Patient Agreement and Telehealth Informed Consent for Treatment

New Clients: Please review this page and complete the form at the bottom of this page.

Your treatment is a collaborative process during which we will work together to determine how to best understand and address treatment needs. This page contains information about the psychological services I offer and my business policies.

Psychological Services

Although each patient's treatment varies, the treatment approaches I offer in my individual sessions include Cognitive Behavior Therapy, Acceptance Commitment Therapy, Dialectical Behavior Therapy, Exposure Response Prevention Therapy and Polyvagal and Somatic Therapy.

Treatment usually begins with a 90 minute intake session with a fee of $350. This is a time for us to discuss the presenting issues and concerns and how they are impacting your life and day to day functioning, as important background information regarding school, work, relationship and significant life events, and family history and dynamics. During this intake session, preliminary treatment goals may be established in order to help organize the first few treatment sessions. Fees for treatment will also be agreed upon and consent, patient agreement and Notice of Privacy forms will all be reviewed.

Our weekly sessions will be for 60 minutes at a fee of $185–$250. I usually use the first 4 sessions to gather as much information as possible and to build a safe environment with a strong emphasis on helping you feel comfortable. Once this initial assessment period is complete, we will work together to develop specific treatment goals, as well as determine what the best treatment approach will be based on your level of need, presenting issues and current functioning. We may also review any possible initial diagnoses, if relevant.

In addition to your weekly individual session, if needed and per your consent, if there are relevant family members or other significant people involved in your life or care, additional collateral or family sessions will be arranged. These sessions are used to discuss how you can gain more support as well as coordinate and carry over treatment at home/in school/at work to improve your day-to-day well being. The frequency of these sessions are determined based on financial resources, scheduling availability and treatment needs.

There are benefits and risks of psychotherapy. Due to the nature of psychotherapy, uncomfortable and often difficult issues are brought to light. I will always try and be aware and supportive of your comfort level, while also encouraging you — in a therapeutic way — to face challenging issues and problem solve around how to grow, work past obstacles and develop new skills. The benefits of treatment vary for each individual. Through the use of therapy and the therapeutic relationship, many individuals gain improved self-esteem, develop coping skills, learn appropriate social skills, increase their emotional regulation, learn to problem solve and work through traumas and stressful life events. The progress of your treatment is largely based on you and/or your family's level of commitment to weekly sessions and any in-between session recommended work. Progress takes time and patience is required. Each individual moves at their own pace and my role is to be supportive and respectful of this pace, with the right amount of encouragement to challenge them along their journey.

Professional Fees & Payment

After the initial session an invoice via the Square payment software will be emailed to the person financially responsible for treatment. When paying this initial invoice, a card will be saved on file to be auto charged after each weekly session.

Payments can also be in the form of cash, check or credit card and are expected at the time of service. For patients who need to be seen for treatment on a sliding scale, those fees are discussed and agreed upon during intake and prior to the first treatment session.

Fees

  • Intake session (90 minutes): $350

  • Individual/Collateral session (60 minutes): $180-$225

  • Family or Couples session (60): $250

Insurance

I do not accept insurance. However, I will complete out-of-network paperwork if reimbursement is needed and I will email these at the end of the month to the financially responsible party.

Collection

In the rare situation that your account has not been paid within 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient's treatment is his/her name, the nature of service provided, and the amount due. If such legal action is necessary, any costs incurred will be included in the claim. Please notify me if any problems arise during the course of therapy regarding your ability to make timely payments so that we may try to reach a solution.

Appointments

Sessions are usually scheduled once a week for 60 minutes per visit, although sometimes visits can be more frequent if needed. These weekly sessions are a commitment and we value this work together by starting on time. If I am ever unable to start on time, I ask for your understanding and I assure you that you will receive the full time agreed to. If you are late, you will receive the remainder of your scheduled time and are required to pay the full fee. This is necessary so I can see other clients at their scheduled time. If I do not have a client scheduled immediately after you and your lateness is not a habitual issue, I will do my best to provide you with your full therapy session. If I have any planned time off, I will notify you in advance. For any unforeseen absences or therapist illness, I will attempt to reschedule your appointment as soon as possible.

Cancellation & Rescheduling Policy

Once an appointment is scheduled, you will be expected to pay for it. If you are unable to make your agreed upon appointment time, you need to provide 24 hour notice at which time we will try our best to reschedule your appointment. The point of rescheduling instead of canceling appointments allows for more consistent treatment which allows more fluid work and continual progress. If we cannot find a time to reschedule and you notified me within the allowed 24 hour time period there will be no fee. If you did not notify me within the proper timeframe or do not show for your appointment, you will be charged the full fee. There are times when emergencies or sudden illnesses occur when last minute cancellations will occur. If this occurs and is not habitual, I will charge only half of your full fee.

Contacting Me

Due to my work schedule, I am often not immediately available by telephone or email. If you have called me and you reach my voicemail, please leave a message. If a crisis or issue that requires more immediate attention arises, please text me. For issues that do not require immediate attention, I will make every effort to return your call, text or email within 24 hours, with the exception of weekends, holidays and planned vacations.

I do not return telephone calls between 8:00 p.m. and 8:00 a.m. If you are unable to reach me and feel that you cannot wait for me to get back to you or if you are in crisis, please call 911 or go to your nearest emergency room. You may also call a mobile crisis team at 1-800-LIFENET or 988.

