Multiple Consents/HIPAA Policy

(If child under 18)

 A: Informed Consent for Telehealth Services

One or more of your appointments at Learning Solutions may be telehealth appointments (held over Zoom or Doxy). In such cases, you need to use a webcam or smartphone. It is important to be in a quiet, private space that is free of distractions (including cell phone or other devices) during the session. It is important to use a secure internet connection rather than public/free Wi-Fi. It is important to be on time. If you need to cancel or change your tele-appointment, you must notify the Learning Solution’s staff member in advance by phone or email (see our cancellation policy above). In the event of technical problems, we may need to call you by phone, or reschedule the meeting.

If you are not an adult, we need the permission of your parent or legal guardian (and their contact information) for you to participate in telehealth sessions. Confidentiality still applies for telehealth services, and nobody will record the session without the permission from the other person(s). You should confirm with your insurance company that the video sessions will be reimbursed; if they are not reimbursed, you are responsible for full payment.


B: Consent to Treat

By signing below, you are providing consent for us to provide treatment to   and are affirming that you are legally authorized to consent to such treatment. (If you do not sign this consent form, we cannot treat you/your child.) After you have signed this consent, you have the right to revoke it, in writing received by us, and we will not provide further treatment from that time on, but we may already have provided treatment and cannot change that.


C: Cancellation Policy

  • Appointments canceled with less than 48-hour notice will be charged to me at $90.
  • Secondary insurance will be billed as a courtesy, but I am responsible for the entire balance of services performed regardless of whether there is insurance coverage.


D: Release of Information and Assignment of Benefits for Insurance




This notice describes how psychological and medical information about you may be used and disclosed and how you can get access to this information.

Please read it carefully!

  1. Uses and Disclosures for Treatment, Payment and Health Care Operations

We may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

  • “PHI” refers to information in your chart that could identify you.
  • “Treatment, Payment and Health Care Operations”

Treatment is when we provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider, such as your PCP or another therapist.

Payment is when we obtain reimbursement for your healthcare. Examples of payment are when We disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters, such as audits and administrative services, and case management and case coordination.

Use applies to activities within my practice, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

Disclosure applies to activities outside of my practice, such as releasing, transferring, or providing access to information about you to other parties.

  1. Uses and Disclosures Requiring Authorization

We may use or disclose PHI for purposes outside of treatment, payment and health care operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when We are asked for information for purposes outside of treatment, payment and health care operations, We will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes we have made about our conversation during a private, group, joint, or family counseling session, which we have kept separate from the rest of your chart. These notes are given a greater degree of protection than PHI. It is PANR’s policy not to keep separate psychotherapy notes. All documentation we keep is a part of your clinical chart.

We will also obtain an authorization from you before using or disclosing PHI in a way that has not been described in this notice.

We will not use your PHI for marketing or sales purposes under any conditions.

III. Uses and Disclosures with Neither Consent nor Authorization

We may use or disclose PHI without your consent or authorization in the following circumstances:

  • Child Abuse: If we, in our professional capacity, have reasonable cause to believe that a minor child is suffering physical or emotional injury resulting from abuse inflicted upon him or her which causes harm or substantial risk or harm to the child’s health or welfare (including sexual abuse), or from neglect, including malnutrition, we must immediately report such a condition to the Massachusetts Department of Children and Families.
  • Adult and Domestic Abuse: If we have reasonable cause to believe that an elderly person (age 60 or older) is suffering or has died as a result of abuse, we must immediately make a report to the Massachusetts Department of Elder Affairs.
  • Health Oversight: The Board of Registration that applies to my particular license to practice has the power, when necessary, to subpoena relevant records should we be the focus of an inquiry.
  • Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law and We will not release information without written authorization from you or your legally-appointed representative, or a court order. The privilege does not apply when you are being evaluated for a third party or where the court evaluation is court ordered. You will be informed in this case.
  • Serious Threat to Health or Safety: If you communicate to us an explicit threat to kill or inflict serious bodily injury upon an identified person and you have the apparent intent and ability to carry out the threat, we must take reasonable precautions. Reasonable precautions may include warning the potential victim, notifying law enforcement, or arranging for your hospitalization. We must also do so if we know you to have a history of physical violence and we believe there is a clear and present danger that you will attempt to kill or inflict bodily injury upon an identified person. Furthermore, if you present a clear and present danger to yourself and refuse to accept further appropriate treatment and we have a reasonable basis to believe that you can be committed to a hospital, we must seek said commitment and may contact members of your family or other individuals if it would assist in protecting you.
  • Workers Compensation: If you file a worker’s compensation claim, your records relevant to that claim will not be confidential to entities such as your employer, the insurer and the Division or Worker’s Compensation.

