THRIVE
Emotionally…Socially…Behaviorally
556 Garrisonville Rd, Suite 212
Stafford, VA 22554
540-602-7266
www.thrivestafford.com
info@thrivestafford.com
SERVICE AGREEMENT
Welcome to THRIVE and thank you for seeking services with our clinicians. This document contains important
information about our professional services and business policies. Please read it carefully and jot down any
questions you might have so that we can discuss them at our next meeting. When you sign this document, it will
represent an agreement between us.
THRIVE is a multi-provider group comprised of Kristin Gartner, LPC; Kelly Givens, MEd; and Dr. Emma B.
Jurrens, Licensed Psychologist. THRIVE specializes in the assessment and treatment of cognitive, behavioral,
academic, emotional and social difficulties in children, adolescents and adults. Services include psychological and
educational assessment; consultation and short-term intervention; individual, group and family counseling and
therapy; and behavioral consultation. THRIVE clinicians have particular expertise in treating eating disorders and
adolescent girls, children with anxiety, also provide evaluations for individuals considering weight loss surgery.
THERAPY and COUNSELING
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the
psychologist and patient, and the particular problems you bring forward. Many different methods may be used to
deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls
for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things
we talk about both during our sessions and at home.
Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life,
you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On
the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often
leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But
there are no guarantees of what you will experience.
The first few sessions will involve an evaluation of your needs, followed by staff offering you some first
impressions of what your work in therapy will include and a treatment plan to follow, if you decide to continue with
therapy. You should evaluate this information along with your own opinions. Therapy involves a large commitment
of time, money, and energy, so you should be thoughtful about the therapist you select. If you have questions about
our procedures, we should discuss them whenever they arise. If your doubts persist, we will be happy to help you
set up a meeting with another mental health professional for a second opinion.
TESTING
Testing takes a variety of forms. We conduct evaluations and assessments for bariatric/weight loss surgery,
attention concerns, emotional difficulties, behavior problems, learning or academic concerns, and other issues.
Although we are often able to complete testing in one or two sessions, our goal is to get the best performance
possible out of clients, therefore during evaluations, we closely monitor clients for signs of fatigue and will
reschedule testing as needed.
In most cases, insurance providers authorize a certain number of testing sessions in order to assist in diagnosis and
treatment planning. One area that is rarely covered by insurance is academic or learning-related evaluation. We
offer a flat fee $200 for academic evaluations, which should be paid upon commencement of the evaluation. If
such testing is completed in conjunction with other assessments, we will bill insurance for those other assessments.
APPOINTMENTS
Office hours vary throughout the week. Evening and Saturday appointments are available. Initial appointments
last about one hour and involve a detailed social/developmental history and diagnostic interview. Subsequent
therapy sessions generally last 45-50 minutes, once per week. Appointments for evaluations vary in length.
Changes or cancellations must be made at least 24 hours in advance, unless THRIVE staff agree that you were
unable to attend due to circumstances beyond your control. A $50 charge will be billed for missed appointments
and late cancellations. Following the third missed appointment your provider will re-evaluate continued therapy.
Please note that insurance carriers do not cover charges for missed appointments.
BILLING, PAYMENTS and INSURANCE REIMBURSEMENT
You are expected to pay for each service on the day that it is provided unless other arrangements have been agreed
upon. If we are billing insurance for you, you are expected to pay your co-pay at the time of service. If you have a
missed/late cancellation fee, the fee should be paid at the time of next appointment unless you have a payment plan
set up with THRIVE.
With your permission THRIVE may obtain necessary authorizations and file claims to your primary insurance
carrier. Our insurance and billing services are performed through our in-house biller, TMAC Medical Billing.
Please know that you may be contacted by a TMAC staff member on the behalf of THRIVE clinicians regarding
insurance or billing matters. Regardless of insurance coverage, you, as the client/financially responsible party, are
responsible for charges incurred. If insurance claims are denied or coverage is not authorized by your insurance
company, you will be billed an hourly rate for appointments.
You are advised to verify your mental health benefits and co-payments, and are responsible for reading and
understanding your insurance plan and benefits. You should carefully read the section in your insurance coverage
booklet that describes mental health/behavioral health services. If you have questions about the coverage, call your
plan administrator. Of course THRIVE staff will provide you with whatever information we can based on our
experience.