Professional Information

Dr. Christie Sosnowski is a licensed clinical psychologist. She received her B.A. in psychology from The State University of New York at Stony Brook, graduating cum laude in 2002. Dr. Sosnowski spent 3 years in between her undergraduate and graduate training working in special education at Southampton Elementary School. Here she delivered ABA services and specialized in teaching children with Autism Spectrum Disorder. Dr. Sosnowski obtained her doctoral degree in clinical psychology from Alliant International University at the California School of Professional Psychology, graduating in 2011 with her Psy.D. During graduate school, Dr. Sosnowski was enrolled in the Child and Family Program allowing her to specify her training to learn about child psychopathology, child development and family dynamics. In addition to her private practice, Dr. Sosnowski has worked at a therapeutic preschool program for children with emotional disturbance, behavioral disorders and Autism Spectrum Disorder and mental health clinics. Her private practice for the past decade has focused on working with young children through Play Therapy, parenting work, and supporting young adults during significant life transitions. Diagnostic issues of focus include Autism Spectrum Disorder, Anxiety and OCD disorders, Depression and Mood Disorders and Attention Deficit Hyperactivity Disorder. If you have any questions about the specifics of Dr. Sosnowski's training, experience or license please ask directly for clarification at any time.

Limits of Confidentiality

With certain specific exceptions described below, you have the absolute right to the confidentiality of your therapy. I cannot and will not tell anyone else what you have told me, or even that you are in therapy with me, without your prior written permission. The following are legal exceptions to your right to confidentiality. Should one of these situations occur, I will make every effort to discuss it with you fully before taking any action.

  • If I reasonably suspect that a person under 18 or over 65, or a disabled person, is being abused or has been abused, I must file a report with the appropriate state agency.

  • If a patient threatens to harm him/herself, I may be obligated to seek hospitalization for the patient, or to contact family members or others who can help provide protection.

  • If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient, or contact others who can assist in protecting the victim.

  • Occasionally, I may find it helpful to consult with professional colleagues about my work in order to determine best treatment practices and interventions for you. In these consultations, I make every effort to avoid revealing the identity of my patient. The consultant is also legally bound to keep information confidential. If you don't object, I will not tell you about these consultations unless I feel that it is important to our work together.

  • If you are involved in a court proceeding and a request is made for information about the services that I provide for you and/or records of them, such information is protected by psychologist-patient privilege law. I cannot provide any information without your written authorization, a court order, or subpoena or discovery from another party to the court proceeding where I do not have grounds for objecting under state law (or you have instructed me not to object). If you are involved in or are contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information.

  • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.

  • If a patient files worker's compensation claims, I must upon appropriate request, disclose information relevant to the claimant's condition to the workers' compensation insurer.

  • I currently do not provide services through insurance companies or managed care panels. However, if you have health insurance it will usually provide some coverage for mental health treatment. If your insurance allows you to seek "out of network" providers then I can provide you with the necessary information needed to submit to be reimbursed for payment of treatment. In doing so, you should be aware that insurance plans often require that I provide relevant information regarding the type of treatment being provided, progress and diagnosis. In such situations, I make every effort to release only the minimum information that is necessary for the purpose of the request.

  • Although certain measures are taken, due to the nature of electronic communication, it is important to remember that communication via cell phones, e-mails and faxes are not totally secure. Please keep this in mind when there is communication with a therapist through such means.

Telehealth Consent

I give consent for myself to participate in Telehealth psychotherapy sessions with Dr. Christie Sosnowski. I understand that "Telehealth" in this capacity includes the practice of mental health care delivery, assessment, diagnosis, consultation, treatment and psychoeducation using interactive audio or video communications.

I understand that using the Telehealth platform allows access to mental health services that are not otherwise available to myself/my family.

Telehealth appointments are considered outpatient services and not intended as a substitute for emergency or crisis services. Crisis or mental health emergencies should be directed to 911.

Technology: I understand that I will need to download an application to engage in Telehealth services (i.e. "Zoom"). I also need to have a broadband Internet connection or a smart phone device with a good cellular connection. I will be sure to have such devices adequately charged prior to each session.

Financial Obligations: Fees associated with Telehealth appointments are payable by credit or debit card. Dr. Sosnowski uses an online payment system called Square, where an invoice will be emailed after the first session, which is expected to be paid within 24 hours of being received. At the time of payment, a credit card will also be saved on file and will be used to auto charge after each subsequent session.

Clients using insurance: I am responsible for contacting my insurance company, if applicable, to determine what my out-of-pocket costs may be and to see if Telehealth services are covered within my plan. I authorize Dr. Sosnowski to release any information to my insurance provider required for processing my claims in order for me to be reimbursed.

Video/Audio Recording: As a general practice Dr. Sosnowski DOES NOT record Telehealth sessions.

Confidentiality: The laws that protect the confidentiality of my medical information also apply to Telehealth. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality including, but not limited to: reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. Dr. Sosnowski's Telehealth platform is HIPAA compliant to protect my privacy and confidentiality.

Rights with Respect to Telehealth

I understand that I have the following rights with respect to Telehealth:

  1. I have the right to withdraw my consent at any time.

  2. I understand that there are risks and consequences associated with Telehealth including, but not limited to the possibility, despite reasonable efforts on the part of Dr. Sosnowski, that sessions could be disrupted by technical failures. In addition, I understand that Telehealth-based services and care may not be as complete as face-to-face services. I also understand that if and when possible, in-person psychotherapy sessions with Dr. Sosnowski are always available to me.

  3. I understand that there are therapeutic benefits from Telehealth services but that results cannot be guaranteed or assured.

I have read and understand the information provided above. I am aware that I can ask any questions or state any concerns regarding the information provided above with Dr. Sosnowski. My signature below indicates my informed and willful consent to treatment.