LAURA FEDERICO, MS, LCSW, CST
POLICIES + CLIENT SERVICE AGREEMENT
As a Licensed Clinical Social Worker, I am governed by various laws
and regulations and by the code of ethics of my profession. The
ethics code requires that I make you aware of my specific practice
policies and procedures, how these policies and procedures may
affect you, and your rights as a client. I welcome any questions
you may have about this document and will address them during your
intake appointment. I am registered and licensed in New York State
and am located in Canada at this time.
CONFIDENTIALITY OF DISTANCE SUPPORT
The laws that protect the privacy and confidentiality of sensitive
information, which may include both the United States Health
Insurance Portability and Accountability Act, the Swiss Federal Act
on Data Protection, and other applicable federal, state and
international laws, also apply to distance support. I contract with
a HIPAA-compliant office platform, CounSol, which allows us to
communicate through secure and safe written messaging, video and
instant message sessions, and keeps sensitive information
protected.
We conduct our clinical communication through our CounSol online
office, allowing for safe and secure support.
There are risks from teletherapy, including, but not limited to,
the possibility, despite reasonable efforts on my part, that: the
transmission of sensitive information could be disrupted or
distorted by technical failures; the transmission of sensitive
information could be interrupted by unauthorized persons; and/or
the electronic storage of sensitive information could be accessed
by unauthorized persons. You agree that I am not responsible for
disruptions or interruptions to our communications.
I ask that you determine who has access to your computer and
electronic information prior to our sessions. This would include
family members, co-workers, supervisors and friends. I encourage
you to only communicate through a computer that you know is safe,
i.e. wherein confidentiality can be ensured. Be sure to fully exit
all online teletherapy sessions and emails. I encourage you to find
a location for our sessions with proper lighting, limited audio and
visual distractions, and a sound barrier to prevent others
overhearing the session.
If you choose to email me from your personal email account, please
limit the contents to basic issues such as cancellation or change
in contact information. I will not respond to clinical concerns via
regular email. If you want to send personal or clinical information
by email then you will need to communicate with me using encrypted
and secure messages via CounSol. You are responsible for
information security on your computer or device. If you decide to
keep copies of our confidential clinical correspondence on your
computer or device, it is your responsibility to keep that
information secure.
There is the possibility of an interruption in service due to
technical difficulties or poor visual quality. In the event that
this happens, I will re-initiate the session. If reconnection is
not possible, then we will message to reschedule. Please note that
CounSol has state of the art HIPAA-compliant security,
including:
Servers housed in Tier-IV data center with SSAE16, HITRUST, ISO
27001 & PCI 2.0 compliance
PCI (Payment Card Industry) standards applied to our internal
systems and software
All traffic is required to use SSL (Secure Socket Layer) with
256-bit encryption
Unique login for all users
Logging of all user activity
256-bit encryption of all sensitive data
No sensitive information is sent via email, only notifications to
login will be sent
Data backed up hourly using 256-bit encryption
Please note that CounSol is located in the United States and that
your personal data may be processed in the United States, Canada,
and the European Union, and you agree to such processing. In
addition, CounSol uses software tags known as "cookies" within
certain functions of its web sites to remember its visitors'
preferences and to maximize the performance of the site and the
individual's experience. Access to certain functionality may not be
available to individuals that do not give their consent to the data
processing carried out through cookies or whose browsers are set to
reject all cookies.
Teletherapy may not be as complete as face-to-face support. I will
tell you if I believe you would be better served by face-to-face
services and will refer you to a practitioner who can provide such
services if necessary. I do not provide emergency or crisis
services within my practice, and will refer you to appropriate
services if it seems distance support is not clinically appropriate
for you at this time.
PROFESSIONAL RECORDS
The laws and standards of my profession require that I keep
Protected Health Information (PHI) about you in your clinical
record. Your clinical record may contain information such as a
diagnosis, intake information, consent to treatment, treatment
plan, phone and email contact, and treatment notes. Treatment notes
are brief summaries of our individual sessions outlining important
issues, facts, or any treatment recommendations discussed. Except
in unusual circumstances that involve danger to yourself and/or
others or where information has been supplied to me confidentially
by others, you may request in writing to examine and/or receive a
copy of your clinical record. These are professional records that
can be misinterpreted and/or upsetting to untrained readers. For
this reason, I strongly recommend that you review them in my
presence or upon your written consent, have them sent to another
mental health professional to review with you. For more information
regarding how I can use and disclose your PHI, please refer to my
Notice of Privacy Practices.
