Download Book ver 16.4 - Clinical Associates

8629 Bluejacket, Suite 100  Lenexa, Kansas 66214-1604
(913) 677-3553  Fax (913) 677-3282
www.clinical-assoc.com
_____________________________________________________________________________________
Licensed Psychiatrist
Teresa M. Varanka, M.D., F.A.A.C.A.P.
Licensed Psychologists
Bruce Michael Cappo, Ph.D., ABPP
Marc A. Schlosberg, Ph.D.
Sheila Swearngin, Ph.D., CEDS
Lynn Lieberman, Ph.D., ABPP
Elizabeth K. Babcock, Ph. D.
Mitchell R. Flesher, Ph.D., J.D.
Martin Zehr, Ph.D., J.D.
Tracey Litwin, Psy.D.
Robert L. McRoberts, Ph.D.
Stella Fernandez, Psy. D.
Lindsay N. Dees, Psy.D.
Marijo Teare Rooney, Ph.D.
Temporary Licensed Psychologist
Saz M. Madison, Ph.D.
Licensed Clinical Marriage & Family Therapist
Wayne C. Witcher, Ph.D., LCMFT
John Myers, LCMFT
Nurse Practitioners
Lila Peckham-Wichman, APRN, B.C.
Valerie Jansen, APRN, B.C.
Martha Baird, Ph.D., APRN/CNS, B.C.
Susan Clavette, APRN, B.C.
Tamara Farmer, APRN, B.C.
Licensed Specialist Clinical Social Workers
Mike Crowley, LSCSW
Gary Christ, LSCSW
Stuart Waldman, LSCSW
Licensed Masters Level Psychologists
Jeff Cowan, LMLP
Joe Wilner, LMLP
Samantha Ciani, T-LMLP
Theresa Grass, LMLP
Mark Carey, T-LMLP
Josh Tanguay, LMLP
Licensed Marriage & Family Therapist
Danielle Singer, LMFT
Licensed Professional Counselor
Quinn Eggesiecker-Mack, LPC
Lisa Bozzoli, LPC
Caryn Hess, T-LPC
James McMillian, LPC
Licensed Addiction Counselor
Robin Rouse, LAC
Associate
Andy Caraway
Table of Contents
Welcome to Our Practice......................................................................................................... 4
Our Professional Staff ............................................................................................................... 5
Teresa M. Varanka, M.D., F.A.A.C.A.P. ....................................................................................... 5
Bruce Michael Cappo, Ph.D., ABPP ............................................................................................ 5
Marc A. Schlosberg, Ph.D ............................................................................................................... 6
Sheila Swearngin, Ph.D. ................................................................................................................. 6
Lynn Lieberman, Ph.D., ABPP...................................................................................................... 6
Elizabeth K. Babcock, Ph.D. .......................................................................................................... 6
Mitchell R. Flesher, Ph.D., J.D. ...................................................................................................... 7
Martin Zehr, Ph.D, J.D. .................................................................................................................... 7
Tracey Litwin, Psy.D. ...................................................................................................................... 7
Robert McRoberts, Ph.D. .............................................................................................................. 7
Saz Madison, Ph.D. .......................................................................................................................... 7
Lindsay N. Dees, Psy.D. ................................................................................................................. 8
Wayne C. Witcher, Ph.D., LCMFT................................................................................................ 8
John Myer, LCMFT ........................................................................................................................... 8
Lila Peckham-Wichman, APRN, B.C. ......................................................................................... 8
Valerie Jansen, APRN, BC .............................................................................................................. 9
Martha Baird, Ph.D., APRN/CNS-BC.......................................................................................... 9
Susan Clavette, APRN BC............................................................................................................... 9
Tamara Farmer APRN BC ............................................................................................................. 9
Mike Crowley, LSCSW .................................................................................................................... 9
Gary Christ, LSCSW ...................................................................................................................... 10
Stuart Waldman, LSCSW ............................................................................................................ 10
Jeff Cowan, LMLP .......................................................................................................................... 10
Joe Wilner, LMLP........................................................................................................................... 10
Samantha Ciani, T-LMLP ........................................................................................................... 10
Theresa Grass, LMLP ................................................................................................................... 11
Mark Carey, T-LMLP .................................................................................................................... 11
Josh Tanguay-LMLP ..................................................................................................................... 11
Danielle Singer, LMFT ................................................................................................................. 11
Quinn Eggesiecker-Mack, LPC.................................................................................................. 12
Lisa Bozzoli, LPC .......................................................................................................................... 12
Caryn Hess, T-LPC ........................................................................................................................ 12
James McMillian, LPC . ................................................................................................................ 12
Andy Caraway, Associate . ......................................................................................................... 12
Robin Rouse, LAC ......................................................................................................................... 13
2
Office Policies ................................................................................................................................. 14
Appointments ................................................................................................................................. 14
