MARLA J. SOMOVA, PH.D., LICENSED PSYCHOLOGIST
OUTPATIENT SERVICES CONTRACT/INFORMED CONSENT
Rev. August 2015
Note: You do not need to print out this entire document, only the last page of this document which you will need to sign.
Welcome to my practice. This document contains important information about my professional services and business
policies. Please read it carefully and let me know if you have any questions. When you sign this document, it will represent an
agreement between us.
About Psychotherapy: the Benefits and Risks
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. There are many different methods I may use 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. You should think about both the benefits and risks when making any treatment
decisions. For example, in therapy, there is a risk that clients will, for a time, have uncomfortable levels of sadness, guilt,
anxiety, anger, frustration, loneliness, helplessness, or other negative feelings. Clients may recall unpleasant memories.
These feelings or memories may bother a client at work or in school. In addition, some people in your community may
mistakenly view anyone in therapy as weak, or perhaps as seriously disturbed or even dangerous. Also, clients in therapy
may have problems with people important to them. Family secrets may be told. Therapy may disrupt a marital relationship and
sometimes may even lead to a divorce. Sometimes, too, a client’s problems may temporarily worsen after the beginning of
treatment. Most of these risks are to be expected when people are making important changes in their lives. Finally, even with
our best efforts, there is a risk that therapy may not work out well for you.
While you consider these risks, you should know also that the benefits of therapy have been shown by scientists in hundreds
of well-designed research studies. People who are depressed may find their mood lifting. Others may no longer feel afraid,
angry, or anxious. In therapy, people have a chance to talk things out fully until their feelings are relieved or the problems are
solved. Clients’ relationships and coping skills may improve greatly. They may get more satisfaction out of social and family
relationships. Their personal goals and values may become clearer. They may grow in many directions—as persons, in their
close relationships, in their work or schooling, and in the ability to enjoy their lives. But there are no guarantees of what you
will experience. I do not take on clients that I know I cannot help. Therefore, I will enter our relationship with optimism about
our progress. In sum, therapy involves a large commitment of time, money, and energy, so you should be very careful about
the therapist you select.
My Approach
I believe that therapy is most effective in the context of a supportive and honest relationship in which we agree to work
together to help you:
-- Gain a better understanding of your feelings and experiences
-- Explore aspects of your life or experience that you may have been avoiding
-- Identify patterns in your actions, thoughts, feelings, experiences, and relationships
-- Live a more authentic life, i.e., a life that is most consistent with your beliefs, values, and feelings
As I listen to your story, I will offer reflections and interpretations with the goal of increasing understanding of your feelings and
experiences, both past and present. An honest, unflinching look at our own feelings and experiences helps us make the best
decisions possible about our lives. While I believe that understanding oneself is of utmost importance, I also make use of skillfocused approaches such as cognitive-behavioral therapy to help with the process of behavior change.
While engaging in a process of self-reflection can be difficult at times, developing self-awareness helps you gain the skills to
live an authentic life. In simple terms, the goal of therapy is to give you the skills to be able to check in with yourself about
what you want and need and take the steps to meet those needs while at the same time nurturing and maintaining your
relationships and social/vocational commitments.
Meetings/Sessions
My evaluation typically lasts from 1 to 3 sessions. During this time, we can both decide if I am the best person to provide the
services you need in order to meet your treatment goals. If psychotherapy is begun, I will usually schedule one hour session
per week. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance
notice of cancellation. Most of my clients see me once a week for 3 or 4 months. After that, we meet less often for several
more months. Therapy then usually comes to an end. Some clients, however, see me on a longer-term basis. The actual
duration of therapy is ultimately a function of who you are and what you are working on. But whatever the length, all therapy
eventually ends. The process of ending therapy, called “termination,” is a valuable part of our work. If you wish to stop
therapy at any time, I ask that you agree to meet for at least one “termination” session to review our work together. If you
would like to take a “time out” from therapy, we should discuss this. I ask that you do not bring children with you if they are
young and need babysitting or supervision, which I cannot provide.