FEES + PAYMENT FOR SERVICES
My current fee for a standard teletherapy session of 45 minutes is
$300, for an extended 60-minute session the fee is $350. My current
fee for sex therapy consultation is $300 for a 50-minute session.
My current fee for couples is $350 per 50-minute session. While I
no longer offer payment packages, the last offered full fee monthly
teletherapy plan is $800. This includes 4 standard sessions of 45
minutes as well as written communication between sessions
pertaining to client care plan. This package will be paid in full
at the beginning of one's billing month, and expires 30 days later.
Messaging between sessions is often a service utilized as part of
your treatment plan - the scope of written communication is
determined by me after careful consideration of best client care.If
a true hardship exists, I will take such matters into
consideration. I reserve about 20% of my practice for reduced-rate,
sliding scale and pro-bono clients. If finances prohibit us from
continuing to work together, I will do my best to direct you
towards a referral better suited to your needs. Fees are to be paid
at time of service through my confidential website. You will be
notified in advance in writing if any changes in fees are to be
made. Please discuss with me if circumstances prohibit you from
paying your bill on a monthly or weekly basis. I am unable to
accumulate balances; if your account is more than 60 days past-due
and suitable arrangements for payment have not been agreed upon, I
have the option of suspending or discontinuing your treatment. If
you carry an unpaid balance after the time of service, the card you
have on file will automatically be run to pay your outstanding
fees. I do not participate in any US or European insurance plans at
this time.
CONTACT BETWEEN SESSIONS
I do not provide emergency services within my practice. A crisis
resource for 24/7 mental health support is the National Suicide
Prevention Hotline 800-273-8255 (24/7) Online
chat: https://suicidepreventionlifeline.org/chat/ (24/7). In
the event of a life or limb-threatening emergency, always call 911
or go to the nearest emergency room. To contact me between
sessions, I ask that you utilize CounSol's safe and secure
messaging platform. I check these messages every 24 hours and will
respond accordingly. In the instance I will be unavailable for an
extended period of time, I will provide you with a referral in
advance.
SESSIONS + CANCELLATION
All sessions will be made in advance by appointment. Other than for
true emergencies, it is expected that you will attend your
scheduled session. If canceling is necessary, I require a minimum
of 48 hours notice; if notice is given under 48 hours, I will
charge you my normal fee of $300 per 45-minute session, $350 per
extended 60-minute session, $350 for a couples/relationship
session, and $300 for a 50-minute sex therapy consultation. If
you have a monthly plan, your missed session will be rolled into
your monthly fee, and will not be deducted from the overall package
cost. I try to accommodate requests to reschedule when conflicts
arise, though it must be within the same week of your appointment
time and is subject to my availability. If you are more than 15
minutes late to a 45-minute session, the session will be
rescheduled and charged in full. 30 minutes or less is not enough
time to ethically and responsibly begin and carefully close an
emotional process.
ENDING SERVICES
You have the right to end services at any time. Should you decide
between sessions to withdraw from services, I request that you
attend at least one additional teletherapy session to discuss the
reasons with me.
COUPLES, POLY, AND RELATIONSHIP SESSIONS
"Couple", used below, includes clients in all types of
relationship constellations.
Boundaries: Because the relationship is the main focus of couples
and relationship therapy both partners of a couple must be
present for the couples session to start. It is often not in the
best interest of the couple to distribute time unevenly between
partners or to have unplanned meetings with only one partner
present. If one partner is late in arriving or does not show for
the appointment, I reserve the right to delay the start of the
session or to cancel the session if necessary.
No secrets: As a couples therapist who IS entrusted with
information from both partners in a relationship, I have a policy
of "No Secrets", which means that I cannot promise to protect
secrets of either partner from the other person, especially if
the secret is harmful or destructive to the process of the
therapy itself or undermines the agreed-upon intention of the
therapy.
