Client Information
  First Name:  * Last Name:  *  
  Date of Birth:  * Gender:  *  
  Address: City:  
  State: Zip Code :  
  Phone No:  
Practice Orientation Agreement

* You have the right to receive services from clinicians who adhere to the professional code of ethics of their respective disciplines.
* You have the right to receive services in accordance with Federal and State regulations and accreditation standards governing behavioral health programs.
* You have the right to privacy and confidentiality regarding the service you receive. All information about you and your treatment, whether written or oral, is protected under Federal and State laws, including the HIPAA Privacy Act.
* You have the right to informed consent for services offered to you.
* Your clinician is responsible for all service coordination.
* You have the right to refuse services at any time. You have the right to withdraw your consent to receive services and discontinue services at any time. You have a right to information concerning your treatment/care.
* You have the right to know treatment recommendations and the possible outcomes if you choose not to follow these recommendations.
* You have the responsibility to assist in planning your treatment at every stage.
* You have the right to express any concerns or complaints regarding the services you receive.  We encourage you to first contact your clinician to resolve any issues. You may also contact the Rights Advisor, Laura Hitt, Office Manager for assistance. A description of how to register a concern is posted in our lobby and on our website.
* You have the responsibility to be timely for your appointments. Late arrivals may result in rescheduled appointments.
* You have the responsibility to arrive for all scheduled sessions, or to notify us 24 hours in advance if you wish to cancel an appointment. You may be charged a practice fee, up to $125, for non-cancelled or late cancelled appointments, when an emergency was not involved, because insurance companies and other third-party payers do not cover missed appointments.
* You are responsible for any fees that may be charged to you at the time of service and, also, for knowing your insurance benefits coverage. We check benefits as a courtesy, but this is not a guarantee of coverage.
* Your case will be closed following 45 days of inactivity, unless other arrangements have been made.
* You have the right to know we may call the police if someone comes to the practice under the influence of drugs or alcohol and tries to leave the practice driving a motor vehicle.
* You have the right to know that no member of our staff is allowed to date or have a personal relationship with current or former clients of the practice.
* You have the right to know that staff and therapists are not allowed to accept gifts from clients of the practice, nor are they permitted to enter into any business relationships of any kind with you.
* You have the responsibility to conduct yourself in a non-disruptive and non-aggressive manner while on the premises. Wentworth &Associates will never use restraints but emergency responders will be called if necessary.
* If we are treating your minor child our policy is to make a concerted effort to engage both parents in the therapeutic process.
Reasons your treatment may be terminated:
• Being under the influence of any illegal substance while on the premises
• Threatening the safety or rights of any client or staff member
• Non-compliance with treatment or an inability of the facility to provide you the care you require
• You have two or more subsequent late cancellations (under 24 hours notice), or two or more failures to appear at a scheduled appointment without notice

*In all instances, you have the right to a referral for a different treatment option

Wentworth and Associates offers an array of mental health services. These services include: individual psychotherapy, group therapy, family therapy, marital therapy and psychological testing, Psychiatric evaluations and medication therapy are also available on site. Your clinician will provide you with a detailed description of the nature of services available. Medication decisions are made by you and your prescribing physician and information about expected benefits and potential risks are available from that physician.   ALL ASSOCIATES ARE INDEPENDENT CONTRACTORS.
Wentworth and Associates will be asking you for ongoing feedback regarding the quality and effectiveness of services you receive. We will ask you to complete clinical outcome questionnaires and satisfactions surveys periodically. We will also review and/or investigate any complaints or suggestions you may have (contact Rights Advisor). Your feedback is considered an important part of your treatment and helps us to improve our services.  

In the event of an emergency, there are fire extinguishers in the receptionist’s office, on the clinic office, and another in the hallway by restrooms. There is a first aid kit available also in the clinic office area. If the premises need to be evacuated, please use the stairs to go either to the basement (tornado warning) or the back parking lot. Persons in clinicians’ offices will be escorted by their clinician. In the second floor offices there is an additional fire extinguisher and  first aid kit.