When the use and disclosure without your consent or authorization is allowed under sections of Section 164.512 of the Privacy Rule and the state’s confidentiality law, this includes certain narrowly defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a state department of health), to a coroner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.

  1. Patient’s Rights and Mental Health Clinician’s Duties

Patient’s Rights:

  • Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, we am not required to agree to a restriction you request.
  • Right to Receive Confidential Communications by Alternative Means and Alternative Locations: You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, we will send your bills to another address).
  • Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We may deny your access to PHI under certain circumstances, but in some cases, you may have the decision reviewed. On your request, we will discuss with you the details of the amendment process.
  • Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request. On your request, we will discuss with you the details of the amendment process.
  • Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, we will discuss with you the details of the accounting process.
  • Right to a Paper Copy: You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.
  • Right to Restrict Disclosures When You Have Paid for Your Care Out-of-Pocket: You have the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket or in full for my services.
  • Right to Be Notified if There is a Breach of Your Unsecured PHI: You have a right to be notified if: (a) there is a breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted to government standards; and (c) my risk assessment fails to determine that there is a low probability that your PHI has been compromised.

Mental Health Clinician’s Duties:

  • We are required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
  • We reserve the right to change the privacy policies and practices described in the notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect. If we revise my policies and procedures, we will notify current clients and post the new policies in the waiting area.
  1. Complaints

If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact our Privacy Officer: Duncan Laird at this office You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request

Effective Date and Changes to Privacy Policy

This notice will go into effect September 24, 2013. We reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain. We will notify current clients of changes in person or by mail and closed client cases can, if interested, call and ask if our policies have changed and obtain a copy by mail or view one in our waiting area.

I understand and acknowledge the HIPAA regulations for Learning Solutions for Learning Success, Learning Solutions for Learning Success, LLC.

Out Patient Services Contract

Welcome to our practice. This document contains important information about our professional services and business policies. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us.


Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you bring forward. There are many different methods we may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.

Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems and significant reductions in feelings of distress. But there are no guarantees of what you will experience.

Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, we will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about our procedures, we should discuss them whenever they arise. If your doubts persist, we will be happy to help you set up a meeting with another mental health professional for a second opinion.



The fee is $200.00 for the first session. Each additional hour will be billed at the rate of $175.00 per hour for a psychologist and $150.00 per hour for a clinical social worker. We charge the above-mentioned fees for any other professional services you may need relating to therapy, though we will break down the hourly cost if we work for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 15 minutes, preparation of records or treatment summaries, and the time spent performing any other service you may request of us.

Speech Language Evaluation

The fee is $950.00 for a speech evaluation and $90.00-$110 per hour for speech therapy, depending on the type of therapy needed. We charge the aforementioned fee for any other professional services you may need relating to therapy, though we will break down the hourly cost if we work for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 15 minutes, preparation of records or treatment summaries, and the time spent performing any other service you may request of us.

Educational Evaluation

The fee is $1200.00 for the educational evaluation. We charge the above-mentioned fees for any other professional services you may need relating to the evaluation or tutoring, though we will break down the hourly cost if we work for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 15 minutes, preparation of records or treatment summaries, and the time spent performing any other service you may request of us.

Educational Tutoring

The fee is 85.00 an hour and is a regular once a week appointment and not billable through your insurance company.

Psychological/Neuropsychological Testing

We charge $175.00 per hour for testing. An hour of testing may include the actual face-to-face contact with the student/adult, data collection and scoring, report writing, interpretation and record review. In addition, we charge $175.00 per hour for any authorized telephone and/or face-to-face consultation with any person that we have agreed has information about you (if you are the client) or your student. We also charge $175.00 for the Learning Solutions Summary Meeting where the discussion about your student or you (if you are the one being evaluated) occurs. This meeting happens prior to your Summary Meeting with all the professionals at Learning Solutions who evaluated your student or you. We charge $175.00 for the time spent performing any other service you may request of us that has to do with the evaluation.

School Consultation/Meetings

We charge $175.00 per hour for each school meeting we attend including IEP meetings. If additional consultation is needed for your student with their school, we charge $175.00 per hour to consult with their teacher, tutor, principal, school professional or other administrator.