Confidentiality: When you attend sessions with a psychotherapist,
the information you share is protected by strict confidentiality
laws enforced both by the licensing board governing my license
and state law. Without your written consent and permission, I
cannot reveal whether or not you are a client of mine and cannot
discuss any information from our sessions with a third party. The
following are exceptions to this rule: If one of you poses an
imminent danger to yourself, your partner, or a third person, I
am allowed to disclose information to law enforcement personnel
or hospital staff to keep you safe and coordinate care. If you
talk about events that lead me to believe that a child under the
age of 18 or an elderly or disabled person is at risk of
emotional, physical, or sexual abuse, neglect, or exploitation, I
am required by law to make a report to New York Family or Adult
Protective Services. If you disclose sexual misconduct by a
previous therapist I am required to make a report to their
licensing board. If a judge in a court of law orders me to
release information or if I need to respond to a lawfully issued
subpoena. If I need to cooperate with legal actions against a
mental health professional by a licensing board.
The couple and relationship is the client: When you attend
couples therapy sessions, you as a couple are considered to be
"the client" and your mental health records therefore belong to
both of you. This means that except in the circumstances above, I
will need written consent from both of you in order to disclose
any information from your record to a third party.
Couples and relationship treatment involves 1. Assessment: This
process includes an interview with the couple, followed by
individual interviews with each partner. Couples also complete
online questionnaires which provide comprehensive data on the
relationship's strengths and challenges. Feedback on the results
of the assessment is provided, and the recommended areas for
intervention are discussed. This phase yields a
scientifically-based, personalized treatment plan from which
interventions are selected. 2. Therapeutic Intervention: In this
phase, structured interventions that are designed to strengthen
friendship, intimacy, and conflict management are introduced and
practiced in each session. Couples learn to replace negative
conflict patterns with positive interactions and to repair past
hurts, and begin to create shared meaning and purpose in their
relationship. The therapy ends once couples have reduced the
behaviors that predict a split and are able to effectively use
conflict management tools without the therapist.
What to expect: Couples and relationship therapy is a process of
identifying interaction and communication patterns that are
negatively impacting the friendship, intimacy, and fulfillment of
needs of any partners in a relationship. Each partner will be
expected to honestly examine their own interaction and
communication styles, identify and express their own feelings,
and make an attempt at experimenting with alternative methods of
communicating and interacting. Each partner will be helped to
further clarify their own values and their own level of
commitment to the relationship, and the outcome of the therapy
may be increased satisfaction with the partnership or increased
clarity about the decision to part ways.
Limitations to couples therapy: Couples Therapy has been shown to
have benefits for couples. It often leads to a significant
reduction of feelings of distress, resolution of specific
problems, and a stronger relationship. In many cases, it has
moved couples from thinking of ending their relationship to
recommitting to it in new ways. However, it is important that you
also understand the risks involved. You will be asked to address
areas of difficulty in your relationship. As a result, you and/or
your partner may experience uncomfortable feelings like sadness,
guilt, anxiety, anger, loneliness, and helplessness. Your therapy
may also involve recalling unpleasant aspects of your history
together and/or individually. Difficulties between the two of you
may become temporarily amplified. Additionally, difficulties with
people important to you may also occur, family secrets may be
disclosed, and despite our best efforts, therapy may not work out
well. Deliberate dishonesty or deceit, unwillingness to
introspect and take responsibility for one's actions, or lack of
interest and motivation to engage in the couples' therapy process
by one or both partners will undermine the therapy. Thus, we can
make no guarantees about how the therapy process will be for you
specifically or what the outcome will be for your relationship.
In addition, couples therapy is not advisable in the following
situations: If there is active alcohol and/or drug misuse on the
part of either or both partners, from either partner's
perspective If there is serious violence in your relationship,
threats by one or both partners that serious violence might
occur, or fear of such serious violence on the part of one or
both partners, if either partner currently has an untreated major
mental illness. This does not include past, successfully treated
psychotic episodes. If there is an undisclosed, current affair
that you are not willing to disclose (such secrets predict
marital therapy failure) If either partner is currently
experiencing suicidal or homicidal thoughts, or has a history of
serious harm inflicted on him/herself or another person. Couple
and relationship therapy will only be effective in cases where
both partners put in a good faith effort to work on their
problems and their relationship. Deliberate dishonesty or deceit,
unwillingness to introspect and take responsibility for one's
actions, or lack of interest and motivation to engage in the
couples therapy process by one or both partners will undermine
the therapy.