Consultations/Referrals
If you could benefit from a treatment I cannot provide, I will provide a referral. Based on what I learn about your problems, I
may recommend a medical exam or use of medication. If you are treated by another professional, I will attempt to coordinate
my services with them and with your own medical doctor (but only after obtaining a written consent from you to do so). If for
some reason treatment is not going well, I might suggest you see another therapist instead of me. As an ethical therapist, I
cannot continue to treat you if my treatment is not working for you. If you wish for another professional’s opinion at any time,
or wish to talk with another therapist, let me know if I need to provide him or her with the information needed.
What to Expect from Our Relationship
As a professional, I will use my best knowledge and skills to help you. This includes following the standards of the American
Psychological Association, or APA. In your best interests, the APA puts limits on the relationship between a therapist and a
client, and I will abide by these. Let me explain these limits, so you will not think they are personal responses to you.
First, I am licensed and trained to practice psychology – not law, medicine, finance, or any other profession. I am not able to
give you good advice from these other professional viewpoints.
Second, state laws and the rules of the APA require me to keep what you tell me confidential (that is, private). You can trust
me not to tell anyone else what you tell me, except in certain limited situations. I explain what those are in the “About
Confidentiality” section of this information packet. As I am sure you have heard, Pittsburgh is more of a ‘big town” than a
“small city.” With this in mind, please note that if we happen to meet in public (on the street, or in some social setting), I may
not acknowledge you or engage unless you choose to do so first. Even if engaged by you, I will likely remain quite reserved
so as to protect your confidentiality.
Third, in your best interest, and following the APA’s standards, I can only be your therapist. I cannot have any other role in
your life. I cannot, now or ever, be a close friend or socialize with any of my clients. I cannot be a therapist to someone who is
already a friend. I can never have a romantic relationship with any client during, or after, the course of therapy. I cannot have
a business relationship with any of my clients, other than the therapy relationship. Even though you might invite me, I will not
attend your family gatherings, such as parties or weddings. Should you find yourself ill or injured in a hospital, as sincerely
concerned as I might be about your well-being, I will not make a visit. As your therapist, I will not celebrate holidays or give
you gifts; I may not notice or recall your birthday; and I will not accept gifts.
Professional Records
The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of the
records unless I believe that seeing them would be emotionally damaging, in which case I will be happy to send them to a
mental health professional of your choice. Because these are professional records, they can be misinterpreted and/or
upsetting to untrained readers. I recommend that you review them in my presence so that we can discuss the contents.
Patients will be charged appropriate administrative and clinical fees for any time spent in preparing information requests (e.g.
for any treatment record summary, records discussion meeting, and/or preparation and transmittal of records to another
professional).
About Confidentiality
In general, the privacy of all communications between a patient and a psychologist is protected by law, and I can only release
information about our work to others with your written permission. But there are a few exceptions.
A. Disclosures for Treatment, Payment, and Practice Operations
I may use or disclose your protected health information (PHI) for treatment, payment and practice operations purposes with
your general consent. If you are a self-pay client, there will be no need to disclose any PHI to any third party (such as an
insurance), except for the purposes of payment (when collecting on overdue accounts). If you are planning to use your
insurance benefits, you will be asked to sign a Release of Information to your insurance as part of this Outpatient Treatment
Contract & Informed Consent. Doing so will authorize Dr. Somova to use and disclose your protected health information for
the purposes of treatment, payment and practice operations (see these terms defined below).
As part of cost control efforts, an insurance company will sometimes ask for more information on symptoms, diagnoses, and
my treatment methods. I will let you know if this should occur and what the company has asked for. Please understand that I
have no control over how these records are handled at the insurance company. My policy is to provide only as much
information as the insurance company will need to pay your benefits. Any further disclosure of your PHI above and beyond
the treatment, payment and practice operations will require a separate consent from you (see section B below).
[Relevant terms: PHI refers to information in your health record that could identify you. Treatment is when Marla J. Somova,
Ph.D. provides, coordinates or manages your health care. Examples of treatment would be when Marla J. Somova, Ph.D.,
with your consent, consults with another health care provider, such as your family physician. Payment is when Marla J.
