not accept clients who I believe I
cannot be helpful to, and if this is the case, I will refer you to others who work well with your particular issues.
Within a reasonable period of time after starting treatment, we will discuss my working understanding of your
issues, my proposed treatment plan, and therapeutic objectives and possible outcomes of the therapy. If you have
questions about any of the procedures used in the course of your therapy, their possible risks, my expertise in
employing them or about the treatment plan in general, please ask me. You also have the right to ask about other
possible treatments for your condition and their risks and benefits. If you could benefit from any treatments that I do
not provide, I have an ethical obligation to assist you in obtaining those treatments.

Termination and Follow- Up

Deciding when to stop our work together is meant to be a mutual process. Before we stop, we will discuss how you
will know if or when to come back or whether a regularly scheduled "check-in" might work best for you. If it is not
possible for you to phase out of therapy, I recommend that we have closure on the therapy process with at least two
termination sessions. I also ask all clients to indicate on their intake form whether they consent to follow-up emails
to assess your satisfaction with my services. You may opt out of both of these follow-up contacts.

Noncompliance with treatment recommendations may necessitate early termination of services. I will look at your
issues with you and exercise my educated judgment about what treatment will be in your best interest. Your
responsibility is to make a good faith effort to fulfill the treatment recommendations to which you have agreed. If
you have concerns or reservations about my treatment recommendations, I strongly encourage you to express them
so that we can resolve any possible differences or misunderstandings.

If during our work together I assess that I am not effective in helping you reach your therapeutic goals, I am obliged
to discuss this with you and, if appropriate, terminate treatment and give you referrals that may be of help to you. If
you request it and authorize it in writing, I may talk to the psychotherapist of your choice (with your permission
only) in order to help with the transition. If at any time you want another professional's opinion or wish to consult
with another therapist, I will assist you in finding someone qualified. You have the right to terminate treatment at
any time. If you choose to do so, I will offer to provide you with names of other qualified professionals whose
services you might prefer.

If you commit violence to, verbally or physically threaten or harass me, the office, or my family, I reserve the right
to terminate your treatment unilaterally and immediately. Failure or refusal to pay for services after a reasonable
time is another condition for termination of services. Please contact me to make arrangements any time your
financial situation changes.
Dual Relationships

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Therapy never involves sexual, business, or any other dual relationships that could impair my objectivity, clinical
judgment or therapeutic effectiveness or could be exploitative in nature. It is possible that during the course of your
treatment, I may become aware of other preexisting relationships that may affect our work together, and I will do my
best to resolve these situations ethically, but this may entail our needing to stop working together, depending upon
the type of conflict. Please discuss this with me if you have questions or concerns.

Benefits and Risks of Psychotherapy

Participation in therapy can result in a number of benefits to you, including improved interpersonal relationships and
resolution of the specific concerns that led you to seek therapy. Working toward these benefits requires effort on
your part. Psychotherapy requires your active involvement, honesty, and openness in order to change your thoughts,
feelings, and/or behavior. I will ask for your feedback and views on your therapy and its progress. Sometimes more
than one approach can be helpful.

During the initial evaluation or the course of therapy, remembering unpleasant events, feelings, or thoughts may
result in your experiencing considerable discomfort, strong feelings, anxiety, depression, insomnia, etc. I may
challenge some of your assumptions or perceptions or propose different ways of thinking about or handling
situations that may cause you to feel upset, angry, or disappointed. Attempting to resolve issues that brought you
into therapy may result in changes that were not originally intended. Psychotherapy may result in decisions to
change behaviors, employment, substance use, schooling, housing, or relationships. Change can sometimes be quick
and easy, but more often it can be gradual and even frustrating. There is no guarantee that psychotherapy will yield
positive or intended results.