GOVERNING LAW
You agree that this Agreement, the rights, and obligations
hereunder, and any claims or disputes remaining thereto,
including, but not limited to, disputes regarding fees and/or
malpractice or other tortious or contractual claims, shall be
governed by and construed in accordance with the laws of the
State of New York without regard to its rules with respect to
conflicts of laws. I further understand that in the event of
litigation arising from a dispute, the federal and state courts
located in the County of New York, State of New York (where I am
licensed), and the courts and regulatory agencies and bodies
therein, shall serve as the venue for all legal disputes. By
entering into the Agreement, you consent to the courts of the
State of New York having personal jurisdiction over me for all
disputes arising in connection with this Agreement.
I agree to the terms and conditions contained in this Client
Services Agreement. I agree to pay for each scheduled therapy
session for the fee established with Laura Federico, MS, LCSW. I
understand that I am financially responsible for paying for all
scheduled sessions. I agree to provide updated credit card
information to be kept on file to cover the cost of scheduled
sessions that I did not show up for or that I did not cancel with
at least 48 hours advance notice. I accept that any missed
appointments or late cancellations will result in my credit card
being charged the regular fee amount for individual sessions as
outlined in this Client Services Agreement. Any unpaid balance
will be charged on my registered credit card at the end of every
billing month.
GOOD FAITH ESTIMATE
Provider EIN # 83-2233922
Provider NPI# 1851898712
License LCSW #73 083023
IMPORTANT: A formal diagnosis may occur after a diagnostic
assessment has been completed. Your therapist will discuss, as
relevant, diagnosis(es) as applicable to treatment. It is within
your rights to decline a formal diagnosis.
Effective January 1, 2022, a ruling went into effect called the
"No Surprises Act," which requires mental health practitioners to
provide a "Good Faith Estimate" (GFE) about out-of-network care
to any patient who is uninsured or who is insured but does not
plan to use their insurance benefits to pay for health care items
and/ or services. You're getting this notice because this
provider or facility isn't in your health plan's network.
The Good Faith Estimate works to show the cost of items and
services that are reasonably expected for your mental health care
needs for an item or service. The estimate is based on
information known at the time the estimate was created. The Good
Faith Estimate does not include any unknown or unexpected costs
that may arise during treatment. The Good Faith Estimate does not
describe Out Of Network reimbursement benefits, which can reduce
the cost of each session.
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 upon the initiation of
psychotherapy, 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.
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.
Primary Service or Item Requested/Scheduled: Psychotherapy
Session
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, depend 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.
______________________________________________________________________________
The current fee for a standard 45-minute psychotherapy session
(via Telehealth) is $300. The current fee for an extended
60-minute psychotherapy session (via Telehealth) is $350. For a
sex therapy consultation (via Telehealth), the fee is $300. For a
couples/relationship session (via Telehealth), the fee is $350
for 50 minutes.
All session fees include out-of-session written correspondence,
homework collaboration, journal processing, and any
treatment-related client/therapist collaboration via the HIPAA
secure online office.
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 individual needs and preference. It is also important, when
determining your total estimate, to take into consideration
vacations, holidays, emergencies, and sick time.
You may project any potential future cost(s) by multiplying the
session fee by the total number of sessions. This will result in
your total estimated cost for mental health service(s). For
example, $300 for a standard 45-minute session x 4 sessions =
$1200. If you attend therapy for a longer period, your total
estimated charges will increase according to the number of visits
and length of treatment. We are providing you with this good
faith estimate based on the information the clinician has
available at this time and actual items, services, or charges may
differ from this good faith estimate as treatment progresses. The
frequency of these visits may vary depending upon your
needs.
Based on the fee scale detailed above, the following are expected
charges of psychotherapy services: Total estimated weekly charges
for 1 session per week
-45-min standard $300
-60-min extended $350
-Sex therapy consultation 45-min $300
-Couples/Polycule/Relationship 50-min $350
Apply the above fee scale as it relates to your treatment - if
you have biweekly sessions, multiply the cost of one session
times two in order to determine your monthly cost. The same
equation applies to monthly or as-needed sessions. During the
course of psychotherapy treatment, you may be subject to
additional costs based on time, frequency, and services
rendered.
