Initial Paperwork
Completing paperwork before you get to the office is a smart move. It means you don't have to frantically scribble in the waiting room in a race against time. It means you have time to actually read about our policies.
So go ahead -- download our intake forms. To the right is the two-page document you sign to authorize us to file insurance claims on your behalf and to show you agree to the terms of the document below.
Below is our "Policies and Procedures," also known as Informed Consent. It explains what terms you are agreeing to when you sign the intake forms. This information is included in the intake manual, and we chose to publish it just once on this website.
I know many people sign the forms without actually reading what they're signing, but it's smart to know what you're agreeing to accept. That way, you know what to expect if you miss a session without calling first, and you know which phone calls can incur a charge.
The entire policy is outlined in the download and is also spelled out on the webpage below. Please also review our financial policies, which are in the "Rates and Insurance" tab. Read the policies, sign the authorizations and bring the intake forms to your first appointment. You deserve to feel smart.
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Two-page forms to fill out and sign. |
Policies and Procedures | INFORMED CONSENT
Thank you for choosing Jennifer Whitlock, LPC as your psychotherapist. The first consultation appointment will take approximately 45-60 minutes and all others sessions will be 45-50 minutes (unless other arrangements are made). This document is intended to inform you of my professional experience, treatment practices, policies, State and Federal Laws as well as your rights.
Jennifer Whitlock, LPC has earned her Bachelor of Arts degree in English and psychology from the University of Pennsylvania and her Masters degree in Counseling Psychology from Kutztown University. She is licensed in New Jersey as a Licensed Professional Counselor and has over 16 years of experience in treating adolescents, adults, couples, families and conducting group therapy.
Confidentiality
Your verbal communication and clinical records are strictly confidential. However, we are required by law to disclose confidential information if any of the following conditions exist:
1. You are a danger to yourself or others.
2. Your therapist was appointed by the courts to evaluate you.
3. Your contract is for the purpose of establishing your competence.
4. You are a minor and your counselor reasonably suspects you are the victim of child abuse or neglect.
5. You file suit against anyone and have claimed mental/emotional damage as part of the suit.
6. You have filed suit against the therapist for breach of duty or your therapist files suit against you.
7. You waive your rights to privilege or give consent to limited disclosure by your therapist.
8. Your insurance company paying for services has the right to review all records.
9. The therapist may share information necessary for case supervision and consultation.
If you have any questions about these limitations, please discuss them with your therapist.
Emergency Situations
Please be advised that we do not provide a 24/7 answering service. In the event that you have a mental health emergency (such as suicidal plans, violent behavior, psychotic symptoms) and you cannot reach Ms. Whitlock, we suggest you dial 911 or contact your local emergency room. If you live in Sussex County, contact Newton Memorial Hospital Psychiatric Emergency Services 24 hours a day at 973-383-0973. In Morris County, call Saint Clare’s 24-hour hotline at 973-625-0280.
If Jennifer Whitlock, LPC assesses that a patient is in crisis or an emergency exists in her office, she has the right and legal obligation to call the police and/or any emergency personnel necessary to ensure that the patient is safe. Jennifer Whitlock has the right to contact immediate family members or your emergency contact and notify them of such emergency.
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The Therapeutic Process
Participation in therapy can help you resolve conflicts, build confidence, lift depression and create a more fulfilling life. I, Jennifer Whitlock, draw on a variety of psychological approaches, choosing the methods that best suit your personality and your particular issues. The following is a sampling of approaches I use:
[ I help clients clarify their values, needs and goals.
[ I inspire clients to see their potential, develop hope and plan a more satisfying future.
[ I help clients get in touch with their sense of spontaneity, joy and creativity.
[ I explore attitudes, emotions and habits that get in the way of one’s desires, and explore ways to address these blocks.
[ I challenge assumptions and beliefs that contribute to depression, anxiety and self-defeating behavior.
[ If a client is afflicted with any condition, such as depression, anxiety or bipolar disorder, I educate them on the nature of their problem and treatment options.
[ I consult with other treatment providers, such as psychiatrists and guidance counselors.
However, we won’t get far without your cooperation. Psychotherapy requires your involvement, honesty and openness. It’s the only way we can examine and adjust your thoughts, feelings, and/or behaviors. Clients who benefit most from counseling most:
[ See therapy as a collaboration – they’re not just a passive recipient of the therapist’s advice.
[ Have an idea of what they want to examine, understand or accomplish.
[ Actively seek solutions and try them.
[ Are honest, even if it doesn’t seem quite flattering.
[ Are curious about their inner life, and interested in gaining insights.
[ Are open to new ideas and new ways of seeing things.
[ Think about what they discussed in session throughout the week.
[ Can stand some emotional discomfort. Therapy can be uncomfortable at first, as feelings and memories you’d been avoiding come to the surface. Those who continue counseling and sort out these feelings enjoy better results than those who face the problems … and run.
Change can be easy and swift, but more often it is gradual and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, I will ask you for your feedback and views on what aspects of therapy are helpful and what are not. There are often a number of theoretical approaches I may draw on, and if you would like a different approach, I am open to feedback.
