CONFIDENTIALITY

The law protects the privacy of all communications between a patient and a therapist. In most situations, if you are 18 years of age or older, I can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA and Illinois law. However, there are several situations in which no authorization is required.  Examples are listed below.  Please see the HIPAA Privacy Notice on page 8 for details and website link for more information.

Consultation with other health or mental health professionals
Teaching and supervision
Malpractice suits or complaints
Judicial and administrative proceedings (e.g., if you are involved in court proceedings)
Workman’s Compensations claims
Government/Health Agency oversight
Health Insurer payment or collection on overdue fees

 

Therapists are mandated reporters.  As such, there are some situations in which I am legally obligated to take actions in order to protect you and others from harm.  If these circumstances arise in the course of your treatment, I may be required to reveal information about you or your treatment without your specific authorization.  If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary.

Exceptions to confidentiality:

If I have reasonable cause to believe that a child under 18 known to me in my professional capacity may be an abused child or a neglected child, the law requires that I report this to the local office of the Department of Children and Family Services.

If I have reason to believe that an adult over the age of 60 living in a domestic situation has been abused or neglected in the preceding 12 months, the law requires that I report this to the agency designated to receive such reports.

If I believe that you present a clear, imminent risk of serious physical or mental injury or death to yourself, I may be required to disclose information in order to take protective actions. These actions may include seeking your hospitalization or contacting family members or others who can assist in protecting you, such as friends or the police.

If you have made a specific threat of violence against another or if I believe that you present a clear, imminent risk of serious physical harm to another, I may be required to disclose information in order to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking your hospitalization.

 

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 have now or arise in the future. The laws governing confidentiality can be complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed.

 

PROFESSIONAL RECORDS

All information client and clinical information, both paper and electronically, is kept according to HIPAA. For all clients, I keep a Clinical Record that includes information about reasons for seeking therapy, diagnosis, treatment goals, progress towards goals, medical and social history, treatment history, past treatment records received from other providers, professional consultations, billing records, and any prepared reports, including those to insurance carriers.  In addition, I may also keep Psychotherapy Notes, which are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary, they can include the contents of conversations, my analysis of conversations, and how they impact treatment. They may also contain sensitive information revealed to me that is not required to be included in your Clinical Record. These Notes are kept separate from your Clinical Record. While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of Psychotherapy Notes without your authorization.  Both sets of records can be misinterpreted and/or be upsetting to untrained readers. For this reason, if you request to review them, I recommend that you do so in my presence, or have them forwarded to another mental health professional to discuss their contents. In most circumstances, I am allowed to charge a copying fee of $2 per page.

 

CLIENT/PATIENT RIGHTS

HIPAA provides you with several rights with regard to your Clinical Records and disclosures of PHI. These rights include requesting amendments to your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of PHI that you have neither consented to nor authorized; having any complaints you make about policies and procedures recorded in your records; and the right to a paper copy of this Agreement and Notice of Privacy Practice. I am happy to discuss these rights with you.

 

MINORS & PARENTS

Patients under 13 years old and their parents should be aware that the law allows parents to examine their child’s treatment records. Parents of children between 13 and 18 cannot examine their child’s records unless the child consents and I find no compelling reasons for denying this access. Parents are entitled to information concerning their child’s current physical and mental condition, diagnosis, treatment needs, services provided, and services needed.  Since parental involvement is often crucial to successful treatment, in most cases, I require that patients between 13 and 18 years old and their parents enter into an agreement that allows parents access to certain additional treatment information. If everyone agrees, I will provide parents with general information about the progress of their child’s treatment and his/her attendance at scheduled sessions. Any other communication will require the child’s authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. 