Emails, Phone Calls, and Emergencies

For small administrative matters such as checking appointment times or changing them, you are welcome to email
me at mblpc@[Link]. I generally receive and return these emails within 24 hours with the exception of
weekends.
If you need to contact me between sessions about a clinical matter, please leave a message for me at 814-572-1561. I
check my messages each day unless I am out of town. If I am planning on being out of town, I will let you know in
advance. I will also let you know who I have covering for me if I plan not to take or respond to phone messages
during my absence.
Emergency phone consultations of five minutes or less are normally free. However, if we spend more than five
minutes in a week on the phone, if you leave more than five minutes’ worth of phone messages in a week, if I spend
more than five minutes reading and responding to emails or coordination of care, I will bill you on a prorated basis
for that time.
If you feel the need for many phone calls and cannot wait for your next appointment, we may need to schedule more
sessions to address your needs. If an emergency situation arises, please indicate it clearly in your message to me. If
your situation is an acute emergency and you need to talk to someone right away, contact the closest 24-hour
emergency psychiatric service:
Dial 911 or
Go to your nearest Emergency Room:
Crisis Services (814)456-2014

Cancellations and Lateness

Missed and cancelled sessions pose some issues for both of us. First, the work of psychotherapy is sometimes
challenging and when we hit a difficult place together, it can feel easier to want to avoid coming in for treatment. I
would prefer we speak about this intentionally rather than you canceling sessions. Also, I hold your scheduled
appointment time specifically for you and you alone. I also see a limited number of clients so that I can give you the
focus and attention you deserve. It is extremely difficult for me to fill your last minute cancelled session on a short
notice. Therefore, I charge for appointments cancelled with less than 24 hours’ notice unless we can find another

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time that week that works for us both. If we are able to do, before the weekend, I will allow you to reschedule at no
extra fee.

If you are running late for your appointment, please phone or text me as soon as you can to let me know you will be
late. If I do not hear from you by 10 minutes into your session, I may assume you do not plan to attend your session.
If you are late for your session, we will still end at our regular time so that I have time to prepare for my next
appointments and I can be on time for them.
Payment and Financial Arrangements

My standard fee is $100 for a 50-minute therapeutic hour. The fee is to be paid at the start of each session unless
other arrangements have been made. If you are late, we will end on time and not run over into the next person’s
session. An annual fee increase may occur every January and I will begin to remind you of this in October and
November.

After Hours Sessions: Some patients request sessions outside of my regular therapy hours (after hours or on a
weekend). I am occasionally able to accommodate a limited number of these requests. Please note that I charge an
additional $100 fee to weekend or after hour’s sessions/meetings. These sessions will not be covered by your
insurance carrier and will be no longer than 50 minutes.

Late Fee: Full payment is expected at the time of service unless otherwise agreed upon. I expect you to remember to
send your payment, even though reminder text/emails are sent regularly.

Balances: I do not permit clients to carry a balance during treatment and if you are unable to pay this balance, we
will discuss whether it makes sense to pause your care or develop another strategy so that you can avoid incurring
additional debt. Please let me know if any problem arises during the course of therapy regarding your ability to
make timely payments.

Fee Reduction: I offer some lower fee slots, based upon income and circumstances, but I prefer to hold these slots
for current clients who are experiencing life transitions. If my fee is a concern, please discuss it with me. If I am
unable to accommodate your financial situation, I will provide you with referrals. If we arrange a reduced fee
and we are meeting weekly, we will discuss a fee increase if you decide to reduce the frequency of our meetings.

Insurance: If I am not an “In-Network Provider” with your insurance carrier, I can provide you with a monthly
billing statement for reimbursement if you wish to submit it to your insurance company. This would be considered
“Out-of-Network”. This monthly statement is your receipt for tax or insurance purposes.

Some or all your fees may be covered by your health insurance, if you have outpatient mental health coverage.
However, insurance companies do not reimburse all conditions that may be the focus of psychotherapy. It is your
responsibility to verify the specifics of your coverage. Please remember that my services are provided and charged
to you, not your insurance company, so you are responsible for payment. Fees you pay for therapy services that are
not reimbursed by insurance may be deductible as medical expenses if you itemize deductions on your tax return.
As described below in the section Health Insurance and Confidentiality of Records, be aware that submitting a
mental health invoice for reimbursement carries a certain amount of risk.

