WELCOME TO MY PRACTICE Welcome! I recognize that it takes a lot of courage to seek services and I truly appreciate your interest in working together. I look forward to making progress with you as we journey along the path of improving mental health and increasing positive well-being. About Care Philosophy Hemingway put it, The world breaks everyone and afterward many are strong at the broken places. While I do not believe that people are broken, this quote holds special meaning for me in my practice because of the emphasis on the growth that people can acquire after enduring life struggles and working through experiences (even if it does not feel like this in the moment). I am here to work with you through challenging times to find that place of healing and growth. My approach is to foster a strong relationship built upon a foundation of trust, openness, support, honesty, non-judgment, and on occasion humor. Working in collaboration with you, I use a strength-based and recovery-oriented approach, coupled with evidence-based interventions to help you develop deeper meaning, increase social connectedness, strengthen coping skills, and help empower you to achieve your therapeutic goals. You are the expert on your life and I will be next to you providing support with my clinical skills along the way. I look forward to working with you on this journey. Professional Background Some of my earliest work entailed volunteering with impoverished children and adults who lived in favelas (shantytowns), when lived in Brazil. I met some of the most courageous and compassionate people who persevered to overcome significant life obstacles, despite all odds. This inspiring experience solidified my desire to continue to work alongside others to help them to live a values-congruent life and achieve their goals. As a result, I used my B.F.A. degree from the School of the Art Institute of Chicago to explore art therapy with people before naturally progressing towards a career in psychology. The next steps in my education included earning an M.A. degree in clinical psychology from Teachers College, Columbia University; followed by my Ph.D. in counseling psychology, from Lehigh University. In a nutshell, I have been providing a diverse array of clinical services for over 10 years. Prior to beginning private practice, I have worked in various settings, which have included veterans affairs medical centers, high schools, college counseling centers, inpatient hospitals and outpatient clinics. My background has provided me with ample opportunities to work with numerous individuals from diverse backgrounds as they prevailed over a variety of issues. Through my experiences and training, I have developed expertise working with individuals on 1
issues pertaining to depression, anxiety, trauma, posttraumatic stress disorder, addictions, relationship difficulties, managing stress, and sleep concerns. It takes courage to seek services and work towards making positive life changes. I look forward to being of service to you for any of the issues mentioned above or any other concerns. Agreement/Informed Consent The following outlines responsibilities for both of us as we journey on your road to healing. Please read the information and let me know if you have any questions. Financial Obligations Currently, I do not accept insurance, but a private pay fee for services will be established. This fee is expected at the time of service. Financial hardship: If you should face a time of financial hardship, please discuss this with me. I will be happy to make arrangements for a temporary reduced fee and/or a payment plan. Making payments: Cash, checks, and credit cards are accepted as payment methods. Please note: credit cards will include an additional service fee of 2.95% + $0.30. There is no additional fee for cash or check payments. Your Sessions Appointment time: Sessions last for about 45-50 minutes. Once scheduled, your appointment time will be reserved. If a change is needed, I will do my best to accommodate you. Please let me know as soon as possible about an expected change, so that I can be flexible with rescheduling. Cancelling appointments: There may be times when you need to cancel an appointment. Because this time is reserved, I ask that you give at least 24 hours notice. This enables me to offer this opening to someone else who may benefit. If you do not provide 24 hours notice, you will be charged $40.00 for the missed appointment. You are responsible for the missed appointment fee in full. Emergency cancellations will be handled on a case-by-case basis. Not showing ( no-show ) for appointments: If you do not show for your appointment, and have not cancelled it, please contact me as soon as possible. If I don t hear from you, I will likely try to contact you myself. In the event of a no-show, a $40.00 missed appointment fee will be charged to you. Frequent cancellations: Consistency of treatment is very important. You will not make the progress you want and deserve if you frequently miss sessions. Should this situation occur, I would discuss the issue with you so that we can work together and improve the situation. 2
