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ELISE BON-RUDIN, Ed.

Ed. D.
Practice in child, adult, and couples psychotherapy
Consultant, Child Health Services
PATIENT INFORMED CONSENT and TREATMENT AGREEMENT
Welcome to my clinical practice. This document contains important information about my clinical
services, confidentiality, and business policies, and constitutes a treatment agreement between you
and me for the course of our work. Please read it carefully. We can discuss any questions you
may have when we meet in person.
My clinical practice offers evaluation and psychotherapy services on an outpatient basis to
individuals and families.1 I am a private practitioner and solely responsible for my clinical work.
From time to time I may consult clinically with one of my colleagues in order to maintain
perspective, get additional expertise, and otherwise enhance the clinical service I am providing, as
is expected of people in my professional discipline.
I am a licensed to practice psychology New Hampshire. I hold a Doctorate from Harvard
University, and Masters degrees from Harvard and Cambridge College. I am a Member of the
New Hampshire Psychological Association. I specialize in problems of attachment and extreme
stress in adults and children, normal and special parenting challenges, anxiety, trauma, grief, and
resuming child-parent contact after abuse concerns. Additional information is on my website.
1. Mental Health Bill of Rights. In compliance with New Hampshire licensing requirements,
there is a display copy in my office. A copy will be provided on request.
2. Confidentiality and limits on confidentiality. Ethically and legally I am bound to keep all
information you share with me confidential and not release it to any party without your written
permission. There are certain exceptions to this rule, in which a therapist is legally bound to act
even if doing so should breach confidentiality:
 Child, adult, and domestic abuse. If a therapist believes that a child under the age of 18 has
suffered, is suffering, or is in danger of suffering physical or emotional abuse, or has been or is
being sexually abused, a report must be made to the proper social service or other public authority.
The same holds true for an incapacitated adult who may be suffering or have died due to abuse or
neglect.
 If the State Board of Mental Health Practice is conducting an investigation, I am required to
disclose your mental health records on receipt of a subpoena from the Board.
 If a therapist believes that you are threatening immediate harm to yourself, through a plan of
action or inaction, s/he is required to contact a family member or other person who can help protect
you, or have you evaluated for hospital admission.
 If you were to threaten physical violence against another person, I have a legal obligation to
take some action to protect that person by notifying him/her and the police, and seek to have you
hospitalized to prevent harm from coming to them and to you.
1

Thenceforth psychotherapy is understood to include evaluation, when that is the service provided.

ELISE M. BON-RUDIN, EdD PATIENT INFORMED CONSENT & TREATMENT AGREEMENT

 Limits placed on confidentiality by health insurance. Your contract with your health insurance
company requires that we provide it with information relevant to the services that we provide to
you. We are required to provide a psychiatric diagnosis from the current version of the Diagnostic
& Statistical Manual of Psychiatric Disorders (DSM). Sometimes we are required to provide
additional clinical information. We will make every effort to release only the minimum
information about information necessary for the purpose requested, such as treatment plans or
summaries, or copies of your entire Clinical Record. This information will become part of the
insurance company files and will probably be stored in a computer. Though all insurance
companies claim to keep such information confidential, my practice has no control over the uses of
your information once it is in their hands. In some cases, they may share the information with a
national medical information databank. The Patient Privacy Rights Foundation warns that over 4
million businesses, employers, government agencies, insurance companies, billing firms, and all
their business associates that may include...marketing firms and data miners are entitled to see
and use individuals healthcare records if the record is held by a psychologist or other mental
health professional who uses electronic billing. Access to medical records creates the possibility of
employment discrimination. Studies have shown that thirty-five percent of Fortune 500 companies
admit to having looked at employees health records before making hiring and promotion
decisions. Even if a psychologist or other mental health professional wants to protect your
confidentiality, after your information is sent out to your insurance company, the professional no
longer has control over who can see or use it.