Due to the rising costs of health care, insurance benefits have increasingly become more complex. Insurance plans
are often limited to short-term treatment approaches designed to work out specific problems that interfere with a
person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of
sessions. Units of testing may also be limited by insurance – THRIVE clinicians will work within those parameters
to meet your evaluation needs.
You should also be aware that most insurance companies require you to authorize THRIVE clinicians to provide
them with a clinical diagnosis. At times, we are required to provide additional clinical information such as
treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the
insurance company files – THRIVE clinicians have no control over what the insurance company does with this
information or how it is stored once it is in their hands.
Please see accompanying Financial Policy for additional information.
CONTACTING US
The office telephone number is (540) 602-7266. If you are connected with voicemail when you call, please leave a
message and we will make every effort to return your call on the same day, with the exception of weekends and
holidays; however we may not be able to get back to you until the following day. It is often easier to reach us by
email at info@thrivestafford.com or at the clinician’s individual email address. If you are unable to reach us and
feel that you can’t wait for a return call, contact your family physician or the nearest emergency room and ask for
the psychologist on call. In the event of a life threatening situation, call 911 or contact the nearest hospital, police or
fire department. If I will be unavailable for an extended time, I will provide you with the name of a colleague to
contact, if necessary.
PROFESSIONAL RECORDS
The laws and standards of the psychology profession require that treatment records be kept. You are entitled to
receive a copy of your records, at your request. Because these are professional records, they can be misinterpreted
and/or upsetting to untrained readers. If you wish to see your records, it is recommended that you review them with
your practitioner so that you can discuss the contents.
MINORS
If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine
your treatment records. When a minor is being seen for therapy, it is THRIVE clinicians’ policy to request an
agreement from parents that they agree to give up access to your therapeutic records. If they agree, THRIVE will
provide parents only with general information about you work in therapy, unless staff believe there is a high risk
that you will seriously harm yourself or someone else. In this case, we will notify them of those concerns. Before
giving parents any information, staff will discuss the matter with you, if possible, and try to handle any objections
you may have.
CONFIDENTIALITY
In general, the privacy of all communications between a patient and a clinician is protected by law, and information
can only be released to others with your written permission. I cannot and will not tell anyone else what you have
told me, or even that you are in therapy with me without your prior written permission. Under the provisions of the
Health Care Information Act of 1992, I may legally speak to another health care provider or a member of your
family about you without your prior consent, but I will not do so unless the situation is an emergency. You are also
protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA), which
is provided in a separate document. This law insures the confidentiality of all electronic transmission of information
about you. If you elect to communicate with me by email at some point in our work together, please be aware that
email is not completely confidential. All emails are retained in the logs of your or my internet service provider.
The following are legal exceptions to your right to confidentiality.
1. If your clinician has good reason to believe that you will harm another person, he/she must attempt to inform that
person and warn them of your intentions. He/she must also contact the police and ask them to protect your intended
victim.
2. If your clinician has good reason to believe that you are abusing or neglecting a child or vulnerable adult, or if
you give me information about someone else who is doing this, he/she must inform Child Protective Services
within 48 hours and Adult Protective Services immediately.
3. If your clinician believes that you are in imminent danger of harming yourself, he/she may legally break
confidentiality and call the police or the crisis team.
These situations have rarely occurred at THRIVE. If a similar situation occurs, staff will make every effort to fully
discuss it with you before taking any action.
Your clinician may occasionally find it helpful to consult other professionals about a case. During a consultation,
staff will make every effort to avoid revealing your identity. The consultant is also legally bound to keep the
information confidential. At times, THRIVE clinicians may ask you to sign a release of information to discuss or
exchange information with other practitioners, such as your medical doctor, or school staff.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential
problems, it is important that you discuss any questions or concerns that you may have with your clinician.
Informed Consent to Treatment
I, _____________________________, (name of client or guardian as applicable), agree and consent to
participate in behavioral health care services offered and provided by Kelly Givens, MEd. I understand that
I am consenting and agreeing only to those services that the above named provider is qualified within: (1)
the scope of the provider’s license, certification, or training; or (2) the scope of the license, certification, and
training of the behavioral health providers directly supervising the services received by the client. If the
patient is under the age of 18 or unable to consent to treatment, I attest that I have legal custody of this
individual an am authorized to initiate and consent for treatment and/or legally authorized to initiate and
consent to treatment on behalf of this individual.
____________________________________________
Signature of Client/Legal Guardian
___________________________
Date