Reports On occasion you may need me to write a report of your treatment to an attorney, employer, or school official. Report writing is charged in 30-minute increments. I will be happy to discuss this with you in further detail should the need arise. Telephone Sessions Tele-psychotherapy is a relatively new practice, which I am happy to provide, if needed. There is no charge for phone contacts that last less than 15 minutes. Phone contacts beyond 15 minutes will be charged the same as in-person sessions. Technology The use of email and texting is available for you for brief issues such as requested appointment changes and/or cancellations. Emailing and texting should not be used to address therapeutic issues. Please understand that although I will do my best to maintain confidentiality in these contacts, no technology service is without the risk of exposure. Therefore your use of these technologies should be considered carefully. At this time, I do not use Facebook, Twitter, Instagram, Skype, or other social media to interact with clients. Emergencies I provide 24-hour 7-day a week emergency coverage through the use of my cell phone. The number is 267-772-8768. At times of personal time off, you will be given the number of a therapist on call. If at any time you are unable to reach me, or the covering therapist, it is your responsibility to go to the nearest emergency center. In the event that Dr. Bremer-Landau is unable to contact you directly due personal circumstances or an emergency situation, a back up therapist, bound by ethical standards and confidentiality, may have access to your files in order to minimize disruption of care. Examples of emergency circumstances may include but are not limited to: Dr. Bremer-Landau attending to a personal emergency or Dr. Bremer-Landau s unexpected death or disability. I understand this is a lot of information. However, by providing you with a range of issues that might come up, I hope to empower you to make informed decisions about your care. I also encourage you to discuss with me any of the topics in this document, or that come up throughout the course of your treatment. Your signature on the following page below represents full understanding and compliance of the above. 3
Welcome to My Practice Informed Consent Signature Page I understand and agree to the above: Client Signature Date Client Signature (if applicable) Date 4
PRIVACY NOTICE Notice of Policies and Practices to Protect the Privacy of Your Health Information. THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. I. Uses and Disclosures for Treatment, Payment, and Health Care Operations Dr. Bremer-Landau may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions: PHI refers to information in your health record that could identify you. Treatment, Payment, and Health Care Operations Treatment is when Dr. Bremer-Landau provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when she consults with another health care provider, such as your family physician or another psychologist. - Payment is obtaining reimbursement for your healthcare. Examples of payment are when Dr. Bremer-Landau discloses your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage. - Health Care Operations. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination. Use applies only to activities such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you. Disclosure applies to activities such as releasing, transferring, or providing access to information about you to other parties. 5
II. Uses and Disclosures Requiring Authorization Dr. Bremer-Landau may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An authorization is written permission above and beyond the general consent that permits only specific disclosures. In those instances when information is sought for purposes outside of treatment, payment or health care operations, Dr. Bremer-Landau will obtain an authorization from you before releasing this information. If Dr. Bremer-Landau keeps Psychotherapy Notes, she will also need to obtain an authorization before releasing your Psychotherapy Notes. Psychotherapy Notes are notes about your conversation during a private, group, or joint counseling session, which are kept separate from the rest of your file. These notes are given a greater degree of protection than PHI. Dr. Bremer-Landau may or may not keep separate Psychotherapy Notes as defined here. You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) Dr. Bremer-Landau has relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy. III. Uses and Disclosures with Neither Consent nor Authorization Dr. Bremer-Landau may use or disclose PHI without your consent or authorization in the following circumstances: Child Abuse If there is reasonable cause to suspect that a child has been or may be subjected to abuse or neglect, or if there is observation of a child being subjected to conditions, which would reasonably result in abuse or neglect, Dr. Bremer-Landau is required by law to report such information to the Pennsylvania Department of Public Welfare. Dr. Bremer-Landau must also report sexual abuse or molestation of a child under 18 years of age. Adult and Domestic Abuse If Dr. Bremer-Landau has reasonable cause to suspect that an older or disabled adult presents a likelihood of suffering physical harm or is in need of protective services, she must report such information to agencies, which provide protective services. Judicial and Administrative Proceedings If you are involved in a court proceeding and a request is made for information about your diagnosis or treatment and the records thereof, such information is privileged under state law, and Dr. Bremer-Landau will not release information without written authorization from you or your personal or legally appointed representative, or a 6