It’s also possible that we could encounter a problem that we cannot solve together. If you decide that my personality or approach is just not the right match for yours, it is in your best interest to discuss this matter. I may be able to alter my approach, or to suggest a counselor who better fits your needs.
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| Bill of Rights
1. Jennifer Whitlock, Licensed Professional Counselor, supports a Patient Bill of Rights and Responsibilities and holds that compliance with these contributes to effective and appropriate patient care and responsibility. All activities related to providing healthcare services are to be conducted with an overriding concern for the patient and the community and above all with the recognition of the patient(s) dignity as a person who has the right to determine his/her own destiny in a socially responsible manner.
2. The patient has the right to considerate, respectful, appropriate and timely services.
3. The patient has the right to participate in the development of his/her service goals and service plan.
4. The patient has the right to obtain from his/her service provider, complete and current information concerning his/her diagnosis, treatment and prognosis in terms the patient can reasonably be expected to understand. When it is not advisable to give such information to the patient, the information should be made available to an appropriate person on his/her behalf.
5. The patient has the right to receive from his/her service provider, information to make informed consent prior to the start of any procedure and/or treatment. This shall include such information as: the significant risks involved with any procedure and service provider. Where clinically appropriate, alternatives for care or treatment should be explained to the patient.
6. The patient has the right to refuse any and all treatment to the extent permitted by law and to be informed of any of the psychological and/or medical consequences of his/her actions.
7. The patient has the right to every consideration of confidentiality and privacy concerning his/her own care limited only by state statues, rules, regulations or imminent danger to the individual or others
8. The patient has the right to be advised if the clinician, hospital, and/or clinic proposes to engage in or perform human experimentation affecting his/her care or treatment. The patient has the right to refuse to participate in such research.
9. The patient has the right to examine and receive an explanation of his/her bill
The patient’s responsibilities are as follows:
1. The patient has the responsibility to give their providers of care complete and accurate information related to their condition and their past and current care.
2. The patient has the responsibility to comply with the treatment plan, which they and their provider of care have mutually developed. Patients are responsible for the medical consequences, which may result, from refusing recommended treatment or for not following the instructions of the provider of care.
3. The patient has the responsibility to be considerate and respectful to the provider and provider’s staff who are committed to assisting all parties in providing effective care.
4. The patient has the responsibility to give complete and accurate insurance coverage information in a timely fashion and to pay for services promptly, so that the provider of care can continue to service the community effectively.
5. The patient has the responsibility to read and sign all forms provided to them to provide continuity of care, payment for such care and to cover all insurance issues.
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Health Insurance Portability and Accountability Act (HIPAA) of 1996
Notice Of Privacy Practices
This is a summary of Jennifer Whitlock’s Notice of Privacy Practices. Jennifer Whitlock promises to maintain the confidentiality of your protected health information (“PHI”). PHI is health information about you that we have in our records.
This notice describes how mental, behavioral, medical and other health care information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.
Uses and disclosures of health information
Except as described in this Notice, it is our practice to obtain your authorization before we disclose your PHI to another person or party. You may revoke an authorization, at any time, in writing. If you revoke an authorization, we will no longer use or disclose your PHI. However, we cannot undo any disclosures we have already made.
We use health information about you for treatment (supervision, referral, recording details of your treatment plan and your progress), to obtain payment (submit claims to billing services, collection agencies, or insurance, and deposit checks into a business account) and for administrative purposes (mailings, appointment reminders).
We may use or disclose PHI about you without your authorization for several other reasons. To comply with certain requirements, we may give out PHI without your authorization for public health purposes, for auditing purposes, for research studies and, to comply with specific laws and to avert a serious threat to health or safety. For example, we are required to report or disclose PHI related to child abuse or neglect. We may use or disclose your PHI in an emergency situation when use and disclosure of the PHI is necessary to prevent serious risk of bodily harm or death to you. Only specific information pertinent to the relief effort and the emergency may be released without your authorization.
We may apply a change to our policies at any time. Before we make a significant change in our policies, we will provide you with a notice.
Individual rights
You have the right, following a written request and agreed upon date and time, to look at, get a copy of or receive electronically protected health information about you that we use to make decisions about you. If you request copies, we will charge you at our cost for each page. You also have the right to receive a list of instances where we have disclosed protected health information about you for reasons other than treatment, payment or related administrative purposes. If you believe that information in your record is incorrect or if important information is missing, you have the right to request in writing that we amend the existing information.
You may request in writing that we restrict and/or not use or disclose your information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law, or in emergency circumstances. We will consider your request but are not legally required to agree to it.
Complaints
If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access or amendment to your records, you may send a written complaint to the US Department of Health and Human Services, Office of Civil Rights.
Our Legal Duty
We are required by law to protect the privacy of your information, provide this notice about our information practices, and follow the information practices that are described in this notice, according to The Health Insurance Portability and Accountability Act of 1996 (HIPAA).
We are also required to comply with any state laws that may be more stringent than the HIPAA Privacy Regulations. If you received mental health, mental retardation, or drug and alcohol abuse rehabilitation services, we will comply with the laws that provide the greatest protection for your health information.
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