Other fees: If you become involved in legal proceedings that require my participation, you will be expected to pay
for my professional time and services even if I have been called to testify by another party. Because of the difficulty
of legal involvement and the interruption to my regular practice, I charge $500 per hour for preparation and
attendance at any legal proceeding. I will provide bills/receipts at the end of each session expect to be paid upon
receipt unless otherwise agreed upon.
Confidentiality

As a psychotherapy client, you have privileged communication. This means that your relationship with me as my
client, all information disclosed in our sessions, and the written records of those sessions are confidential and may

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not be revealed to anyone without your written permission, except where law requires disclosure. Most of the
provisions explaining when the law requires disclosure are described in the enclosed Notice of Privacy Practices.

When Disclosure Is Required by Law: Disclosure is required when there is a reasonable suspicion of child,
dependent or elder abuse or neglect and when a client presents a danger to self, to others, to property, or is gravely
disabled.

When Disclosure May Be Required: Disclosure may be required in a legal proceeding. If you place your mental
status at issue in litigation that you initiate, the defendant may have the right to obtain your psychotherapy records
and/or my testimony. If you have not paid your bill for treatment for a long period of time, your name, payment
record and last known address may be sent to a collection agency or small claims court.

In couple or relationship therapy, or when different family members are seen individually, confidentiality and
privilege do not apply between the couple or among family members. I will use my clinical judgment when revealing
such information.

Emergencies: If there is an emergency during our work together or after termination in which I become concerned
about your personal safety, the possibility of you injuring someone else, or about you receiving psychiatric care, I
will do whatever I can within the limits of the law to prevent you from injuring yourself or another, and to ensure
that you receive appropriate medical care. For this purpose, I may contact the person whose name you have provided
on your General Information form.

Health Insurance and Confidentiality of Records: Your health insurance carrier may require disclosure of
confidential information in order to process claims. Only the minimum necessary information will be communicated
to your insurance carrier, including diagnosis, the date and length of our appointments, and what services were
provided. Often the billing statement and your company's claim form are sufficient. Sometimes treatment summaries
or progress toward goals are also required. Unless explicitly authorized by you, Psychotherapy Notes will not be
disclosed to your insurance carrier. While insurance companies claim to keep this information confidential, I have
no control over the information once it leaves my office. Please be aware that submitting a mental health invoice for
reimbursement carries some risk to confidentiality, privacy, or future eligibility to obtain health or life insurance.

Confidentiality of E-mail, and Voice mail Communication: E-mail and voice mail communication can be easily
accessed by unauthorized people, compromising the privacy and confidentiality of such communication. I do use
hush mail, a service which promises secure, encrypted email. Please notify me at the beginning of treatment if you
would like to avoid or limit in any way the use of any or all these communication devices. Please do not contact me
via email or faxes for emergencies.

Consultation:
I consult regularly with other professionals regarding my clients in order to provide you with the best possible
service. Names or other identifying information are never mentioned; client identity remains completely anonymous
and your confidentiality will be fully maintained. If, for some reason, I believe it is important to consult with another
professional in-depth, and I believe identifying information about you may be shared, I will have you sign a release
of information allowing me to share this information. Without such a release, I will not consult with professional
providing information that might lead another person to be able to identify you.

Release of Information: Considering all of the above exclusions, upon your request and with your written consent,
I may release limited information to any person/agency you specify, unless I conclude that releasing such
information might be harmful to you. If I reach that conclusion, I will explain the reason for denying your request.

Complaints

If you have a concern or complaint about your treatment, please talk with me about it. I will take your criticism
seriously and respond with care and respect.

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Please let me know if you have concerns or questions about any of these policies and procedures or this agreement
for working together in psychotherapy.

When signing this document, you are confirming that you understand the contents:

_____________________________________________________________________________________________
Client Signature Date
Makeda Bostwick LPC
141 Randall Ave, Suite #2, Girard, Pa 16417 (814) 572-1561
Website: [Link] Email: mblpc@[Link]

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