Welcome to Martino Psychotherapy & Associates. We are pleased to have the opportunity to work with you and support your mental health care. Martino Psychotherapy & Associates is a group practice, and services may be provided by one of our licensed clinicians, associate clinicians, or supervised clinicians, depending on your assigned provider and clinical needs.

The purpose of this document is to review important practice policies, including attendance, cancellations, confidentiality, electronic communication, telehealth, court-related matters, and additional fees. Please read this document carefully and ask your clinician or the practice administration team if you have any questions.

ATTENDANCE AND CANCELLATION POLICY

Appointment times are reserved specifically for each client. Consistent attendance is important in order to receive the full benefit of therapy and to allow your clinician to provide appropriate and effective care.

If a client does not participate in therapy for five consecutive weeks, the clinician and/or practice reserves the right to discharge the client from the clinician's active caseload after providing appropriate notice. If a client is discharged or chooses to discontinue therapy and later wishes to resume services, the client may be placed on the practice waiting list, depending on clinician availability.

Martino Psychotherapy & Associates requires at least 24 hours' notice for cancellations or rescheduling. Missed appointments or cancellations made with less than 24 hours' notice may be subject to the full session fee.

For clients using insurance, insurance cannot be billed for missed appointments or late cancellations. Therefore, a late cancellation or missed appointment fee of $85 may be charged.

For Saturday appointments, due to high demand and limited availability, Martino Psychotherapy & Associates requires at least 48 hours' notice for cancellations or  escheduling.

If a client arrives more than 15 minutes late to a scheduled session, the appointment may be considered missed and may be subject to the applicable missed appointment or late cancellation fee. For out-of-pocket clients, the full session fee may apply.

We understand that emergencies and unexpected circumstances may occur. Each client is permitted one grace cancellation, meaning one late cancellation may be waived without charge. If you are unsure whether you have already used your grace cancellation, please contact the practice.

CONSENT FOR TREATMENT AND LIMITS OF SERVICES

Therapy can provide many benefits, including reduction in distress, improved coping skills, improved relationships, and support with specific emotional, behavioral, or relational concerns. However, therapy also involves some risks. Clients may experience uncomfortable emotions, discuss painful or unpleasant experiences, or address difficult aspects of their lives.

Although therapy can be highly beneficial, Martino Psychotherapy & Associates and its clinicians cannot guarantee specific outcomes, symptom resolution, or cures. Progress in therapy depends on many factors, including the nature of the concerns, client participation, consistency of attendance, and outside circumstances.

Your clinician will make reasonable efforts to provide services in a respectful, supportive, and clinically appropriate manner. Your clinician will also work with you at a pace that is clinically appropriate and mindful of your comfort level.

LIMITS OF CONFIDENTIALITY

Information discussed in therapy is generally confidential. Martino Psychotherapy & Associates will not release information about your treatment without your written authorization, except when permitted or required by law.

Exceptions to confidentiality may include, but are not limited to, the following:

1. Risk of Harm to Self or Others: If you disclose intent, a plan, or a serious risk of harm to yourself or another person, your clinician may be required to take steps to protect your safety and/or the safety of others. This may include contacting emergency services, appropriate authorities, a potential victim, emergency contacts, or other appropriate individuals or agencies.
2. Abuse or Neglect of Children, Elderly Individuals, or Vulnerable Adults: If abuse, neglect, or exploitation of a child, elderly person, disabled person, or vulnerable adult is disclosed or reasonably suspected, your clinician may be required to report this information to the appropriate state agency and/or legal authorities.
3. Prenatal Exposure to Controlled Substances: If prenatal exposure to controlled substances is disclosed and may be harmful to the mother or child, your clinician may be required to report this information as required by applicable law.
4. Insurance and Third-Party Payers: If you use insurance or another third-party payer, Martino Psychotherapy & Associates may be required to provide certain information to the insurance company or payer. This may include diagnosis, dates of service, treatment information, progress, or other information requested for payment, authorization, audit, or coverage purposes.
5. Legal, Regulatory, or Professional Requirements: Information may be disclosed when required by federal or state law, court order, subpoena, licensing board investigation, professional regulation, or other legally authorized request.

AUTHORIZATION FOR ELECTRONIC COMMUNICATION

Email, text message, phone, voicemail, and other electronic communications.