Confidentiality ................................................................................................................................ 14
Messages........................................................................................................................................... 16
Initial Contact ................................................................................................................................. 16
Treatments ........................................................................................................................................ 17
Medication Treatment and Medication Refill Protocol.................................................. 17
Individual, Family and Couples Treatment ........................................................................ 17
Group Therapy............................................................................................................................... 17
Adult Anger Control Group ....................................................................................................... 17
Adult Substance Abuse Group ................................................................................................. 18
Aftercare for Adult Anger Group and Adult Substance Abuse Groups .................... 18
Adolescent Groups ....................................................................................................................... 18
Anger Control Group for Adolescents ................................................................................... 18
Adolescent Substance Abuse Group ...................................................................................... 18
Adolescent Substance Abuse Aftercare Group .................................................................. 19
Immigration Evaluations ........................................................................................................... 19
Sex Offender Group ...................................................................................................................... 19
Sex Offender Treatment Program .......................................................................................... 19
Other Areas of Emphasis ............................................................................................................ 22
Other Psychological Services .................................................................................................... 22
Termination .................................................................................................................................... 22
Patients Who Are Dependents ............................................................................................................22
Patient's Rights ............................................................................................................................. 23
Substance Abuse Grievance Procedure ................................................................................ 25
Financial Obligations and Responsibilities.......................................................... 27
Charges.............................................................................................................................................. 27
Restrictive Legends ...................................................................................................................... 28
Billing and Transcription ........................................................................................................... 29
Insurance.......................................................................................................................................... 29
Disclosures ....................................................................................................................................... 30
Reference Forms ......................................................................................................................... 31
General Consent for Treatment ............................................................................................... 31
Forensic Informed Consent Contract .................................................................................... 32
Consent to Release Information .............................................................................................. 33
Confidentiality of Alcohol and Drug Abuse ......................................................................... 34
Group Therapies Policies ........................................................................................................... 35
Infectious Diseases ....................................................................................................................... 36
Child Therapy Agreement ......................................................................................................... 37
Collaterals Service Agreement ................................................................................................. 38
Acknowledgement of Receipt........................................................................................... 40
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Welcome to Our Practice …
We are pleased to have the opportunity to serve you and hope that this
booklet will provide information helpful in making an informed
decision concerning our services.
The Health Insurance Portability and Accountability Act (HIPAA)
requires that we provide you with a Notice of Privacy Practices (the
Notice) for use and disclosure of Personal Health Information (PHI) for
treatment, payment and health care operations. The Notice, which is
provided for you later in this document, explains HIPAA and its
application to your PHI in greater detail. The law requires that we
obtain your signature acknowledging that we have provided you with
this information. Although these documents are long and sometimes
complex, it is very important that you read them carefully if you have
not already done so. We can discuss any questions you have about the
procedures at that time. When you sign the document acknowledging
that you have read this booklet, it will also represent an agreement
between us. You may revoke this Agreement in writing at any time.
That revocation will be binding on Clinical Associates, P.A. (CA) unless
we have taken action in reliance on it; if there are obligations imposed
on us by your health insurer in order to process or substantiate claims
made under your policy; or if you have not satisfied any financial
obligations you have incurred.
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Our Professional Staff
Teresa M. Varanka, M.D., F.A.A.C.A.P.