Somova, Ph.D. obtains reimbursement for the services he provided. Example of payment is when Marla J. Somova, Ph.D.
discloses your PHI to your health insurer to obtain reimbursement or to pre-authorize services. Practice operations are
activities that relate to the performance and operations of Marla J. Somova, Ph.D. These health care operations may, for
example, involve such business-related matters as billing, collection, quality assessment (such as insurance-mandated
audits), and care coordination.]
B. Release of Information/Disclosures that Require Specific Consent/Authorization
I may use or disclose your protected health information (PHI) for purposes outside of treatment, payment and practice
operations after I obtain an appropriate authorization from you. Please, note that you may revoke all such authorizations at
any time, by providing a written revocation. You may not revoke an authorization to the extent that (1) Marla J. Somova, Ph.D.
provider has already relied on that authorization and has already released the information in question; or (2) the
release/authorization was obtained as a condition of obtaining insurance coverage.
C. Releases/Disclosures Without Your Consent/Authorization
I may release/disclose PHI without your consent/authorization in the following circumstances:
Intent of Self-Harm/Suicidal Ideation & Behavior:
If the patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family
members or others who can help provide protection. These situations have rarely occurred in my practice. If such a situation
occurs, I will make
every effort to fully discuss it with you before taking any action.
Serious Threat to Health or Safety of Others:
There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal
some information about a patient’s treatment. If I believe that a patient is threatening serious bodily harm to another, I am [may
be] required to take protective actions. These actions may include notifying the potential victim, contacting the police, or
seeking hospitalization for the patient. If you express a serious threat or intent to kill or seriously injure an identified or readily
identifiable person or group of people, and Marla J. Somova, Ph.D. determines that you are likely to carry out the threat, he
must take reasonable measures to prevent harm. Reasonable measures may include directly advising the potential victim of
the threat or intent.
Child Abuse:
If I have reason to suspect, on the basis of my professional judgment, that a child is or has been abused, I am required to
report my suspicions to the authority or government agency vested to conduct child-abuse investigations. I am required to
make such reports even if I do not see the child in my professional capacity. I am mandated to report suspected child abuse if
anyone aged 14 or older tells me that he or she committed child abuse, even if the victim is no longer in danger. I am also
mandated to report suspected child abuse if anyone tells me that he or she knows of any child who is currently being abused.
Adult and Domestic Abuse:
If Marla J. Somova, Ph.D. has reasonable cause to suspect that an older adult is in need of protective services, he may report
such to the agency which provides protective services.
Legal, Judicial and Administrative Proceedings:
If you are involved in a court proceeding and a request is made about the professional services Marla J. Somova, Ph.D. has
provided you or the records thereof, such information is privileged under state law, and Marla J. Somova, Ph.D. will not
release the information without your written consent or a court order. The privilege does not, however, apply when the
evaluation is mandated by a third party or court ordered. You will be informed in advance if this is the case. In most legal
proceedings, you have the right to prevent me from providing any information about your treatment. In some proceedings
involving child custody and those in which your emotional
condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it.
Additionally, Marla J. Somova, Ph.D. may, in response to a warrant or subpoena, disclose health information about you to a
law enforcement official for certain law enforcement purposes. For example, Marla J. Somova, Ph.D. may be required to
assist law enforcement to locate someone such as a fugitive or material witness, or to provide other information pertinent to an
investigation.
If a worker's compensation claim is filed, Marla J. Somova, Ph.D. will be required to file periodic reports with your employer
which could include history, diagnosis, treatment and prognosis.
Confidentiality and Clinical Consultations
There are two situations in which I might talk about your case with another therapist, with your permission. First, if I am going
to be away from the office for an extended period of time, I might arrange for a trusted fellow therapist to “cover” for me. This
therapist will be available to you in emergencies. Therefore, he or she needs to know about you. Of course, this therapist is
bound by the same laws and rules as I am to protect your confidentiality. Second, I sometimes consult other therapists or other
professionals about my clients. This helps me in giving high-quality treatment. These persons are also required to keep your
information private. Your name will never be given to them, and they will be told only as much as they need to know to
understand your situation.
