Melinda Macht-Greenberg, Ph.D.
209 Burlington Road
Bedford, MA 01730
CONSENT TO SERVICES
I hereby consent to the evaluation, consultation and/or treatment of myself (parent or child) and/or my minor child for mental health and/or educational services.
I hereby accept responsibility for payment for consultation services with Melinda Macht-Greenberg, Ph.D.
I understand that if I cancel any appointment without 48 business hours notice or fail to show for my scheduled appointment, that I will be billed the full fee for the session.
I agree to and authorize Dr. Macht-Greenberg to e-mail me at the e-mail address I have given her.I understand that this is a non-secure internet line. Dr. Macht-Greenberg will do everything possible to protect confidentiality in e-mails at all times and use it primarily, but not necessarily exclusively, for administrative purposes such as arranging appointment times.All e-mails are deleted on a regular basis.
I understand that unless there is a matter of safety, all information provided is private and confidential and cannot be released without my written consent.
I understand that there are situations involving the safety of children where information may need to be shared with others (DCF, law enforcement, peer or clinical supervision etc) in order to provide optimal care and/ or to attempt to insure safety of children.I understand that psychologists are mandated to report any suspicion, threat and/or act of violence or abuse regarding myself (parent or client), children, the elderly, or disabled.
In the midst of this current public health crisis, Dr. Macht-Greenberg is available for 30 minute phone consultations to parents at a rate of $80 per half hour. Payment is due via electronic modality on the date of service. Upon request, Dr. Macht-Greenberg will provide information for client submission for reimbursement from their health insurance carriers.
For psychotherapy, the hourly fee for an evaluation is $300.00 per hour and $250.00 for each 45 minute follow-up visit. In addition to appointments, a prorated fee of $250.00 per hour is charged for other professional services I may need (see below), prorated if the work is for periods of less than one hour.
For educational consultation and all other services such as telephone or electronic consultations lasting longer than 5 minutes, consulting with other professionals with my permission, and the time spent performing any other services I request are at the rate of $250.00 per hour. There is a cost of $250.00 per hour for attendance by Dr. Macht-Greenberg at school meetings or for classroom observations (including travel time), for all school or educational consultations by phone, in person, or electronically. There is a fee of $300.00 per hour for report writing.
If I, the client, become involved in legal proceedings that require participation, I agree to pay for all Dr. Macht-Greenberg’s professional time, including preparation and transportation costs, even if Dr. Macht-Greenberg is called to testify by another party. Because of the difficulty of legal involvement, the charge is $300.00 per hour for preparation and attendance at any legal proceeding or report writing used for legal purposes.I will be informed verbally if this fee structure changes and may request an updated written copy of any changes.
I understand that I may revoke this agreement in writing at any time.Exceptions to this revocation are: if action has been taken in reliance on it, there are obligations imposed on Dr. Macht-Greenberg by my health insurer in order to process or substantiate claims, if I have not satisfied any financial obligations incurred.
My signature below indicates that I have read and understand this agreement and reviewed it with Dr. Macht-Greenberg and that I agree to its terms. My signature also serves as an acknowledgment that I have received or reviewed the HIPAA Notice of Privacy Practices.
Signature of Client or Parent/Legal Guardian Date
Melinda Macht-Greenberg, PhD Date
Effective April, 2003 Revised: 2020