Office hours are usually 7AM to 10PM, 7 days a week. All clinicians are available during all open hours. Appointment dates and times and after hours contacts may be arranged with your treating clinician. An outdoor elevator is located in the back parking lot of the building for individuals with physical disabilities. In emergencies, you can contact or go (if able) to the nearest crisis center (Macomb County Crisis Center at 586-307-9100; Oakland Crisis Center at 248-456-0909). You may also contact the nearest emergency room. We practice in a non-smoking environment. Illicit drugs, alcohol, and weapons are not allowed on the premises. Persons in possession of any of these will be asked to leave immediately.

Federal and State laws protect the privacy of communications between a client and a clinician. In most situations, release of information about your services/treatment to others can only be done if you sign a written Authorization to Release that meets certain legal requirements. However, there are limits to confidentiality, such as if you intend to harm yourself or others. Information about privacy and limits to confidentiality will be provided by your primary clinician and is also provided in our Notice of Privacy Practices (please see our website. STATE LAW REQUIRES REPORTING OF SUSPECTED CHILD ABUSE/NEGLECT, ELDER ABUSE, AS WELL AS ABUSE TO VULNERABLE ADULTS.

You are expected to pay for service at the time it is rendered, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when requested. A fee adjustment or a payment installment plan may be negotiated with your therapist in circumstances of unusual financial hardship. All clients will be informed of payment fee schedules prior to rendering services. Although we are likely to inform you of your insurance deductible and co-pays (if any), you are ultimately responsible for knowing this information and for paying both in full.  A $25 charge may be required for returned checks.   You may be charged up to $25.00 if you request records to be sent out.  If your client balance exceeds $200.00 service may be suspended, and you will be offered a referral to another clinic where you will be able to continue your treatment.

If your account has not been paid for more than 90 days and arrangements for payment have not been agreed upon, legal action may be used to secure the payment. This may involve hiring a collection agency or going through small claims court, which will require disclosure of otherwise confidential information. In most collection situations, the only information released regarding a client's treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its cost will be included in the claim.
My therapist is:
* If I am paying privately, based on my ability to pay, I agree to pay:
Intake Evaluation  Individual Therapy  Family Therapy 
Testing  Extended Sessions  Supplemental Professional Services 
Fee Schedule for Supplemental Professional Services
It is our goal to provide the most comprehensive care and coordinated professional services to our clients. The charges outlined in this section are for additional professional services not traditionally covered by insurance companies and other third party payers.  When provided they are billed directly to the client.
               1. Phone calls
                   a. Phone calls lasting under 15 minutes are considered part of ongoing clinical care and are gladly answered and returned by therapists as soon as possible without charge.
                   b.When phone calls last 15 minutes or longer, your therapist will encourage the scheduling of an appointment to discuss the matter in the context of a traditional face-to-face session.
                   c. Phone calls lasting between 15 and 30 minutes are subject to a flat fee of $60.00.
                   d. Phone calls exceeding 30 minutes are subject to a fee of $60.00 for the first 30 minutes, and a $15.00 per charge for each additional 5 minute increment.
                   e. These rates apply for phone consultations with clients as well as with authorized third party contacts such as school professionals, attorneys, physicians, psychiatrists, etc.

While therapists will make every effort to address issues of clinical concern over the phone in a concise and time-sensitive manner, phone calls between the client and the therapist lasting longer than 15 minutes suggest the need for a face-to-face session.  Phone calls involving third party contacts are at times needed and/or requested to address important coordination of care concerns. Therapists will gladly engage in such consultations.  
              1. Professional letters and requests for medical documentation:
                  a. These letters and medical documentation include written communication and/or requested medical documentations to be sent to third parties such as schools, court, attorneys, employers, etc. (This does not include missing work/school letters). This also includes requests of medical documentation for the individual client’s use.
                  b. Letters and/or request for medical documents are subject to a $50.00 fee.
              2. Individualized Education Plan(IEP) or school meetings:
                  a. Meetings where a therapist is attending a meeting outside of the office at a different site is subject to a fee of $125.00 per hour, including travel, waiting, and actual meeting time.

