Our ethical obligations
1. I and my associates are dedicated to serving the best interest of each client.
2. We will not discriminate between clients or professionals based on age, race, creed, sexual orientation, disabilities or HIV status.
3. We maintain an objective and professional relationship with each client.
4. We respect the rights and views of other mental health professionals.
5. We will appropriately terminate services or refer clients to other providers or programs when appropriate.
6. We will evaluate our personal limitations, strengths, biases, and effectiveness on an ongoing basis for the purpose of self-improvement. We will continually attain further education and training.
7. We will adhere to the Code of Ethics of the National Association of Social Workers.
Your rights as a client of ours
1. You are encouraged to discuss with Larry Cohen, LICSW, any questions, concerns, suggestions and/or complaints you may have regarding any aspect of the services I or an associate provide you. I will respond to your concerns in a timely manner. You may also submit a complaint to the U.S. Department of Health and Human Services and/or the District of Columbia Social Work Board. If you file a complaint I will not retaliate in any way.
2. Your civil rights are protected by federal and DC laws.
3. You may request services from someone with training or experience from a specific racial, cultural, spiritual, gender, or sexual orientation background. If these services are not available, we will help you in the referral process.
4. You have the right to take part in formulating your psychotherapy goals and treatment plan.
5. We will inform you of how much you will pay for each service prior to being provided that service.
6. You may refuse services offered to you and will be informed of any potential consequences.
7. We will inform you as to what behaviors could lead to termination of services at our clinic.
8. You may terminate psychotherapeutic services with us any time for any reason. Should you decided to do so, we strongly encourage you to attend at least one additional session to discuss your reasons, to try to resolve any concerns you may have, and to consult about any follow-up services to which we can refer you. If you are a member of a therapy group, you are responsible to pay the remaining group tuition due as specified in the Payment Contract for Services, below.
9. You may discuss your treatment with your doctor or another psychotherapist. We encourage you to notify us when doing so.
10. You have all the rights concerning your protected health information that are specified in the "Notice of Policy & Practices to Protect the Privacy of Your Health Information."
Your responsibilities
1. You are responsible for your financial obligations to my office as outlined in the Payment Contract for Services, below.
2. You are responsible for adhering to the norms in any group therapy contract which you have signed.
3. You are responsible for treating me, my associates and other clients in a respectful manner in which their rights are not violated.
4. You are responsible for providing accurate information about yourself.
5. You are responsible for following any other policies or rules of this office of which I have informed you.
Benefits and risks of treatment
The potential benefits of psychotherapy services with me and my associates are: to help you reach your psychotherapy goals which we have mutually agreed upon early in our work together; and to help you develop cognitive and behavioral skills and techniques which you can continue using on your own after services have ended. Success in psychotherapy does require hard and consistent work on your part both during and between sessions. Potential risks of psychotherapy services include: experiencing uncomfortable feelings, thoughts and other symptoms; and working with or otherwise experiencing unpleasant life situations.
Non-voluntary termination of services
Services to a client may be terminated non-voluntarily if: 1. the client exhibits physical violence, verbal abuse, carries weapons, or engages in illegal acts--or threatens to engage in illegal acts--at my office or directed against me or any of my associates; 2. the client refuses to comply with stipulated rules, refuses to comply with treatment recommendations, or does not make payment or payment arrangements in a timely manner. The client will be notified of the non-voluntary discharge in writing. The client may appeal this decision with me, and may request to re-apply for services at a later date.
Consent to Treatment
I, [print your full name] ____________________________________________________, the undersigned, hereby attest that I have voluntarily entered into psychotherapeutic treatment, or give my consent for the minor or person under my legal guardianship mentioned above, with Larry Cohen, LICSW, and his associates. I certify that I have received and read a copy of this "Notice of Your Rights and Responsibilities," and that I understand its content. The rights, benefits and risks associated with the treatment have been explained to me. I know I may ask Larry Cohen, LICSW, for further explanation of the provisions of this document at any time.
Signature: ______________________________________________________
Date: _____/_____/_____
Signed by: __client __guardian __personal representative
I offer a few different payment plans to try to make my services affordable, as well as to accommodate those who do not have, or do not wish to use, their insurance. I accept checks, cash or credit/debit cards (Visa and Mastercard) for face-to-face sessions. I accept credit card payment only for sessions held over the phone.
Per-Session Payment Plan for Group & Individual Therapy
My fee is $95 for individual sessions (60 minutes, whether in-person or over the phone) and $62 for group sessions (150-180 minutes, depending on group size). You agree to pay your fee at each session unless other arrangements are made with me in advance. I will give you a Statement of Service at each session or, if you prefer, once per month, for you to submit to your insurance company or employer program so that you can be reimbursed whatever you are due. In some cases, we may make arrangements in advance for me to do the submitting to your insurance company, in which case you need only pay your co-pay at each session.
If your insurer provides less coverage than was originally anticipated, then you agree to pay the difference within one week of notification. If your insurer ends coverage before a therapy group you are in is over, then you agree to continue participation for the remainder of your group commitment (20 sessions in total), making payments according to the Tuition Payment Plan (below). If you miss more than two group sessions, then you agree to pay the full fee for each such unattended session. (Insurance does not cover missed sessions.) If, for any reason, you drop out of group early, then you agree to pay for the remaining group sessions (20 in total) according to the Tuition Payment Plan (below).
There is a $10 per month late fee for any payment of yours that is over one week late.Tuition Payment Plan for Group Therapy
You agree to pay a total tuition of $200 per month for each of the five months of the group to which you have committed. There are a total of 20 group sessions in the social anxiety therapy group, averaging $50 per session. This is a 20% discount from the cost you would pay for each of the group sessions individually.
Payment is due on or before the first group session of each of the first five months of the group. Some months have more sessions than others; still, the tuition payment is $200 per month for five months. If the group continues into a sixth month, no further payments are due. No discounts or refunds are given for any sessions you do not attend. If, for any reason, you drop out of group early, then you agree to pay for the remaining group sessions according to the Tuition Payment Plan. You agree to pay for the initial individual session, as well as any subsequent individual sessions you may wish to have (whether in-person or over the phone), at the rate of $95 per session, due at the time of the session.
For those using the Tuition Payment Plan, I will not submit claims to your insurance or managed care company. Nor will I write treatment plans or make authorization requests for your insurance or managed care company. If you wish, I will give you a monthly Statement of Services at every fourth session which you may submit on your own to your insurance company or employer program in order to seek reimbursement.
There is a $10 per month late fee for any payment of yours that is over one week late.
Sliding Scale Payment Plan
(For those who have no insurance coverage and earn less than $40,000 per year or have a specific financial hardship, I try to negotiate an individualized payment plan that you can afford. The terms of this plan are written below.)
Same as the Per-Session / Tuition payment plan, except:
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Policy on Absences (for all payment plans)
Individual therapy sessions require 24 hours advance notice for a cancellation or rescheduling. The full fee is charged when less notice is given. (Insurance does not cover absences.) One hour advance notice of an absence for a group session is sufficient. (See your payment plan for any costs associated with group absences.)
Payment Contract for Services
I, [print your full name] _________________________________________, the undersigned, hereby agree to abide by the [circle one]
Per-Session / Tuition / Sliding Scale Payment Plan as well as the Policy on Absences.
Signature: ________________________________________________
Date: _____/_____/_____
Signed by: __client __guardian __personal representative