Teresa Maria Varanka, M.D., F.A.A.C.A.P., a licensed psychiatrist in Kansas and
Missouri, is double board certified in Child and Adolescent Psychiatry and Adult
Psychiatry. She obtained her training at Kansas University focusing in diagnosis and
management of mood disorders, anxiety disorders, A.D.H.D., eating disorders and
pervasive development disorders. She has participated in several pediatric studies
focusing on obsessive compulsive disorders and manic-depressive illness. Dr.
Varanka is a Fellow of the American Academy of Child and Adolescent Psychiatry.
She works with children age five and older, adolescents and adults. Dr Varanka
focuses on out-patient medication management of psychiatric disorders. Dr.
Varanka is not available via email.
Bruce Michael Cappo, Ph.D. ABPP
Dr. Cappo started Clinical Associates, P.A. in 1992 and practices as a board certified
licensed psychologist in this multidisciplinary private practice setting. Clinical
Associates includes more than 75 professional service providers including licensed
psychiatrists, licensed doctoral psychologists, nurse practitioners, licensed masters
level psychologists, licensed specialist clinical social workers, licensed clinical
marriage and family therapists, substance abuse counselors and other masters level
associates. Clinical Associates frequently hosts interns and post-doctoral fellows.
While the group provides a full range of services to all ages, Dr. Cappo’s practice is
limited to evaluation and consultation. He is a Fellow and Past-President of the
Kansas Psychological Association and a Past-President of the Kansas Association of
Professional Psychologists. He has served on the University of Minnesota Press
Advisory Committee related to psychological assessment and is an Ad Hoc reviewer
for Psychological Assessment as well as several other journals. His practice is
focused in three areas: Forensic evaluations and consultation, evaluations related to
public safety, and evaluations related to diagnosis and treatment planning.
Forensic evaluations and consultation: Psychological evaluations are offered on an
outpatient, inpatient and incarcerated basis. He provides drug and alcohol
evaluations as well as mental health evaluations and sex offender evaluations to
individuals who are under the jurisdiction of the United States Court Drug and
Alcohol Treatment Services Program as well as to the U.S. Bureau of Prisons. Dr.
Cappo also performs evaluations for both the defense and prosecution in federal,
state, county and municipal courts. General psychological evaluations as well as
mental status at the time of offense, juvenile waive to adult, competency and other
specific evaluations are provided as well as review of relevant documents and
consultation regarding trial issues or strategy. Public Safety: Dr. Cappo provides
services in the field of public safety including applicant and promotional
assessment, fitness for duty related issues, consultation and training to various
Federal, State and local agencies as well as private entities. He is currently a
consultant for the Overland Park Police Department as well as working with a
number of other local and nearby police departments. He also provides evaluations
for DEA, ICE, TSA and other federal agencies. Diagnosis and Treatment Planning: Dr.
Cappo receives referrals from other practitioners to clarify diagnostic and treatment
planning issues through psychological assessment.
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Marc A. Schlosberg, Ph.D.
Dr. Schlosberg is a licensed psychologist (Kansas) with a doctoral degree in Clinical
Psychology. He has training and experience in a number of areas including
individual, family and group therapies for children, adolescents and adults. He has
had extensive training in personality and forensic assessment. He has a great deal of
experience working with addictive behaviors and substance abuse. He is certified by
the Board of Governors of the APA College of Professional Psychology in the
Treatment of Alcohol and Other Psychoactive Substance Use Disorders. Dr.
Schlosberg also has experience working with individuals and families who
experience psychological concerns related to physical illness and health issues. He
frequently performs presurgical psychological evaluations for patients considering
bariatric surgery and other medical issues. He works with patients both pre– and
post-operatively to help incorporate lifestyle changes as well as maximize mental
and behavioral patterns to optimize the overall weight loss experience. Additional
areas of emphasis include evaluation and treatment of Attention-Deficit
Hyperactivity Disorder and behavior difficulties. Dr. Schlosberg also has an active
interest in performance enhancement for both athletes and musicians. He is a past
president of the Kansas Psychological Association.