School consultation around educational programming and accommodations is billed at a rate of $250.00.

Legal Proceedings

If you become involved in legal proceedings that require our participation, you will be expected to pay for our professional time even if we are called to testify by another party. Because of the difficulty of legal involvement, we charge $250.00 per hour for preparation and attendance at any legal proceeding. If we are to be in court for a full day, we charge $2000.00 for the day.


You will be expected to pay for each session at the time it is held, unless you have insurance coverage which requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, we may be willing to negotiate a fee adjustment or payment installment plan.

We are requesting that you provide a credit card number to be kept on file, in a secure setting, for payments such as insurance deductibles, coinsurance and copays for services rendered.

If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we 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 we release regarding a patient’s treatment is his/her name, the nature of service provided and the amount due.


In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for medical/mental health treatment. We will fill out forms and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of our fees. It is very important that you find out exactly what medical/mental health services your insurance policy covers.

You should carefully read the section in your insurance coverage booklet that describes medical/mental health services. If you have questions about the coverage, call your plan administrator. Of course, we will provide you with whatever information we can based on our experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, we will be willing to call the company on your behalf.

Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs require authorization before they provide reimbursement for medical/mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow us to provide services to you once your benefits end. If this is the case, we will do our best to find another provider who will help you continue your services.

You should also be aware that most insurance companies require you to authorize us to provide them with a clinical diagnosis. Sometimes, we have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, we have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. We will provide you with a copy of any report we submit if you request it.

Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for services yourself to avoid the problems described above unless prohibited by contract.


We are often not immediately available by telephone. While we are usually in our office between 8:00 a.m. and 8:00 p.m., we probably will not answer the phone when we are with a patient. When we are unavailable, our telephone is answered by voice mail or by our secretary, whom we monitor frequently and who knows where to reach us. We will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform us of sometimes when you will be available. In emergencies, please contact Emergency Services at (413) 586-5555. If you are unable to reach us and feel that you can’t wait for us to return your call, contact your family physician or the nearest emergency room and ask for the psychologist/psychiatrist on call. If we will be unavailable for an extended time, we will provide you with the name of a colleague to contact, if necessary.


The laws and standards of our profession require that we keep treatment records. You are entitled to receive a copy of your records, or we can prepare a summary for you instead.

Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, we recommend that you review them in our presence so that we can discuss the contents. We are sometimes willing to conduct a review meeting without charge. Patients will be charged an appropriate fee for any professional time spent in responding to information requests.


If you are under 18 years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is our policy to request an agreement from parents that they agree to give up access to your records. If they agree, we will provide them only with general information about our work together, unless we feel there is a high risk that you will seriously harm yourself or someone else. In this case, we will notify them of our concern. We will also provide them with a summary of your treatment when it is complete. Before giving them any information, we will discuss the matter with you, if possible, and do our best to handle any objections you may have with what we are prepared to discuss. At the end of your treatment, we will prepare a summary of our work together for your parents, and we will discuss it before we send it to them.


In general, the privacy of all communications between a patient and a psychologist is protected by law, and we can only release information about our work to others with your written permission. But there are a few exceptions.

In most legal proceedings, you have the right to prevent us from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order our testimony if he/she determines that the issues demand it.

There are some situations in which we are legally obligated to take action to protect others from harm, even if we have to reveal some information about a patient’s treatment. For example, if we believe that a child, elderly person or disabled person is being abused, we may be required to file a report with the appropriate state agency.

If we believe that a patient is threatening serious bodily harm to another, we are required to take protective actions. These actions may include notifying the potential victim, contacting the police or seeking hospitalization for the patient. If the patient threatens to harm himself/herself, we may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. These situations have rarely occurred in our practice. If a similar situation occurs, we will make every effort to fully discuss it with you before taking any action.

We may occasionally find it helpful to consult other professionals about a case. During a consultation, we make every effort to avoid revealing the identity of our patient. The consultant is also legally bound to keep the information confidential. If you don’t object, we will not tell you about these consultations unless we feel that it is important to our work together.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have at our next meeting. We will be happy to discuss these issues with you if you need specific advice, but formal legal advice may be needed because the laws governing confidentiality are quite complex and we are not attorneys. If you request, we will provide you with relevant portions or summaries of the state laws regarding these issues.

Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.


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Document name: Multiple Consents/HIPAA Policy
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October 19, 2021 7:58 am EDTMultiple Consents/HIPAA Policy Uploaded by Leslie Roberts - IP
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