Confidentiality and Business Associates
Marla J. Somova, Ph.D. may share health information about you with her business associates who are performing services on
his behalf. For example, Marla J. Somova, Ph.D. may contract with an answering or billing service. Marla J. Somova’s
business associates are obligated to safeguard your health information. Marla J. Somova, Ph.D. will share with her business
associates only the minimum amount of personal health information necessary for them to assist her.
Confidentiality and Guardian/Personal Representative
If you are an adult who has a legally appointed guardian, Marla J. Somova, Ph.D. may disclose health information about you to
that person as necessary to make decisions about your health care.
Record Review
You can review your own records in my files, in my office only, on an appointment basis only. You may offer a written
statement of addition and correction to your records and I will file such statement along with my clinical notes. You can have
copies of your records. You will be charged for any expenses of time and/or applicable administrative costs in such a case. I
ask you to understand and agree that you may not examine records created by anyone else other than me that might be a part
of your file. For example, if your previous therapist, per your request, submitted clinical documentation that has become part
of your records in my practice, you will have to review the corresponding records with the original provider. In some very rare
situations, I may temporarily remove parts of your records before you see them. This would happen if I believe that the
information will be harmful to you, but I will discuss this with you.
Payment Policies and Procedures
All payments (or co-payments, if applicable) are expected to be made in full, on the day of service and are collected at the
beginning of each encounter. Cash, checks, and credit cards are accepted as payment during the office visit. Services can be
pre-paid online. Inability to pay on the day of service or a partial payment on the day of service incurs an
administrative/processing fee of $5. I reserve the right to discontinue services if your account is 30 days past due and to
forward the following protected health insurance (PHI) to a collection agency if your account is 60 days past due: your name,
address, date of birth, your SSN, your phone number, dates of services, and the amount/balance due. If you paid for the
services with a personal check and your check "bounced" because of insufficient funds, an administrative (processing) fee of
$100 will be added to your balance for each invalid check. Please, note that I do not offer discount services (reduced fees or a
sliding fee schedule).
Advantage of Self-Pay:
1. Paying for psychotherapy out of pocket minimizes the exposure of your protected health information (PHI). In the case of
self-pay, however, your therapy remains completely private (mandated reporting exceptions notwithstanding). No reports of
your treatment are shared with your insurance and all records remain with the therapist only. 2. The additional advantage of
Self-Pay includes the fact no records of therapy exist in the Medical Information Bureau which could potentially compromise
your ability to get current or future life, health, disability, or long-term care insurance. Self-Pay, thus, involves no psychiatric
diagnosis code. If, however, you were using your insurance benefits, you would have to be assigned a psychiatric diagnosis in
order for the provider to justify the medical necessity for the services provided. Once such diagnosis code is recorded by the
insurance, it becomes part of your health care record.
Self-Pay Rates/Fees:
$160 for initial assessment/evaluation session (clinical hour is 53 min per CPT 90837); $140 for follow up session, individual
therapy or couple's therapy (clinical hour); $55 for group therapy session (clinical hour). Please, note that all rates are subject
to change; rates agreed upon at the outset of therapy will remain in effect until the next calendar year.
Late-Cancellation/No-Show Policy
If you do not show up for your scheduled appointment, and you have not notified Dr. Somova at least 24 hours in advance,
you will be required to pay the full cost of the treatment as booked. The Late-Cancel/No-Show fee is $120. Please, note that I
the following discounts for paying off the late-cancellation and no-show fees:
If you pay within 24 hrs of the missed appointment, the fee is $90 ($30 discount)
If you pay within 48 hrs of the missed appointment, the fee is $100 ($20 discount)
If you pay after 48 hrs of the missed appointment, the full $120 fee applies.
The reason behind this policy is to protect the provider's time, not to penalize you financially. If you are wondering why you
should pay for the services you have not received, please, consider the fact that when you make an appointment, you are
booking the provider's time that is no longer available for scheduling. Your session time is reserved/booked for you. If you
late-cancel a session or no-show, I will have to charge you for the lost time unless I am able to fill it. Please, note that your
insurance will not cover this charge.
