Consent and Disclosure
Welcome to my practice. This document contains important information about my 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 submit/sign this document, it will represent an agreement between you and Ann Smollon.
I hold an MSW from Adelphi University and I am a licensed clinical social worker with The University of the State of New York Education Department. I have been in private practice for more than 30 years.
I am not a medical doctor nor do I prescribe medications. It is important that you are under the care of a medical doctor and that you follow the recommendations of that practitioner.
My methods of treatment consider the context of your entire life. When coming up with the best treatments for solutions, we will focus on any or all of the following: your thoughts, your emotions, your behaviors and your biography. Looking at these will help to restore balance and health within yourself, your life and your relatioships.
During my years of practice, I have found that many of my clients have physical health issues that are impacting their emotions, at times we will discuss physical health matters.
You are ultimately responsible for the decisions you make in your life, should you ever receive information from me with which you do not agree nor feel comfortable, then you should not follow that suggestion(s).
You agree to ask any questions you may have about the interventions I use and express any concerns you have with the process(es).
By consenting to therapy with me, you consent to willingness to experience changes in your life.
The best outcomes occur with consistancy, when we work together, and when you take responsibility for your health and healing.
I do not get involved in providing legal records. If you have a legal case involving a need for medical records, please let me know that in advance.
In the interest of your safety and effective care, all questions are handled through scheduled appointments, unless it is a simple question, then you can email me or call me.
I am available by phone and respond to calls as soon as possible, and certainly within the same day. If you are in need of an urgent appointment, please let me know that when we are communicating so that I can see you as soon as possible.
If you have an emergency, please go to your nearest emergency room.
My session fee is $175.00. By submiting/signing this agreement you are agreeing to my private pay policy and schedule. Because my interventions frequently fall outside of what major medical insurance companies accept and pay for, by submiting/signing this agreement you are agreeing to receiving interventions and treatments (i.e. meditation, visualization, hypnosis, etc.) that are not paid for by most major medical insurance policies.
You will be expected to pay for each session at the time it is held, unless we agree otherwise. Payment schedules for other professional services will be agreed to when such services are requested.
If you reserve an appointment with me and you cancel it, 48 hour notice is required otherwise you are responsible for payment of the reserved time (unless it is an urgent matter, such as illness).
To facilitate billing, we ask that you keep a credit card on file with us. We need to have your credit card information on file prior to appointments. By signing this consent, you consent to the use of your credit card for outstanding balances. If at any point you need to change or remove your card from our records, it is important that you contact us with that request.
Your records are confidential and protected according to HIPAA public Law (https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html)
If you ever have any concerns regarding our work together, you agree to contact me to discuss those concerns so that we can resolve any miscommunications together. Thank you and I look forward to working with you.