              3. Court appearances and/or testimony:
                  a. Any presence in court or taped disposition is subject to a fee of $125.00 per hour including travel, waiting, and actual service time. (***Please note: In cases where a court-ordered subpoena legally requires the therapist to appear in court and/or provide a deposition, fees for court appearances will be charged, regardless of whether or not the client/client representative signs this documentation agreeing or choosing to decline to privately pay for these professional services).

Clients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child's treatment records. Parents should also be aware that clients over age 14 can consent to (and control access to information about) their own psychosocial treatment that does not exceed 12 sessions or 4 months. While privacy is very important, particularly with teenagers, parental involvement is often essential to successful treatment. Therefore, it is Wentworth and Associates policy to request (but not require) an agreement from any client between 14 and 18 and his/her parents which would allow the sharing of general information with parents about the progress of treatment and the child's attendance at scheduled sessions.

While family treatment may be useful at times, involvement of family members is to be negotiated with the client and therapist. Unless family therapy is warranted and all members consent to treatment, it is up to the client and therapist to determine the level of family (or other persons) involvement in sessions. In any case, the therapist may not release any information to anyone regarding the client without the client's written consent. In the case of minors, it is strongly suggested to keep most of the client's treatment between the client and therapist and only involve family members in treatment when necessary.

My signature below indicates that I:

           • Have been made aware of my rights and responsibilities and how to file a grievance or complaint.
           • Have been informed of the name, discipline, and credentials of my primary clinician.
           • Have been informed of practice-specific information and given an orientation to services including fees.
           • Have been informed of privacy practices, confidentiality, and limits to confidentiality (including limit in use of phone calls, texts, e-mail, and other electronic communication).
           • Have been informed of all the emergency evacuation procedures of the practice and its premises.
           • Understand that chidren under 12 must be accompanied by an adult if waiting in our waiting rooms.

My signature below also indicates that I have understood this document and consent to receive services at Wentworth and Associates, and that I understand I may discuss any questions I have regarding services and that I maintain the option to terminate my consent at any time.
Coordination of Care Consent Form
* Authorizing person name
* I authorize the release or obtaining of confidential information
Yes   No  
* Information is for
Myself   My child or ward  
* Primary care physician
* Primary care physician addresses
Besides my primary care physician, I would like my therapist to coordinate care with the following physicians and specialists    (please list name, address, and phone)
  Name Address Phone
* Information to be disclosed
Diagnoses  Medication information  Assessments and testing information 
* Instructions/Requests
* Requesting clinician name
* Purpose of such a disclosure
Coordination of care 

I hereby give my informed consent to have my case presented at case conferencing or group supervision meetings at Wentworth and Associates, PC only.
I understand that my therapist will make every effort to protect my confidentiality and will not be using names or other specific identifying information. I understand that the purpose of presenting my case at these case meetings is to get a multidisciplinary team approach in order to improve my treatment.
I understand that any clinical staff person or student may attend these meetings and that they are facilitated by the CEO, Dr. Lawrence T. Wentworth, PhD, Licensed Psychologist.
I understand that the staff members are not liable in any way for treatment suggestions, case conceptualizations or recommendations made to my therapist in an effort to improve my care.
I understand that I may revoke my authorization at any time.
case conferencing consent
** All cases will be reviewed by Kristi LeBeau, Clinical Director, and Robert Burnstein, M.D. our Medical Director. **
* ELECTRONIC SIGNATURE    By entering my email address or home address in this box, I am signing this Practice Orientation Agreement and Coordination of Care. I hereby certify that I am either the client as entered above or a parent/legal guardian for the client. I agree to the terms and conditions set forth in this agreement. My signature below indicates that I consent to receive services at Wentworth & Associates, that I understand I may discuss any questions I have regarding services, and that I maintain the option to terminate my consent at any time.
Form Updates
Name Date Action
    Form Started
  1. Click the "Submit" button to save the data entered on this form.
  2. Click the "Cancel" button to exit without saving recent updates on this form.