Note: there is an unconditional $20 no-show fee for any missed group psychotherapy sessions.
Administrative Costs
If a third party (another provider, a lawyer, etc.) requests a copy of your treatment records, such notification, to be completed
in time, would have to be made 10 work days in advance. A minimal $50 administrative fee will apply (for time, processing,
and copying).
Documentation (report-writing, filling out forms, letters) for court-mandated, employer-mandated and disability (FMLA, etc.)
purposes will be billed at a $160 per hour. Please, note that a minimum of 1 hour will be charged. On-site depositions
(taken at Dr. Somova's office) will incur the fee of $300 per hour. Off-site depositions will be billed at $400 per hour with a
minimum of 2.5 hours.
Financial Responsibility, Cessation of Insurance Coverage, Filing Insurance Claims
While my office will submit appropriate claims to your insurance company, you (and not your insurance company) are
ultimately responsible for full payment of my fees. For this reason, it is important that you find out exactly what mental health
services your insurance policy covers. If you have questions about the coverage, call your plan administrator. If I do not
receive payment on time from your insurance company, I will then expect this payment from you directly.
If it so happens that your insurance coverage ended before you feel ready to end our sessions, you will have the option to
continue on a self-pay basis or to ask for a referral to a provider who might be willing to work with you at a discount rate.
To seek payment from an insurance company that I do not work with, you must first obtain a claim form from your employer’s
benefits office or call your insurance company. Complete the claim form. Ask me for a statement of services (an invoice). Then
attach my statement (invoice) to the claim form and mail it to your insurance company.
Areas/Focus of Initial Assessment
As part of the initial assessment, you can be expected to be asked about the presenting problem that brings you into therapy,
history of psychological and/or psychiatric management of this issue, social history (to include military history, family history,
educational history, professional history, romantic/marital history); you may also be asked about any history of legal
charges/arrests/incarceration; you can also expect to be asked about any history of suicidal or homicidal ideation; you will be
also assessed for substance use (with the help of clinical inquiry and/or self-report questionnaires); you may also be asked to
share your medical/health history, etc. Please, be assured that these questions are not motivated by personal curiosity but by
the necessity to gather all the relevant clinical context. Additional tests and questionnaires may be recommended for further
assessment. The clinical rationale for the use of these additional assessment tools (if clinically necessitated) will be offered.
Please, keep in mind that you can always decline to answer a question. Should you do so I will have to document/note (in
your clinical record) the fact of your refusal to answer a specific assessment question. For example, if I ask you about the
extent of your substance use and you decline to answer this question, I will write down that “the client declined to discuss
his/her current substance use status.”
Availability/Access
From the point of the initial contact, I will do my best to offer you an initial evaluation appointment within 14 work days (unless I
am out of town, on a vacation, business trip, or out of town/country on a personal matter). If you are in a life-threatening crisis
and you have requested an immediate follow-up appointment (for established clients only, not for the initial clients), I will do my
best to accommodate you immediately unless I find that your needs would be better served by going immediately to an
emergency room. If you are in a non-life-threatening crisis and you have requested an appointment during the work hours I
will do my best to accommodate you within 48 business hours.
Custody Evaluations
If you ever become involved in a divorce or custody dispute, I want you to understand and agree that I will not provide
evaluations or expert testimony in court. You should hire a different mental health professional for any evaluations or
testimony you require. This position is based on two reasons: (1) My statements will be seen as biased in your favor because
we have a therapy relationship; and (2) the testimony might affect our therapy relationship, and I must put this relationship first.
Principles of Practice
It is my intention to fully abide by all the rules of the American Psychological Association (APA) and by those of my state
license. I am an Equal Opportunity Provider: in my practice as a therapist, I do not discriminate against clients because of
any of these factors: age, sex, marital/family status, race, color, religious beliefs, ethnic origin, place of residence, veteran
status, physical disability, health status, sexual orientation, or criminal record unrelated to present dangerousness. This is a
personal commitment, as well as being required by federal, state, and local laws and regulations.