Sheila Swearngin, Ph.D. CEDS
Dr. Swearngin is a licensed psychologist (Kansas and Missouri) with a doctoral
degree in Counseling Psychology. Her training and experience includes individual,
family and group therapies for children, adolescents and adults. She has specialized
training in the treatment of eating disorders. Other areas of training including
stress management, women's issues, and psychological concerns related to health
issues.
Lynn Lieberman, Ph.D., ABPP
Dr. Lieberman is a licensed psychologist (Kansas and Missouri) with a doctoral
degree in Counseling Psychology. She is Board-Certified in Clinical Psychology by
the American Board of Professional Psychology and is a Certified Forensic Examiner
in the State of Missouri. She was a member of the medical staff at a state psychiatric
hospital, and an Assistant Professor of Psychiatry at the University of Missouri
School of Medicine for 14 years. Areas of specialization include forensic
assessments including competency, responsibility, dangerousness, sexual predation,
and risk assessment; neuropsychological evaluation for patients with neurological
diseases, head injuries, chronic substance abuse, and memory difficulties; geriatric
issues and assessment of dementia, dementia versus depression, and matters of
competency; and psychological evaluations including psychological functioning and
differential diagnosis, cognitive and intellectual functioning, readiness for various
medical procedures and adaptations to life-changing illness/disabilities. She has
training and experience providing services to patients with chronic mental illness
including affective disorders, conducting care-giver support groups, providing
individual and group psychotherapy, and addressing work related issues.
Elizabeth K. Babcock, Ph.D.
Elizabeth K. Babcock, Ph.D., is a licensed psychologist with a doctoral degree in
Counseling Psychology. She specializes in women’s issues including depression,
anxiety, relationship problems, work stress, self esteem, weight, childhood trauma
and other issues confronting today’s woman.
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Mitchell R. Flesher, Ph.D., J.D.
Dr. Flesher is a licensed psychologist and licensed attorney in the state of Kansas.
His practice is devoted to clinical and forensic assessment. He completed a
postdoctoral fellowship in forensic psychology at Western Missouri Mental Health
Center and worked as a forensic psychologist in the Kansas Department of
Corrections (KDOC) from 2003 until 2010. He performed hundreds of evaluations
of Kansas prisoners to determine risk of violence and sexual recidivism, as well as
sexual predator status. He has been conducting clinical and forensic evaluations in
private practice since 2005, including such forensic issues as competency, criminal
responsibility, mitigation of sentencing, Miranda waiver, and Sexual Violent
Predator status, as well as clinical evaluation of mental health conditions and
disabilities. He has been admitted as an expert witness in forensic and mental
health issues in numerous jurisdictions in Kansas and Missouri state courts and
federal court. He previously served as Regional Mental Health Coordinator for the
mental health contractor for the Kansas prison system, and he is currently the
Veterans Justice Outreach Specialist for the Eastern Kansas VA Health Care System.
Martin Zehr, Ph.D., J.D.
Martin Zehr, Ph.D., J.D., is a clinical psychologist licensed to practice in Kansas,
Missouri and New York. The focus of his work is with adult and geriatric
populations and forensic evaluations in civil and criminal settings. He also conducts
fitness-for-duty evaluations and dementia screening evaluations by physician
referral. He was formerly Director of Neuropsychology Services at the Kansas City
Veterans Affairs Medical Center and Research Medical Center in Kansas City,
Missouri and a member of the board of directors of the Heartland Chapter of the
Alzheimer's Association. He is a member of the Missouri Bar Committee tasked with
revising Missouri's Guardianship statutes.
Tracey Litwin, Psy.D._______________________________________________________________________
Dr. Litwin is a licensed psychologist (Kansas, Missouri and California) with a
doctoral degree in Clinical Psychology. She has had training and experience with
diverse populations in several different settings. Her current area of focus is
assessments and evaluations, and working with adults, children and families dealing
with issues of attachment, childhood trauma, sexual assault, anxiety, depression and
eating disorders. She also consults with the Research Transplant Team where she
performs psychological evaluations pre- and post-surgery for potential kidney
donors.
Robert McRoberts, Ph.D.__ _____________________________________________________________
Dr. McRoberts is a licensed psychologist in Missouri and Kansas. He has experience
and training in attention-deficit/hyperactivity disorder, anxiety, depression and
applied behavior analysis, seeing clients of all ages. He is a member of the
Association of State and Provincial Psychology Boards and the American
Psychological Association.
