|Read this before your
Mark R. Zitlin, Ph.D.
This is a copy of the agreement that I ask patients to read
and sign prior to starting therapy. It includes information
about patients' rights to confidentiality, a brief description of
the psychotherapy process, my fees, and insurance issues.
Please go ahead and read through this document before
you come for your first appointment. You can use the
links below to print out this document (be sure to sign
the last page), and fill out the Patient Information Form.
Please bring all five pages with you to your first session.
Please take your time and read this carefully. It contains information about psychotherapy, confidentiality,
and other topics. Please feel free to ask me any questions you may have.
The New Federal “HIPAA” Regulations
The federal government recently passed the Health Insurance Portability and Accountability Act (HIPAA),
which includes new privacy protections for patients and rules about the use and disclosure of medical
information. In addition to this document, The HIPAA regulations require that I provide you with a
separate “Notice of Privacy Practices” that describes, in detail, the rules about the use and disclosure of
your clinic records. After you have received this document, please read it, and feel free to ask any
questions about it today, or at any time in the future.
Psychotherapy begins as a conversation between you and myself. Initially you will be asked questions
about the problems you are having, about your personal and family history, about your current living
situation, and about any other information that will help me to determine a diagnosis, treatment goals,
and a treatment plan; this process may take more than one session. Treatment goals and plans may
change as psychotherapy progresses, and we will discuss these changes as they occur.
Certain techniques are also commonly used in psychotherapy. These include interpretation, identification
of repetitive behavior patterns, self-monitoring, journal-keeping, integration of thoughts and feelings,
emotional self-regulation, visualization, cognitive reframing, relaxation training, and stress management.
You have the right to refuse any suggestion, or refuse to try any technique if you so choose. Successful
psychotherapy will require an active effort on your part during the session, and on your own between
Psychotherapy can have benefits and risks. Therapy may sometimes result in recalling painful memories, or
experiencing difficult, upsetting emotions. Making changes in your attitudes and behaviors can lead to
unfamiliar feelings or experiences, and may disrupt relationships that you are in. Psychotherapy has also
been shown to have many benefits, which may include significant reductions in feelings of distress and
I have a Ph.D. in Clinical Psychology from the University of Tennessee at Knoxville. I am a Licensed
Psychologist in the State of Texas (Number 2-4460). I have training and experience in working individually
with adults and adolescents, as well as couples and families. If you for any reason are not comfortable in
working with me, I will gladly assist you by providing the names of other qualified psychotherapists. If
medications or other medical treatment may help you with your problems, I can recommend a physician, or
you may see a physician of your own choosing.
You may reach me by the office phone 24 hours a day. During clinic hours, I may not be able to come to
the phone immediately, and will return calls as soon as possible. If for some reason you cannot reach me,
do not hesitate to seek care at an emergency room, or by contacting your family physician
Anything you tell me is confidential, with some specific exceptions that will be explained. I will not tell
anyone else what you have told me, discuss your case in any way that identifies you, acknowledge that I
have you as a patient, or release your clinic records. You can give me permission to release information
about you to specific people or institutions by filling out an Authorization Form. As described in my Notice
of Policies and Practices, you are entitled to a copy of your records, and may obtain this by making a
written request for them.
Your clinic record is divided into two parts. First is Protected Health Information (PHI). PHI includes
information about your reasons for seeking therapy, the ways your problems are affecting your life, your
diagnosis, treatment goals, progress toward these goals, your medical and social history, any past records
that I have received from other providers, your billing records, and any reports or communications that have
been communications that have been sent to anyone, including an insurance company.
The second (and separate) part of your record is the Psychotherapy Notes. These Notes are for my own
use and are designed to assist me in providing you with the best treatment. Notes may include details of
our conversation, my assessment of these conversations, and how they impact on your therapy. The Notes
may contain sensitive information that you have revealed to me; this type of information would not appear
in you Protected Health Information. No one, including insurance companies, can receive a copy of these
Notes without your signed, written authorization.
You have the right to review inspect and copy either the PHI or Psychotherapy Notes unless I determine
that release of that portion of your record would be harmful to your physical, mental, or emotional health.
These are the exceptions, or limits, to your legal right to confidentiality and the privacy of your records.
Under the following conditions, I am legally permitted or required to disclose information without your
consent or Authorization:
1. If I have been given information regarding the physical abuse, sexual abuse, or neglect of a child
(under the age of 18), an elderly person, or a disabled person, I am legally obligated to report this to
either Child Protective Services or Adult Protective Services within 48 hours.
2. In emergency situations, where there may be imminent danger of physical harm to yourself, the
appropriate medical or police personnel may be contacted without your consent.