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Pagone Psychological Services Therapist-Client Services Agreement Signature Page


Review Privacy Policy

 Jenn Pagone, LCPC (IL), LPC (WI)

Pagone Psychological Services,PLLC at Whispering White Horse Stables, LLC

p 773.339.7949 / f 847.660.7997 / jennpagone@yahoo.com / www.pagonepsychologicalservices.com

_____________________________________

Therapist-Client Services Agreement & Notice of Privacy Practices

SIGNATURE PAGE

Your signature below indicates that you have read the Therapist-Client Consent for Services Agreement / Professional Disclosure Statement and the Notice of Privacy Practices. These documents are electronically located on my website with a hard copy (which you may view at any time) in my office. It is your responsibility to read them in their entirety as you will be held accountable for their contents, policies and procedures. In addition, your signature indicates that you agree to abide by the terms stated in these documents as well as the below bullet pointed items.  

The Therapist-Client Services Agreement/Professional Disclosure Statement and the Notice of Privacy Practices represent an agreement between you and the psychology practice of Jenn Pagone, LCPC (Pagone Psychological Services, PLLC and Whispering White Horse Stables, LLC). You may revoke this agreement at any time in writing. Furthermore, revoking or breaking these agreements will result in termination of the professional services provided to you by Jenn Pagone, LCPC (Pagone Psychological Services, PLLC and Whispering White Horse Stables, LLC).

I Agree
Please note that if you have a lapse in therapeutic services for two (2) months your account will go inactive and you will lose the ability to electronically schedule sessions. Should you wish to return for therapeutic services please contact me to re-activate your account. Since you are responsible for scheduling your own appointments, I will assume that you no longer need my services if you do not have any appointments scheduled for two months. Your initials (or checkmark) indicate that you understand that once your account goes inactive you are no longer under my care. Should you decide that you need additional services, or would like to change providers and this is the reason that you are not booking further appointments, I am happy to provide you with referrals. It is important that we have an understanding and communicate about these matters.

 

To highlight specific terms within the Therapist-Client Services Agreement, your signature below indicates that you agree to each of the following (please also initial/checkmark by each bullet point):

I Agree
I will schedule my own appointments and understand it is my responsibility for any changes or deletion of appointments. I will abide by the 24 hour cancellation policy and understand that if my appointment is not cancelled and I do not attend my session I will be charged a $50 no show/less than 24 hour cancellation fee. If I cancel my appointment on the same day I will be charged $75.00. Cancellation fees are not covered by insurance. Cancelation fees can be paid by Zelle (jennpagone@yahoo.com / 773-339-7949) or Venmo (@Jenn-Pagone) within a week of the scheduled date of service. If paying by credit card a $2.50 convenience fee will be applied (for under $50, $5.00 for over $50). I am aware that my account is set up to receive session notification reminders over 24 hours prior to each appointment, giving me ample time to cancel, if needed.


I Agree
I understand that therapy appointments can be changed or modified at any time by Jenn Pagone, and it is my responsibility to stay up to date on all of my scheduled appointments.


I Agree
I understand that three (3) or more no show appointments (under 24 hour cancellations) within a six (6) week time period, may result in losing the ability to schedule my own appointments, or termination of this agreement. Depending upon the circumstances this may lead to termination from further therapeutic services. At which time I will contact my insurance company for a referral to another provider.


I Agree
I understand that my balance and understanding my insurance policy are ultimately my responsibility, and will pay all co-pays and/or co-insurance and/or deductible on the date of service by Zelle or Venmo. If I pay by credit/debit card I understand that I will be charged a $2.50 convenience fee (for charges under $50; $5.00 for over $50 charges).


I Agree
I understand that if I change insurance companies, I am obligated to immediately provide that information to Jenn Pagone, LCPC. Failure to do so will result in owing my complete balance out of pocket and on the date of service. NO ACCEPTIONS.


I Agree
I understand that I have full access to my appointments and my account balance, and therefore it is my responsibility to keep my account up to date. I understand that Jenn Pagone, LCPC does not provide monthly statements because this information is readily available to me.


I Agree
I understand that if I am on a sliding scale for session fees I need to pay the full session fee the day of my appointment. Should I cancel under 24 hours I will need to pay my full session fee prior to my next appointment.