Saz Madison, Ph.D. _________________________________________________________________
Dr. Saz Madison joins us at Clinical Associates, P.A. after completing over 10 years of
teaching in the Psychology Department at Rockhurst University. Dr. Madison has a
doctorate in Clinical Psychology from Central Michigan University. He completed
his pre-doctoral internship at Michigan State University Counseling Center. He is
well researched and keeps abreast of best practices in treatment and assessment.
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Diagnostic and risk assessment are an area of specialty. Dr. Madison has had
extensive training in cognitive behavioral therapies, including: Behavior Therapy,
Dialectical Behavior, REBT, Cognitive Therapy (for depression and anxiety),
Problem Solving Therapy (personal/social), and Acceptance and Commitment
therapy (ACT). He’s also well versed in interpersonal and insight-oriented forms of
therapy including: Psychoanalytic psychotherapy (Freudian), Analytic Therapy
(Jungian), Core Conflictual Relationship Therapy (which is a short-term empirically
supported psychodynamic approach), Client Centered Therapy, and Gestalt
Therapy. His areas of specialty are anxiety disorders, depressive disorders,
obsessive-compulsive related disorders, trauma and stressor-related disorders,
sexual dysfunction and gender dysphoria.
Lindsay N. Dees, Psy.D.
_______________________________________________________________
Lindsay N. Dees, PsyD., is a licensed psychologist in Kansas and Colorado with a
doctoral degree in Clinical Forensic Psychology. She works as a clinical psychologist
at the Military Correctional Complex in Fort Leavenworth, KS in addition to her
association with Clinical Associates. She has specialized experience conducting
clinical and forensic evaluations in civil commitment and correctional settings on
issues such as sexual dangerousness, competency, psychological functioning and
differential diagnosis, and criminal responsibility. Her current area of focus is in
forensic assessment and evaluations with all populations.
Wayne C. Witcher, Ph.D., LCMFT
Dr. Witcher has a doctoral degree in Counseling and Guidance and has been
practicing since 1977 in the areas of individual, adult, child and family therapy. He
has worked extensively with blended and stepfamily issues as well as with issues of
violence and abuse. One of his specialties is marriage counseling. He also works in
the areas of men's issues in regard to anger, depression and violence. He also has
extensive experience in working with substance abuse issues. He is a clinical
member of the American Association for Marriage and Family Therapy. He is a
Licensed Clinical Marriage and Family Therapist in Kansas and practices
independently in these areas.
John Myer, LCMFT
John Myers earned a Master of Science in Marriage and Family Therapy from Friend’s
University in 2005. He enjoys working with all couples, families and individuals
including those in the military. John has worked with military families across the country
and in Europe to provide counseling as they navigate the unique challenges that come
with serving in the armed forces. This experience has informed John’s approach to
therapy that includes providing a warm, empathetic approach to help clients clarify and
find solutions to problems that are difficult to overcome. John has extensive experience
in Cognitive Behavioral Therapy, Solution Focused Therapy and Structural Strategic
Therapy. He also has consulted with organizations that provide therapy to children and
families engaged with the foster care system.
Lila Peckham-Wichman, APRN, B.C.
Lila Peckham-Wichman is a nurse practitioner who has been in practice for several
years in the Kansas City area. She is both a Psychiatric and Adult/Geriatric Nurse
Practitioner. Lila attended her undergraduate studies at St. Francis School of
Nursing and Emporia State University. She completed both graduate programs at
Kansas University. Lila has experience as a Nurse Practitioner in home health
8
settings; adolescent and child psychiatry; community mental health settings;
inpatient psychiatric hospital units; outpatient psychiatric settings; intensive
outpatient treatment programs; partial hospitalization programs; and long-term
care facilities. She enjoys working with geriatric patients and her practice is with
patients aged 13 and above.
Valerie Jansen, APRN, B.C.