Contacting the Provider
I am not immediately available by telephone. I do not offer call-in hours. My toll-free telephone (1-866-683-3204) is answered
by an answering service [voice mail and/or answering service operator] [that I monitor frequently, or who knows where to
reach me]. I will make every effort to return your call within 24 business hours, with the exception of weekends and holidays. If
I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. I only use
email for scheduling. If you wish to email me a blog-post or a journal entry, please, do not do so unless you first consult me.
In rare cases, it might be clinically appropriate for you to submit agreed-upon clinical data (e.g. journal entries) prior to or in
between the appointments. This would be first discussed in session. Please, note that if I am expected to review these
materials in between sessions, there will be billed for the time used (on the basis of my hourly fees).
If you are experiencing a clinical emergency (for example, if you feel you are at risk for harming yourself or someone else),
please, consider the following options: 1) call UPMC's Re:solve Crisis Network (1-888-7-YOUCAN); 2) call 911 and/or go to
the nearest emergency room; 3) call my practice (866) 683-3204, press 0 to speak to the operator, who will contact me. If you
are experiencing suicidal thoughts, consider calling the National Suicide Prevention Lifeline (1-800-273-TALK).
Marla J. Somova, Ph.D., LICENSED PSYCHOLOGIST
OUTPATIENT SERVICES CONTRACT (INFORMED CONSENT)
(please, review, initial where indicated, sign and date)
I, the client, understand I have the right not to sign this form (in which case I will not be able to enter into treatment with Dr.
Somova). My signature below indicates that I have read and discussed this agreement; it does not indicate that I am waiving
any of my rights. I understand I can choose to discuss my concerns with the therapist, before I start formal therapy. I
understand that if at any time during the treatment I have questions about any of the subjects discussed in this information
packet, I can talk with the therapist about them.
I, the client, understand that after therapy begins I have the right to withdraw my consent to therapy at any time, for any
reason. However, I, the client, will make an effort to discuss my concerns about my progress before ending therapy.
I, the client, understand that no specific promises have been made to me by this therapist about the results of treatment, the
effectiveness of the procedures used by this therapist, or the number of sessions necessary for therapy to be effective.
I, the client, have read, or have had read to me, the issues and points in this information packet. I have discussed those points
I did not understand, and have had my questions, if any, fully answered. I agree to act according to the points covered in this
information packet. I hereby agree to enter into therapy with this therapist, as shown by my signature here
I, the client, have read and understood privacy and financial policies in their entirety. My consent below indicates my
acceptance of privacy (confidentiality limitations) policies and financial terms (fees and late-cancellation/no-show policies) of
practice with Marla J. Somova, Ph.D., as well as my understanding that Marla J. Somova, Ph.D., does not provide emergency
phone-in coverage.
I have read and understood that certain protected health information (PHI) will have to be released to my insurance carrier
(note: does not apply to self-pay clients). My signature below authorizes Marla J. Somova, Ph.D. to release the necessary PHI
to my insurance carrier (note: does not apply to self-pay clients).
I have read and understood Dr. Somova’s No-Show/Late-Cancellation Policies. I understand that if I fail to show up for a
scheduled appointment or if I late-cancel a scheduled appointment with a less than 24hr notice, I will be responsible for a latecancellation/no-show fee (which is $120 for individual/couple's therapy sessions and $20 for group therapy sessions).
__________ (initial)
Inability to pay on the day of service or a partial payment incurs an administrative fee of $5.
__________ (initial)
I understand and agree that Marla Somova has the right to discontinue her professional services if my account is 30 days past
due and to forward my protected health insurance (PHI) to a collection agency if my account is 60 days past due.
__________ (initial)
I understand and agree that If I paid for the services with a personal check and my check "bounced" because of insufficient
funds, an administrative fee of $100 will be added to my balance for each invalid check.
__________ (initial)
CLIENT
Name:________________________________________Sign:______________________________Date:_____________
OFFICE USE ONLY:
I, Marla Somova, find no reason to believe this person is not fully competent to give informed consent to treatment.
______________________________________________ ____________
Signature of therapist
Date