 Whenever possible, discussion with the patient will take place before any action is taken.
In legal proceedings, the courts usually respect your rights to confidentiality in the treatment
relationship, and the therapist is legally bound to protect that right when testifying in legal or
administrative procedures, even when a lawyer issues a subpoena. However, there are some
circumstances where some judges overrule the privilege and issue a court order requiring the
therapist to testify. A typical situation when confidentiality privileges are overrules is in a
contested custody procedure in a divorce.
 Confidentiality with minors. In cases of therapy with minors, parents or legal guardians have
rights to information regarding treatment. However, in order for therapy to be effective, the child
must have an assurance of confidentiality. Because of this, it is my policy when conducting
therapy with minors, to ask parents to waive their rights to the confidential information.
Information will be shared only with the childs permission, except in situations where the childs
welfare is being compromised by maintaining the confidentiality. By signing the Consent Form
the parent agrees to the above.
Confidentiality with couples and families. When there is more than one person in treatment, such
as in couples and family therapy, confidentiality is more complicated. In these cases, the unit is
defined as the couple or the family. Usually, and unless otherwise specified, information that is
shared by a member of the unit within the context of that therapy cannot be considered
confidential from the other parties involved in the therapy. For example, this means that if one
member of the couple I am seeing in couples therapy calls me in between sessions, I will inform the
other member of the couple about the call. To ask the therapist to keep inappropriate secrets from
other members of the therapy can disrupt the trust necessary for effective treatment.

ELISE M. BON-RUDIN, EdD PATIENT INFORMED CONSENT & TREATMENT AGREEMENT

3. My Policies & Practices to Protect the Privacy of your Health Information


The federal Health Insurance Portability and Accounting Act (HIPAA) requires that you be
informed regarding how psychological and medical information available in this office can be
disclosed and how you can amend and/or gain access to these records. Notice of these terms is
included in a separate HIPAA which has been given to you.
The State of New Hampshires Mental Health Bill of Rights contains information about
confidentiality and other aspects of psychotherapy. For your convenience, a copy is on display in
the waiting area. You may obtain a copy by contacting the Board of Mental Health Practice, 49
Donovan Street, Concord, NH 03301; 603-271-6762. The document may be accessed at
http://www.nh.gov/mhpb/bill_of_rights.html
4. Informed consent. You have the right to be informed about your (or your childs) assessment,
the treatment and rationale, and the risks and benefits associated with psychotherapy work. You
are free to terminate our work at any time without penalty (Note that this right may be limited and
involve consequences if you have been mandated to see me by an employer or a court of law). If
you are unclear about your rights please speak with me directly. If you have a complaint about me
please raise this with me as soon as possible.
5. Risks and Benefits. Risks may include experiencing heightened uncomfortable and distressing
feelings (such as sadness, guilt, anxiety, anger, frustration, loneliness, or helplessness), unwanted
relationship changes (including altered patterns of intimacy, divorce, separation, change in work
roles or time together), unanticipated lifestyle changes (such as a new job), and recalling or coming
to a new understanding of unpleasant aspects of your life. Benefits include significant reduction in
uncomfortable or distressing feelings, improved relationships, resolution of specific life problems,
and more meaningful appreciation for life. There is no reliable way to predict whether the benefits
of psychotherapy will outweigh the potential risks, and so no guarantees can be made about what
psychotherapy will offer for you. Please talk with me about your concerns to help you decide if
you wish to pursue or continue psychotherapy. Also, I will ask you to update me regularly about
your progress to monitor the effectiveness of our work. If you do not find our work helpful, please
let me know. We may be able to change the way we work together, our goals, or the frequency of
our sessions. I may also be able to refer you to a therapist who might be a better fit.
6. Consents for exchange of information. If you would like me to speak with someone else
regarding our therapy work, I will ask you to sign a release of information form. I would prefer
to include you in any conversations I have about you, since you know yourself best.
7. Participation. Psychotherapy is unlike most visits to a medical doctor because it requires a very
active effort on your part or, if your child is the patient, active support of your child. You (or your
child, with your collaboration) will be asked to identify goals near the start of therapy, work on
these goals in your sessions and at home, monitor your progress, and continue or discontinue
therapy based on progress towards these goals or new goals.
8. Clinical sessions. Most sessions paid by insurance are 45 minutes in length. Brief additional
time before and after our session is used to review past work and to complete a clinical note, as

