Office and Privacy Practice Form
OFFICE POLICIES & GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICES: This form contains important information about Laura Glanville Psy.D. professional services and business policies. Please read it carefully, and feel free to raise any thoughts or questions you may have. When you sign this document, it will represent an agreement between you and Dr Laura Glanville. I understand that I am solely receiving treatment in the private practice of Dr. Laura Glanville and that payment will be made to Laura Glanville Psy.D.
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law.
When Disclosure Is Required By Law: Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent or elder, abuse or neglect; and where a client presents a danger to self, to others, to property, or is gravely disabled (for more details see also Notice of Privacy Practices form). Disclosure may be required pursuant to a legal proceeding if you place your mental status at issue in litigation initiated by you. Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. If you so instruct Laura Glanville, Psy.D. the minimum necessary information will be communicated to the carrier.
TELEPHONE & EMERGENCY PROCEDURES: If you need to contact Laura Glanville, Psy.D. between sessions, please contact me at 203-610-1505 and your call will be returned as soon as possible. If an emergency situation arises, please indicate it clearly in your message. If you need to talk to someone right away, you can call the emergency National Hopeline at 800-784-2433, go the nearest hospital emergency room or dial 911. Again, in case of emergency, I agree to call 911 or go to the nearest emergency room.
PRIVATE PAY & INSURANCE REIMBURSEMENT: Please pay at the end of each session unless other arrangements have been made. You may pay by check, cash or credit card. As I am not a member of any insurance panels, patients are responsible for submitting any bills to their insurance company. Receipts for treatment will be provided at the patient’s request. If you account has not been paid in full for more than 60 days and payment arrangements have not been agreed upon, I have the option of using legal means to secure the payment. If such legal actions are necessary, its costs will be included in the claim.
Cancellation Policy: There is a 24-hour cancellation policy. Appointments must be canceled 24 hours prior to the session or the session will be charged.
Patient agrees to Unencrypted Email and Text Communication: This form authorizes Laura Glanville, Psy.D. to communicate with you via unencrypted email and text messaging. I understand communication (including sending of receipts with diagnosis codes) over the internet or cell network may not be secure and there is no assurance of confidentiality of information communicated via unencrypted email and unencrypted text messaging. I have the right at any time to revoke this authorization. The email address below is accurate and I agree to have emails sent to that address. The cell phone below is accurate and I agree to have text messages sent to that cell phone number.