court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. You will be informed in advance if this is the case. Serious Threat to Health or Safety If you express a serious threat, or intent, to kill or seriously harm yourself or another person, Dr. Bremer-Landau must take reasonable measures to prevent such an event from occurring. This may include providing information to the appropriate professional workers, public authorities, the potential victim, his or her family, or your family. Workers' Compensation If you file a worker s compensation claim, Dr. Bremer-Landau will be required to file periodic reports with your employer which shall include, where pertinent, history, diagnosis, treatment, and prognosis. IV. Your Rights and Psychologist's Duties Your Rights: Right to Request Restrictions You have the right to request restrictions on certain uses and disclosures of protected health information. However, Dr. Bremer-Landau is not required to agree to a restriction you request. Right to Receive Confidential Communications by Alternative Means and at Alternative Locations You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. Right to Inspect and Copy You have the right to inspect or obtain a copy (or both) of PHI in mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Dr. Bremer-Landau may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. Upon request, Dr. Bremer-Landau will discuss this with you. Right to Amend You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. Dr. Bremer-Landau may deny your request. On your request, she will discuss this with you. Right to an Accounting You generally have the right to receive an accounting of disclosures of PHI. On your request, Dr. Bremer-Landau will discuss this with you or refer you to her billing agency. 7
Right to a Paper Copy You have the right to obtain a paper copy of the Privacy Notice upon request. Psychologist s Duties: Dr. Bremer-Landau is required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI. Dr. Bremer-Landau reserves the right to change the privacy policies and practices described in this notice. Unless Dr. Bremer-Landau notifies you of such changes, however, she is required to abide by the terms currently in effect. If Dr. Bremer-Landau revises her policies and procedures during the course of your treatment, she will make available to you a revised notice at your next appointment or as is feasible. V. Complaints If you are concerned that Dr. Bremer-Landau has violated your privacy rights, or you disagree with a decision made about access to your records, please discuss this with Dr. Bremer-Landau. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. VI. Effective Date, Restrictions and Changes to Privacy Policy This notice will go into effect on December 16th, 2006. Dr. Bremer-Landau reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that is maintained. If Dr. Bremer-Landau revises this notice during the course of your treatment, she will make available to you a revised notice at your next appointment or as is feasible. 8
PRIVACY OF HEALTH INFORMATION SIGNATURE SHEET I acknowledge that I have received a copy of Dr. Bremer-Landau s Notice of Policies and Practices to Protect the Privacy of Health Information. Signature of Patient or Responsible Party Date Witness Date Written acknowledgement of receipt of Notice of Policies and Practices to Protect the Privacy of Health Information was not obtained. Reason(s): Dr. Jodi Bremer-Landau Date 9
FINANCIAL AGREEMENT I understand that Dr. Bremer-Landau does not currently take insurance and that the agreed upon private pay fee for services is $ per session at this time. Dr. Bremer-Landau currently accepts cash, checks, or credit cards for payment. Please note: credit cards will include a service fee of 2.95% + $0.30. There is no additional fee for cash or check payments. In the event of a missed appointment, late cancellation (within 24 hours of the scheduled session; see Welcome to My Practice for details), or lack of payment at the time of service, I understand that my credit card will be charged with the associated fees unless other arrangements have been agreed upon. Emergency situations will be handled on a case-by-case basis. If you are experiencing a financial hardship, alternative payment options may be available. Credit Card Information Credit Card Number: - - - Expiration Date (MM/YY): / CVC (located on the back of the card): *Your credit card will not be charged unless one of the aforementioned circumstances applies or unless you request for your credit card to be charged. Client Date Dr. Bremer-Landau Date Client (if applicable) Date 10
Name: INTAKE INFORMATION FORM *Please fill out one form per person Preferred Nickname: Permanent Address: Home Phone: Work Phone: Cell Phone: Email Address: Birth Date: Automated Appointment Reminder Preference: Text Phone Call Email Confirmations Not Needed Please note: if a confirmation is not received, the appointment is still scheduled unless notified directly. Source of Referral: Emergency Contact Name and Relationship to Client: Emergency Contact Phone Number: Person Responsible for this Account: Relationship to Client: Marital Status: Number of Previous Marriages: Current Spouse/Partner Name and Phone Number(s): Race/Ethnicity: Gender: Sexual Orientation: Veteran: Employment and/or School Status: Employer and/or School Name: Yes No Presenting Concerns: Previous Treatment: 11
Medical and Mental Health Conditions: Medications: Physician/Health Care Provider Name and Address: Physician s Phone Number: Current Sleep Concerns (e.g., issues falling or staying asleep, sleep apnea, nightmares, etc.): Nutritional Status (e.g., appetite, weight gain/loss, etc.): Trauma History: History of Head Trauma and/or Traumatic Brain Injury: History of Substance Abuse (illicit or prescription drugs and/or alcohol): Legal History: Current Family Makeup (Who is in your immediate family? Names and ages of children?): Childhood Family Makeup (Who was in your family when you were growing up?): Current Support (e.g., names of family, friends, community organizations, etc.): Recreation and Leisure Activities: Strengths: 12