I Agree
I understand that in case of an emergency I will call 911 and/or go to my nearest emergency room. I understand that Jenn Pagone, LCPC is not an on-call clinician and may not be available to me during a crisis. I also understand that Jenn Pagone, LCPC will make every effort to attempt to meet my needs, but immediate support is not guaranteed.


I Agree
I understand if I need an extended appointment that my insurance company may not cover the extra session time. I understand that I will be charged a $65 fee for every half hour, and $130 per extra hour, and payment should be submitted via Zelle or Venmo prior to my next appointment.


I Agree
I understand each session is 45-55 minutes in length and I will take responsibility to start and end each session on time. I understand that Jenn Pagone, LCPC needs 5 minutes in between session to prepare for her next client. I am aware that my inattention to time impacts Jenn Pagone, LCPC and other clients. I understand that due to the nature of therapy unforeseen emergencies may arise which may impact the length of my session. I understand that my session will not automatically be extended, and may be prorated for actual session time. I also understand that if Jenn Pagone, LCPC has an emergency or needs to cancel for any reason, that she will make an effort to offer me another appointment that week, if possible.

I Agree
I understand that Jenn Pagone, LCPC ultimately determines whether sessions will be in-person or virtual. I understand that if I am booked for an in-person session and it is determined, for whatever reason, that the session needs to be held virtually and I do not wish to engage virtually, I will let her know immediately. I understand that if I cancel my appointment for this reason without previously expressing my preferences prior to my appointment, that I will be charged a cancellation fee.

I Agree
I understand that communicating through text and email are not secure forms of communication and I assume all risks should information be breached. I understand that I may use the encrypted email through my account through therapyappointment.com or through the free and encrypted text app Signal. I am also aware that Jenn Pagone, LCPC uses encrypted forms of telehealth services through Signal, VSee, and Zoom, and that all attempts are made to ensure safety, but it is ultimately not guaranteed.

I Agree
I understand that Pagone Psychological Service and Whispering White Horse Stables take reasonable measures to ensure the safety of my Protected Health Information (PHI).

I Agree
Should I have any complaints about the services rendered by Jenn Pagone, LCPC, or if I feel that there has been a rupture in our therapeutic relationship, I understand that it is my responsibility to bring this to her attention so a repair may be made. I understand that Jenn Pagone, LCPC adheres to the ethical standards of the American Psychological Association, and will be willing to have any discussions needed to repair our relationship, as this is part of the healing process and strengthens interpersonal effectiveness.

First Clients Name

First Name*

Last Name*

Phone*
First Clients Age Acknowledgment*
First Clients Date of Birth*
I certify that I am 18 years of age or older
First Clients Signature*
Second Clients Name

First Name*

Last Name*

Phone*
Second Clients Date of Birth*
Second Clients Signature*
Third Clients Name

First Name*

Last Name*

Phone*
Third Clients Date of Birth*
Third Clients Signature*
Fourth Clients Name

First Name*

Last Name*

Phone*
Fourth Clients Date of Birth*
Fourth Clients Signature*
Fifth Clients Name

First Name*

Last Name*

Phone*
Fifth Clients Date of Birth*
Fifth Clients Signature*
Sixth Clients Name

First Name*

Last Name*

Phone*
Sixth Clients Date of Birth*
Sixth Clients Signature*
Seventh Clients Name

First Name*

Last Name*

Phone*
Seventh Clients Date of Birth*
Seventh Clients Signature*
Eighth Clients Name

First Name*

Last Name*

Phone*
Eighth Clients Date of Birth*
Eighth Clients Signature*
Ninth Clients Name

First Name*

Last Name*

Phone*
Ninth Clients Date of Birth*
Ninth Clients Signature*
Tenth Clients Name

First Name*

Last Name*

Phone*
Tenth Clients Date of Birth*
Tenth Clients Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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