3. Records will be released in response to subpoenas from the Court. Every attempt will be made to
promptly notify you of the subpoena and the subsequent release of your records to the Court, so that you
can discuss your rights about your record with your attorney.
4. If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that
patient in order to defend myself.
5. If a patient files a Worker’s Compensation claim, I must, upon appropriate request, provide records
relating to treatment or hospitalization for with compensation is being sought
6. If a government agency is requesting information for health oversight activities, I may be required to
provide it for them.
The rules of confidentiality are a little different for psychotherapy with couples or families. I will review
these differences with you if psychotherapy sessions include more than one person. When working with
couples or families, it can also be useful to have individual sessions with some or all of the family
members. I will discuss how and when confidential information or records from individual sessions can or
cannot be disclosed to the other participants prior to any individual sessions taking place.
For Minors and Their Parents
If you are under 18 years of age, your parent(s) have the right to ask for and obtain information about your
treatment. However, if you are 16 – 18, and if the treatment is for suicide prevention, chemical addiction
or dependency, or sexual, physical or emotional abuse, the law provides that parents may not access their
For teenagers under 18, when the above exceptions don’t apply, it often remains crucial to the success of
psychotherapy for the teenager to be assured of the privacy of their discussions in therapy with me.
Therefore, I may request an agreement with a teenager’s parent(s) that the parents agree to give up
access to their child’s records. Such an agreement would include my providing progress reports to parents,
and attendance at sessions. Any other communication would require the consent of the teenager, unless I
feel that the teenage is in danger or is a danger to someone else, in which case I would notify the parents,
after telling the teenager that I was going to do so.
Psychotherapy sessions last approximately 45-50 minutes. Every effort will be made to start on time.
Standing appointments can be arranged. My fees are as follows:
Initial Evaluation.............................$225 (one hour)
Individual Psychotherapy..................$150 per one hour session
Marital or Family Therapy................. $175 per one hour session
Crises/Emergency Psychotherapy....... $200 per one hour session
Telephone Consultation.................... $40 per 15 minute segment
Other Professional Services...............$175 - $300 per hour
Payment for services is expected at the time of service, unless other arrangements have been made. If
you wish to use insurance to help pay for services, your deductibles and co-pays will vary depending on
your particular policy. You are responsible for any pre-certification of services that your insurance company
Your signature on this form will also mean that in the event of delinquent payment, you understand and
agree that a collection agency and/or the Courts may be used to collect from you, and that such action
could require that information that identifies you, your diagnosis, and treatment dates and types of
charges, may be released to a collection agency, attorneys, and/or the Courts.
If You Are Filing Health Insurance Claims
There is an additional form you will be asked to complete if you are filing health insurance. As a courtesy,
we will file insurance claims on your behalf. My staff and myself will make every effort to help you
understand the specific details of your policy, such as the amount of your co-payments or deductibles.
However, you are ultimately responsible for the full payment of fees. If I have agreed to a discounted fee
with your insurance company, you will not be responsible for any amount above that discounted fee.
If you are filing insurance, than your PHI will be processed by a claim filing service. This company has
contracted to follow all HIPAA regulations, including the following of procedures to protect your
confidentiality as provided by federal law.
Healthcare insurance companies require that I provide diagnostic and sometimes other treatment
information before they will pay on claims. I will provide the insurance company with the minimal
necessary health information needed. This can include diagnosis, symptoms, a treatment plan, or a brief
treatment summary. Please feel free at any time to ask questions about any information that is released
to your insurance company.
Your Consent to Psychological Evaluation, Diagnosis, and Treatment, and Acknowledgement of
Receipt of Notice:
I have read this information, have asked any questions that I wished about it, and I understand and agree
to the terms and financial policies described. I hereby consent to treatment in the form of psychotherapy
with Mark R. Zitlin, Ph.D. I have also received a copy of the “Notice of the Policies and Practices of Mark R.
Zitlin, Ph.D. to Protect the Privacy of Your Health Information”.
___________________ ____________ ____________________________ ___
Patient Signature Patient Name (printed)
_________________ _____________________ __________
Date Guardian (if patient is a minor)
|INFORMATION FOR PATIENTS
PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT
San Antonio, TX 78209
ph: (210) 822-5795
fax: (210) 822-5939
Copyright 2009 - 2013 Mark R. Zitlin, Ph.D.
Clinical Psychologist. All rights reserved
Once an appointment hour is scheduled, you will be expected to pay for it unless it is
cancelled within 24 hours. Please remember that insurance companies will not pay for
missed sessions; you will be fully responsible for this fee. If the appointment can be
rescheduled and kept the same week, than no cancellation fee will be charged.