Treatment Policies Form

TREATMENT POLICIES
Please sign below, indicating that you have read and understand this Consent to
Treatment form, and agree to abide by treatment policies.

1. I agree to be responsible for charges due to Dr. Winston Wilde for services rendered to me. Services rendered include fifty minute long psychotherapy sessions as well as any other services specifically requested by the patient which may include but are not limited to: psychological testing, paperwork preparation, court appearances, and consultations with other professionals.

2. Fees are agreed upon at the beginning of treatment. Fees are due at the beginning of each session unless otherwise negotiated. If the fee was negotiated according to the patient’s ability to pay, the fee may be renegotiated and raised according to the patient’s increased income. Fees may be reset annually to account for cost of living increases. All checks are to be made payable to Winston Wilde.

3. Dr. Wilde will be happy to help you process your insurance claims for reimbursement for your payments to him. You will receive a monthly statement from this office via postal mail to accompany your insurance claim form.

4. I understand that I will be charged in full for any session missed, and for any session canceled with less than 24 hours notice.

5. Professional records: Both law and standards of the profession require that appropriate treatment records be kept. These records include a summary of your history and other pertinent information, a diagnosis if appropriate, and a preliminary treatment plan. Also included is a typically brief summary of each session, a record of your payments and any other information pertinent to your treatment.

6. Confidentiality: In general, the confidentiality of all communications between a patient and a psychotherapist is protected by law, and Dr. Wilde can only release information about psychological treatment with your written permission. However, there are a number of exceptions and disclosure may be required in the following circumstances: where there is reasonable suspicion of child or elder abuse or neglect; where there is reasonable suspicion that the client presents a danger of violence to others or when the client is likely to harm him/herself unless protective measures are taken. In most judicial proceedings, you have the right to prevent your therapist from providing any information about your therapy. However, in some circumstances, such as child custody proceedings and proceedings in which your emotional condition is an important element, a decision by a judge or an uncontested valid subpoena may result in the loss of confidentiality of your records.

Good Faith Estimate Notice
You have the right to receive a “Good Faith Estimate” explaining how much your 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 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 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 or call (800) 985-3059.