ELISE M. BON-RUDIN, EdD PATIENT INFORMED CONSENT & TREATMENT AGREEMENT

required by insurers and by standards of sound professional practice. Because each person is the
best judge of her own well-being or distress, it is the patients responsibility to request additional
sessions as needed.
9. Social Media. Mainly for reasons of confidentiality, I do not "friend," "like," "follow," "link to" or
otherwise connect to patients or former patients online. The exception is emails about scheduling
or cancelling. I use LinkedIn, a professional networking site. You are welcome to view my profile,
but I will not link with or follow current or former patients because these communications are not
as private as email. I will not use SMS (mobile phone text messaging) or respond to your texts for
the same reason: this technology is not secure, and I am duty-bound to maintain your
confidentiality. My professional FaceBook page is passive (does not accept comments), as is my
website. Both sites are used to convey information about psychology, my approach to helping you
make the changes you seek, and the business policies of my practice. I do not Google prospective,
current, or former patients. Instead, I prefer to learn about you from you.
10. Contacting me. To maintain a balanced life which I see as crucial to good collaboration with
patients, I do not participate in a 24/7, always-available form of psychotherapy. Here are some
details of my work-related availability: Phone: In general I am not available immediately by
phone. Confidential voice mail is available. I check for messages many times during the day,
whether or not I am in the office, and several times on the weekends. I return most calls the same
day. I do not respond to routine calls in the evenings or on weekends. Leaving your phone
number(s) every time you call will assist me in contacting you quickly. Please note that I
sometimes return patient calls from a secure phone outside the office. If your caller ID is blocked I
may not be able to reach you. In that case, I will call you the next time I am in the office. Email: I
do not read or respond to routine emails in the evenings or weekends. Unless it is encrypted,
email is not secure. I am duty-bound to maintain your confidentiality. Therefore it is best to use
email mainly to arrange or modify sessions. Also, with the exception of true psychological
emergencies, our work is done exclusively in our face-to-face sessons. Because reading and giving
careful attention to responding to emails which have substantive content are forms of professional
work and are not considered a covered service by insurers, you will be billed for time spent
reading and responding to such emails.
In my absence emergency calls can be placed to the number available on the outgoing office voice
mail. If I am unreachable within a time period which you can tolerate or if you are in immediate
physical or emotional danger, please go to your nearest hospital emergency room.
11. Business aspect of our agreement. The substance of our work is to help you to make the
changes you want to make and/or increase your understanding of yourself, your relationships and
your life. It is also important that the business aspect of our relationship be clear and acceptable to
you and to me.
a. Our agreed fee is $130 per hour for any service not paid by insurance. Clinical services are
charged on the basis of a 45-50 minute clinical hour. The remaining time is used to prepare for our
session and to make additional notes after our session. Payment, including copays, is due at the
beginning of each session. The following forms of work are charged at my hourly rate, pro-rated to
the quarter hour: substantive emails and phone calls (including emergency calls), record review,