See below for a list of possible additional services:
Additional Fees Estimated potential fees based on time, frequency
and services rendered
Cancellation Fee 0 if cancelled with 48 hours notice, full fee if
cancelled within 48 hours of scheduled session
Record Request Fee $25 admin plus cost of postage and
printing
Consultation With Other Providers $50 billed in 1/2 hours *this
does not apply to regular treatment planning, which is covered as
a part of session fee
Letter or Report Writing $325 per request
Crisis Communication (between sessions) billed at $350 per hour
Travel Time for Out of Office Sessions or Court Appearances In
this instance, a new Good Faith Estimate will be provided based
on circumstances, services, and amount of time needed including
the cost of a retainer and hourly fees
Forensic and/or Legal Fees A new Good Faith Estimate will be
provided to you based on the services and amount of time needed
______________________________________________________________________________
Laura Federico Psychotherapy recognizes every client's therapy
journey is unique. How long you need to engage in therapy and how
often you attend sessions will be influenced by many factors
including:
-Your schedule and life circumstances
-Therapist availability
-Ongoing life challenges
-The nature of your specific challenges and how you address
them
-Personal finances and resources
You and your therapist will continually assess the appropriate
frequency of therapy and will work together to determine when you
have met your goals and are ready for discharge and/ or a new
"Good Faith Estimate" will be issued should the frequency of
session(s) or needs change. As related, you may request a new GFE
at any time in writing during your treatment.
Good Faith Estimate Disclaimer: This Good Faith Estimate shows
the costs of items and services that are reasonably expected for
your health care needs for an item or service. The estimate is
based on information known at the time the estimate was created.
Your provider may recommend additional services that are not
reflected in this Good Faith Estimate. The Good Faith Estimate is
only an estimate-actual items/ service charges may differ. The
Good Faith Estimate does not include any unknown or unanticipated
costs that may arise and are not reasonably expected during
treatment due to unforeseen events. You could be charged more if
complications or special circumstances occur.
Other potential items and/ or services associated with therapy
charges may include but is not limited to no show/ late
cancellation fee(s), record request(s), letter writing(s), legal
fee(s)/ court attendance(s), professional collaboration(s), and
in-between session support). These potential items/services and
associated fee(s) are discussed further within the "Therapy
Consent, Policies, and Agreements" documentation, and should
these items/services be initiated a new Good Faith Estimate will
be provided. The Good Faith Estimate does not obligate the client
to obtain listed items or services.
The Good Faith Estimate does not include any unknown or
unexpected costs that may arise during treatment. You could be
charged more if complications or special circumstances occur. If
this happens, and your bill is $400 or more for any provider or
facility than your Good Faith Estimate for that provider or
facility, federal law allows you to dispute the bill. 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. You may
contact the health care provider or facility listed to let them
know the billed charges are higher than the Good Faith Estimate.
You can ask them to update the bill to match the Good Faith
Estimate, ask to negotiate the bill or ask if there is financial
assistance available. You may also start a dispute resolution
process with the U.S. Department of Health and Human Services
(HHS). If you choose to use the dispute resolution process, you
must start the dispute process within 120 calendar days (about 4
months) of the date on the original bill. If you dispute your
bill, the provider or facility cannot move the bill for the
disputed item or service into collection or threaten to do so, or
if the bill has already moved into collection, the provider or
facility has to cease collection efforts. The provider or
facility must also suspend the accrual of any late fees on unpaid
bill amounts until after the dispute resolution process has
concluded. The provider or facility cannot take or threaten to
take any retributive action against you for disputing your bill.
There is a $25 fee to use the dispute process. If the Selected
Dispute Resolution (SDR) entity reviewing your dispute agrees
with you, you will have to pay the price on this Good Faith
Estimate, reduced by the $25 fee. If the SDR entity disagrees
with you and agrees with the health care provider or facility,
you will have to pay the higher amount.
To learn more and get a form to start the process, go to
www.cms.gov/nosurprises/consumers or call 1-800-985-3059. For
questions or more information about your right to a Good Faith
Estimate or the dispute process, visit
www.cms.gov/nosurprises/consumers, email
FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059. Keep a
copy of this Good Faith Estimate in a safe place.