I authorize Martino Psychotherapy & Associates, including my clinician and appropriate administrative staff, to communicate with me regarding my care by electronic communication, including email, text message, phone, voicemail, and/or other electronic methods.

I understand that electronic communication may include protected health information, such as appointment information, scheduling details, diagnosis, medication information, treatment-related information, billing information, progress-related information, and other individually identifiable information related to my care.

I understand that there are risks associated with electronic communication. These risks may include messages being lost, delayed, intercepted, misdirected, accessed by unauthorized individuals, corrupted, altered, incomplete, or not delivered. I understand that email and text communication may not be encrypted and may not be fully secure.

By signing this authorization, I acknowledge that I have been informed of the risks of electronic communication and still authorize Martino Psychotherapy & Associates to communicate with me electronically.

I understand that electronic communication should not be used for emergencies or crisis situations. If I am experiencing a medical or mental health emergency, I will call 911, go to the nearest emergency room, or contact appropriate crisis services.

COURT CASES, CUSTODY MATTERS, AND LEGAL PROCEEDINGS

Martino Psychotherapy & Associates provides outpatient mental health treatment. The practice and its clinicians do not serve as custody evaluators, forensic evaluators, parenting coordinators, legal experts, or court-appointed experts unless there is a separate written agreement specifically stating otherwise.

Martino Psychotherapy & Associates and its clinicians do not make custody recommendations, parenting-time recommendations, or legal determinations. If custody or forensic evaluation services are needed, the practice may provide referral information for an appropriate custody evaluator, forensic evaluator, or other qualified professional.

Clinicians at Martino Psychotherapy & Associates do not voluntarily participate in court proceedings, custody disputes, depositions, attorney communications, or legal matters. Any involvement in legal proceedings, including responding to subpoenas, court orders, records requests, attorney requests, or testimony requests, will be handled in accordance with applicable law, ethical obligations, and practice policy.

I understand that Martino Psychotherapy & Associates is a treatment provider and does not become involved in custody disputes, court-related matters, or legal proceedings outside the role of providing clinical treatment.

TELEHEALTH CONSENT

Doxy, phone, video, and virtual services

I consent to participate in telehealth services with Martino Psychotherapy & Associates when clinically appropriate and agreed upon by my clinician.

Telehealth may include psychotherapy, assessment, diagnosis, consultation, treatment, transfer of clinical information, and psychoeducation using interactive audio, video, phone, or other approved telehealth platforms, including doxy.me or another platform used by the practice.

I understand that telehealth may be offered when in-person services are not available, when virtual care is clinically appropriate, or when the client and clinician mutually agree that telehealth is suitable.

I understand that the same laws and ethical rules that protect the confidentiality of my in-person treatment also apply to telehealth services. Information disclosed during telehealth sessions and records related to those sessions are confidential, except when disclosure is permitted or required by law.

I understand that telehealth is not a substitute for emergency or crisis services. If I am experiencing a mental health emergency or crisis, I will call 911, go to the nearest emergency room, or contact an appropriate crisis service.

I understand that I must be physically located in a state where my clinician is legally permitted to provide services at the time of each telehealth session. Unless otherwise approved by the practice and permitted by law, I understand that I must be located in New Jersey during telehealth sessions.

I agree to participate in telehealth sessions from a private, secure, and confidential location. I understand that it is my responsibility to ensure privacy on my end of the telehealth session.

OUT-OF-NETWORK INSURANCE PAYMENTS

Including BCBS and other insurance companies

Some insurance companies may reimburse out-of-network claims by sending payment directly to the client instead of sending payment to Martino Psychotherapy & Associates.

If Martino Psychotherapy & Associates submits claims on my behalf and my insurance company sends reimbursement checks or payments directly to me, I understand that I am responsible for promptly providing those payments to Martino Psychotherapy & Associates.

I understand that if I receive insurance reimbursement directly and fail to submit the payment to the practice, I may be charged the amount reimbursed by the insurance company, in addition to any applicable client responsibility, balance, deductible, coinsurance, or fee owed.

ACKNOWLEDGMENT OF PRACTICE POLICIES

By signing below, I acknowledge that I have reviewed and understand the policies of Martino Psychotherapy & Associates, including the attendance and cancellation policy, confidentiality and its limits, electronic communication authorization, telehealth consent, court-related policy, additional fees, and insurance reimbursement policy.

I understand that I may ask questions about these policies at any time.