Informed Consent

Fees and Insurance The fee for service is $200 per therapy hour (50 minute session). 

Individual Sessions and conjoint (marital /family) sessions are approximately 50, or 90 minutes if you choose. Fees are payable at the time that services are rendered.  

By this agreement, you acknowledge that the therapist is not on any insurance preferred  provider panels and has no relationship with insurance companies, nor Medicare, and aside from providing you  with a receipt which you may elect to use to get reimbursement commensurate with your  coverage, the therapist does not engage in insurance billing. Any amount of reimbursement and  the amount of any co-payments or deductible depends on the requirements of your specific  insurance plan. You should be aware that insurance plans generally limit coverage to certain  diagnosable mental conditions. You should also be aware that you are responsible for verifying  and understanding the limits of your insurance coverage. As such, we are unable to guarantee  whether your insurance will provide payment for the services provided to you. 

If for some reason you find that you are unable to continue paying for your therapy, you should  inform your therapist. Your therapist will help you to consider any options that may be available  to you at that time.  

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You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost. Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the expected charges for medical services, including psychotherapy services. 

You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency healthcare services, including psychotherapy services.

You can ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule a service.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.

 For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.

YOUR GOOD FAITH ESTIMATE

Provider Name Alexander J Mackenzie, MFT

License/#: MFT29374

Provider Phone #: ( 408   ) 359-7427
 

For Psychotherapy – individual, group, family, and/or conjoint couple therapy, You are entitled to receive this “Good Faith Estimate” of what the charges could be for psychotherapy services provided to you. While it is not possible for a psychotherapist to know, in advance, how many psychotherapy sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of psychotherapy sessions you attend, your individual circumstances, and the type and amount of services that are provided to you.

There may be additional items or services I may recommend as part of your care that must be scheduled or requested separately and are not reflected in this good faith estimate. This estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here. 

You have the right to initiate a dispute resolution process if the actual amount charged to you substantially exceeds the estimated charges stated in your Good Faith Estimate (which means $400 or more beyond the estimated charges).

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit https://www.cms.gov/nosurprises/consumers or call 1- 800-985-3059. The initiation of the patient-provider dispute resolution process will not adversely affect the quality of the services furnished to you.

The fee for a 50-minute psychotherapy visit (in-person or via telehealth) is $___200____.  Most clients will attend one psychotherapy visit per week, but the frequency of psychotherapy visits that are appropriate in your case may be more or less than once per week, depending upon your needs. Based upon a fee of $___200____ per visit, if you attend one psychotherapy visit per week, your estimated charge would be $800_______for four visits provided over the course of one month; $__1600_____for eight visits over two months; or $___2400_____for 12 visits over three months.  If you attend therapy for a longer period, your total estimated charges will increase according to the number of visits and length of treatment.

This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of psychotherapy visits. The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your therapist.  You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.

You are encouraged to speak with your provider at any time about any questions you may have regarding your treatment plan, or the information provided to you in this Good Faith Estimate.

Date of this Estimate : Estimate is dated in accordance with e-signature or verbal acceptance of informed consent terms and conditions.     

Confidentiality:  As with all HIPAA-protected records, All communications between you and your therapist will be held in strict  confidence unless you provide written permission to release information about your treatment. If  you participate in marital or family therapy, your therapist has a "no secrets" policy, which means that he will not keep secrets between participants in a conjoint (relationship) therapy. When you participate in family, and/or marital/couples therapy, your  therapist is permitted to use information obtained in an individual session or other communication that you may have had  with him or her, when working jointly or individually with other members of your family. Please feel free to ask your  therapist about his or her “no secrets” policy and how it may apply to you.  (For example, if you disclose infidelity, I may not keep that secret.)

There are exceptions to confidentiality. For example,  therapists are required to report instances of suspected child, dependent adult or elder abuse. 

Therapists may also be required or permitted to break confidentiality when they have determined  that a patient presents a serious danger of physical violence to another person or when a patient  is dangerous to him or herself. 

If you participate in marital or family therapy, your therapist will not disclose confidential  information about your treatment unless all person(s) who participated in the treatment with you  provide their written authorization to release such information.  

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Minors and Confidentiality Communications between therapists and patients who are minors  (under the age of 18) are confidential. However, parents and other guardians who provide  authorization for their child’s treatment are often involved in their treatment. Consequently, your  therapist, in the exercise of his or her professional judgment, may discuss the treatment progress  of a minor patient with the parent or caretaker. Patients who are minors and their parents are  urged to discuss any questions or concerns that they have on this topic with their therapist.  

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Appointment Scheduling and Cancellation Policies:  Sessions are typically scheduled to occur one  time per week at the same time and day if possible. Your therapist may suggest a different  amount of therapy depending on the nature and severity of your concerns, and you are free to accept or reject that recommendation. Your consistent  attendance greatly contributes to a successful outcome.

In order to cancel or reschedule an  appointment, notify your therapist at least 24 hours in advance of your  appointment. If you do not provide at least 24 hours’ notice in advance, you  are responsible for payment for the missed session.  Please understand that your insurance  company will likely not pay for missed or canceled sessions.  

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Therapist Availability/Emergencies: You are welcome to phone, text, or email your therapist in between  sessions. However, as a general rule, it is our belief that important issues are better addressed  within regularly scheduled sessions. You may leave a message for your therapist at any time on  his confidential voicemail. If you wish your therapist to return your call, please be sure to  leave your name and phone number(s), along with a brief message concerning the nature of your  call. Non urgent phone calls are returned during the therapist’s normal workdays within 24  hours. If you have an urgent need to speak with your therapist, please indicate that fact in your  message and follow any instructions that are provided by your therapist’s voicemail. In the event  of a medical or psychiatric emergency or an emergency involving a threat to your safety or the  safety of others, please call 911 to request emergency assistance. Please be sure to leave your  name and phone number(s), along with a brief message concerning the nature of your call. In the  event of a medical or psychiatric emergency or an emergency involving a threat to your safety or  the safety of others, please call 911 to request emergency assistance.

Electronic Communications

Potential Risks

Electronic Communications: Potential risks of using electronic communication may include, but are not limited to; inadvertent  sending of an e-mail or text containing confidential information to the wrong recipient, theft or  loss of the computer, laptop or mobile device storing confidential information, and interception  by an unauthorized third party through an unsecured network. E-mail messages may contain viruses or other defects and it is your responsibility to ensure that it is virus-free. In addition, e mail or text communication may become part of the clinical record.  

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You further understand and agree that any virtual  (zoom sessions) may be electronically summarized by the Zoom AI Meeting Summary technology.  You will receive a notification on your screen each time, and can ask the therapist not to use this if you object

Our Partnership/Advice