UPDATED Practice Policies 7/12/2021

Turntable Counseling, LLC

11720 Beltsville Dr. Suite 500 Beltsville, MD 20705

Dr. Princess Souvenir-Wiedemann, DBH, LCPC, BC-TMH

Practice Owner, Clinical Director

PRACTICE POLICIES

APPOINTMENTS AND CANCELLATIONS Please remember to cancel or reschedule 24 hours in advance.You will be responsible for the full session rate if cancellation is less than 24 hours. By signing this document, you consent to the card on file being charged. In the event that a dispute for late-cancellation, no-show, or session charges are made, you agree to an additional $200 dispute charge. All further sessions will be canceled until the full balance on the account is cleared.

Session reminders are a courtesy of the practice but are the responsibility of the client. Concessions will not be made for missed sessions due to the lack of appointment reminders sent from the system.

The cancellation fee is strictly enforced.

The standard meeting time for psychotherapy is 50 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the 50-minute session need to be discussed with the therapist in order for time to be scheduled in advance.

A $50.00 service charge will be charged for any checks returned for any reason for special handling.

Despite insurance co-payment or co-insurance amount, a less than 24-hour cancellation and no-call, no show, is not covered by the insurance and will be charged the full cost of the session detailed on the Fee Schedule. Cash rate clients will be charged 24-hours prior to the session. Clients on a sliding scale will also be charged the full cost of the session, not the sliding scale amount.

Again, cancellations and the re-scheduled session will be subject to a full charge if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time.

You are required to have an updated card on file despite having no co-payment or co-insurance.

FEE SCHEDULE Updated 7/1/2021

90791 Intake Session – Psychiatric Diagnostic Evaluation 60 minutes at $200

90837 Psychotherapy, 60 min 55 minutes at $180 (Standard Session)

90834 Psychotherapy, 45 min 45 minutes at $150

90839 Psychotherapy for Crisis, 60 min 50 minutes at $350

90840 Crisis additional 30-minute add-on 30 minutes at $125

90846 Family Therapy without patient present 50 minutes at $200

90847 Family Therapy with the patient present 50 minutes at $200

90853 Group Therapy 50 minutes at $100

90875 Other Psychiatric Services or Procedures 50 minutes at $150

96130 Psychological testing, evaluation, first hour 50 minutes at $200

96131 Psychological testing, evaluation, each additional hour 50 minutes at $200

96136 Psychological test administration and scoring first 30 minutes $200

96137 Psychological test administration and scoring, each additional 30 minutes $200

99404 EAP 50 minutes at $175

Clients with deductibles will be responsible for the insurance contracted rate that Turntable Counseling, LLC has with their insurance provider until the deductible is met. At that time, all co-payment and co-insurance amounts will apply. Your intake session and standard session costs will be discussed with you at the time you schedule your session.

TELEPHONE ACCESSIBILITY If you need to contact me between sessions, please leave a message on my voice mail. I am often not immediately available; however, I will attempt to return your call within 24 hours. Please note that Face-to-face sessions are highly preferable to phone sessions. However, in the event that you are out of town, sick, or need additional support, phone sessions are available. If a true emergency situation arises, please call 911 or any local emergency room.

SOCIAL MEDIA AND TELECOMMUNICATION Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.

ELECTRONIC COMMUNICATION I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine by the State of California. Under the California Telemedicine Act of 1996, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist chose to use information technology for some or all of your treatment, you need to understand that: (1) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. (2) All existing confidentiality protections are equally applicable. (3) Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee. (4) Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent. (5) There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs. Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnoses, and interventions based not only on direct verbal or auditory communications, written reports, and third-person consultations, but also on direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist’s inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as your physical condition including deformities, apparent height, and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming, and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally to the therapist.

MINORS If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential. By signing this document and placing a card on file, you are consenting to all financial responsibilities associated with services and fees of services and missed sessions.

TERMINATION Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after an appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.

Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.

BY CLICKING ON THE CHECKBOX BELOW I AM AGREEING THAT I HAVE READ, UNDERSTAND, AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT. I ALSO AGREE THAT A COPY OF THE MOST CURRENT POLICIES AND PROCEDURES WILL BE LISTED ON THE WEBSITE. I AGREE THAT IT IS MY RESPONSIBILITY TO REVIEW ALL UPDATED PRACTICE POLICIES AND PROCEDURES LISTED ON THE WEBSITE AS THEY MAY CHANGE. http://www.turntablecounseling.com