ELISE M. BON-RUDIN, EdD PATIENT INFORMED CONSENT & TREATMENT AGREEMENT

travel, consulting with other professionals at your request, and generating reports, letters, and
treatment plans. There is no charge for local, brief phone calls or emails about routine scheduling.
Negotiated fees may be discussed on a case-by-case basis.
b. Payment for services not paid by insurance or, for self-pay patients, exclusive of routine
treatment sessions, such as record review, reports, non-routine billing, and letters must be received
before these work products or discussion about them are reviewed or released to their intended
recipient or to an authorized third party. Your insurance will be verified before your first session.
If your insurance will not cover your treatment after successive, reasonable, and documented
efforts, you will be billed for your care.
c. Psychotherapy, like other services, is conditioned on payment arrangements. If you wish to
access an insurance benefit your insurance will be verified before your initial consultation session.
If you wish to pay out of pocket, I will be glad to accept your personal check, cash, cashiers
check or similar check. Insurance-based co-pays are due at each session. Any amounts billed to
you as the patient, such as payment towards your deductible, are due before the next scheduled
session or at the start of the next scheduled session. Services for non-emergency situations may be
withheld if payment is not made.
d. Retainer. A retainer may be required in advance for some assessment and forensic services
and other special circumstances. A contract specifying services, estimated costs, and a retainer
request, if applicable, will be provided.
e. Insurance limitations. (i) Most insurance plans do not reimburse for any services except
direct, face-to-face contact in the clinicians office. Also they may limit the duration of these
services. Early in our work together, it may be helpful for you to inform yourself about the policies
of your insurance provider on this matter. For this reason, under the terms of most insurance
policies, you will be billed for any work on your behalf that is conducted outside our clinical
sessions. (ii) Divorced parents will be billed 50% each for services not reimbursed by insurance,
unless a separate signed agreement is made. (iii) Accessing your insurance requires that I assign
(and you accept) a psychiatric diagnosis from the code book used for these purposes, the DSM 5.
However, many valid human problems which benefit from psychological services do not meet the
criteria for a psychiatric disorder or diagnosis as defined in the DSM. I cannot guarantee that the
above-named patient will meet the criteria for any psychiatric disorder or diagnosis as defined
in the DSM. (iv) I cannot guarantee the confidentiality of medical records held by an insurance
company.
f. Suspension. Except where suspension of services puts a patient at risk of harm, I reserve the
right to suspend services until payment agreements have been met.
g. Separate fee agreement. If discussed and agreed, any other fee agreement will be clearly
noted in a separate signed document.
h. Receipts. On request I will provide a receipt for services with any additional information you
need me to provide to your health insurance provider.
i. Scheduling sessions. Many sessions will be scheduled ahead of time or at the end of a session.
Sometimes the clinical part of our work will continue to the very end of your session time, leaving
no time to discuss sessions. In keeping with the spirit of psychotherapy, which reflects your wish
to make changes or gain new understandings, it is up to you to request additional sessions for
yourself or, in the case of a minor, for your child. (Exceptions will be negotiated for mandated
patients.)

ELISE M. BON-RUDIN, EdD PATIENT INFORMED CONSENT & TREATMENT AGREEMENT

12. Additional services. Typically insurance will cover only an allowed number of office visits.
Typically, no other clinical or administrative services are reimbursed by insurance. Unfortunately,
these limitations may restrict optimal clinical care. For example, speaking with a childs teacher
about school-based problems is not considered a covered service by most insurers. If you wish
further services, such as phone calls, emails about issues other than scheduling, travel for home
visits or related meetings, phone meetings, reports, review of documents, legal testimony,
consultation with attorneys or Guardian ad Litem, response to subpoenas, and time spent in
preparation for these activities, you will be charged at the rate of $130 per hour. As a disincentive
to involvement in legal matters, a higher rate and a retainer will be required. Depending on the
complexity and difficulty of legally required involvement, I reserve the right to request payment in
advance of release of reports, evaluations, letters, and other work products and to charge a
minimum of $1,000 in advance for any legal activity required by a legal entity. Related meetings
which are cancelled with less than 48 hours notice will be billed at the full amount of time
originally scheduled to be available for the meeting, including transportation time. Charges will
accrue also for the time spent in reviewing the record as well as all time I am out of the office and
specifically including time spent waiting and/or for cancelled meetings.
13. No-shows or late cancellations. It is the policy of this practice to charge for no-show visits
and late cancellations (less than 24 hours). Except for your verifiable illness, if you are unable to
attend a planned session, you will be charged for the session unless I receive 24 hours notice by
voice message, email, or U.S. postal service. The cancellation policy reflects the difficulty of
offering a no-show or late-cancelled session to current and waitlisted patients with less than 24
hours notice. A.) For non-Medicaid insured patients, the fee is 100% of the regular charge for the
scheduled visit. B.) Under federal aw Medicaid patients cannot be charged for missed appointments. Unfortunately, this means that more than 1 missed session may mean that we cannot
continue working together. In this circumstance, if you wish I will do what I can to help you (or
your child) transfer to another therapist. Hopefully we will not face this difficulty. C.) For patients
not accessing an insurance benefit, the fee is 50% of my hourly rate. Payment is due in full at your
next session. This fee cannot be submitted to your insurance. It is your responsibility.
By signing below I indicate that I have read this information, and understand that, excepting
weather emergencies and verifiable illness as discussed above, I will be charged a fee if I noshow a schedule session or if I cancel a scheduled session less than 24 hours in advance. I also
understand that I will need to pay this charge in full at my next scheduled session.
14. Weather. Scheduled sessions are times set aside for each patient. Sessions cancelled 24 hours
in advance allow sufficient time for another patient to be offered that time. Sessions cancelled on
short notice cannot be made available for another patient.
I recognize that there are differences in individuals comfort with driving in inclement weather.
Some individuals will drive in difficult weather conditions, while other individuals prefer to not
drive in light snow, rain, or wind. I make no judgment whatsoever about these choices.

ELISE M. BON-RUDIN, EdD PATIENT INFORMED CONSENT & TREATMENT AGREEMENT

Fees for weather and non-weather cancellations are customary among mental health professionals
in private practice. My policy is that a fee of $40 will be charged when patients cancel due to
weather, with these exceptions:
A. For school-aged child patients: when the schools schedule has been changed, as
reflected on its website or by phone confirmation with a school administrator.
B. For adult patients: when officials in the patients home municipality or in Amherst,
New Hampshire, have issued a weather emergency (not a lower level school closing).
15. Your agreement about billing and charges. I consent to charges for my treatment being
submitted to my insurance company, if applicable.
I consent to the use of a diagnosis for billing purposes, if applicable. I consent to Dr. Bon-Rudins
using information needed to access my insurance benefit through billing, treatment plans, and
clinical reviews as required by my insurance.
I agree to pay co-payments at each session and other charges, including deductibles, at the next
session after being billed.
I agree to pay for any service provided in good faith by Dr. Bon-Rudin that is not paid by my
insurance company for any reason, including lack of authorization, pre-existing conditions, lack of
medical necessity, etc.
I agree to pay timely any charges related to my or my childs therapy that are not covered by
insurance and are due from me. I understand that unpaid bills may be submitted for collection. I
understand that administrative charges related to collection will be billed at my usual and
customary rate, $130/hour, unless a different rate is agreed and documented.

ELISE M. BON-RUDIN, EdD PATIENT INFORMED CONSENT & TREATMENT AGREEMENT

I have read in full this document and the HIPAA document given to me separately. I have
received a copy of both documents. I have had sufficient time to consider them. I have asked
questions if I did not understand or if I had concerns. (In couples therapy, both must sign. In
family therapy, the parent(s) or guardian(s) must sign.)
A. When the child is the patient:

_____________________________________________________
Name of child patient; please print
_____________________________________________________ Date ___________________________
Parent(s) or Guardian(s) signature (if minor)
_____________________________________________________ Date ___________________________
Parent(s) or Guardian(s) signature (if minor)

B. When an adult is the patient:


_____________________________________________________________
Name of adult patient(s); please print
_____________________________________________________ Date _____________________________
Signature of adult patient 1
_____________________________________________________ Date _____________________________
Signature of adult patient 2

Patient Agreement 0316

This is the signature page only.

82A Ponemah Road, Amherst, New Hampshire 03031


Phone & Fax 603 672-0777
elise_bon-rudin@earthlink.net www.elisebon-rudin.com