Valerie Jansen is a nurse practitioner whose practice includes children, adolescents
and adults. Valerie provides psychotherapy and medication management to her
patient population. That population includes stress related disorders, mood
disorders and substance abuse disorders. Valerie has experience in psychiatric
home health, inpatient psychiatric settings along with inpatient substance abuse
treatment. She is certified by the Kansas State Board of Nursing as an Advanced
Practice Registered Nurse and as a Clinical Nurse Specialist in the Adult Psychiatric
and Mental Health Nurse by the American Nurses Credentialing Center.
Martha Baird, Ph.D., APRN/CNS-BC
Martha Baird PhD, APRN, CTN-A provides medication management for adults,
adolescents and children. Dr. Baird has over 36 years of clinical experience. She is a
member of the faculty at the University of Kansas Medical Center where she teaches
advanced practice nursing students in the psychiatric mental health program.
Susan Clavette, APRN, B.C.
_________________________
Susan Clavette, APRN-BC is a nurse practitioner, board-certified as a family mental
health nurse practitioner. Susan’s practice includes adolescents and adults. She has
experience in hospice and holistic nursing practice and is a member of Sigma Theta
Tau and the American Holistic Nurses Association. Susan holds certifications in a
number of holistic complementary health modalities. Susan integrates medication
management, psychotherapy and holistic health practices for an empowering
approach to healing.
Tamara Farmer, APRN, B.C.
_________________________
Tamara Farmer is a nurse practitioner who practices in Lenexa and in rural areas of
Kansas. Her practice includes children aged 5 and up, adolescents, and adults.
Tamara provides medication management and psychotherapy to her patients. She
enjoys treating Depression, Bipolar Disorder, Anxiety Disorder, PTSD, ADHD, and
childhood behavioral disorders. Tamara has experience in both in-patient and outpatient facilities for all age groups. She is certified by the KSBN as an APRN and as a
CNS in adult psychiatric and mental health nursing by the ANCC.
Mike Crowley, LSCSW
Mike Crowley is a Licensed Specialist Clinical Social worker and has experience
working with children, adolescents, couples and families. He also has experience
with anger control and substance abuse groups. He has been working in the field
since 1993. Mike has presented workshops on domestic violence and is KDADS
certified in the State of Kansas. He also works with court-related adolescents,
families, and adults.
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Gary Christ, LSCSW
Gary M. Christ is a Licensed Specialist Clinical Social Worker. He has extensive
experience working with adolescents, young adults and families. He has many years
of experience working with court-involved youth and children in foster care. He
also works with adolescents who are seriously emotionally disturbed and young
adults with a serious and persistent mental illness. Areas of specialization include
anger management, self-esteem, depression and family conflict. He offers
individual, family and group counseling.
Stuart Waldman, LSCSW
Stuart Waldman is a clinical social worker who is licensed in Kansas and Missouri.
He has been working in the field since 1993 providing individual, couples, family
and group therapy to children, adolescents and adults. His practice focuses on the
treatment of depression, anxiety, low self-esteem, trauma, family conflict, behavioral
challenges, and substance abuse. Stuart has extensive training in cognitive
behavioral therapy, family therapy and solution focused therapy. His background
includes leading programs in child welfare agencies, schools, community mental
health centers, and healthcare settings. He also works with teens and adults
involved in court-mandated treatment. Stuart is licensed as a clinical addiction
counselor in the state of Kansas.
Jeff Cowan, LMLP
Jeff Cowan has a Master's degree in Psychology and is licensed with the Behavioral
Science Regulatory Board as a Master's Level Psychologist. He has been working in
the field since 1993 with a primary focus on anger management for both the
adolescent and adult populations. He has experience in issues related to substance
abuse, self-esteem, depression and behavior difficulties. Jeff offers individual, group
and family therapy.
Joe Wilner, LMLP
___
Joe is a Licensed Master Level Psychologist (LMLP) in the state of Kansas. His
education includes a Masters in Counseling Psychology from the University of Saint
Mary and a Masters in Liberal Arts with a Concentration in Management and
Leadership from Baker University. Joe is also a Certified Coach Practitioner, an
advisory board member for the American Institute of Health Care Professionals
(AIHCP), and is a certified meditation instructor. He utilizes a strengths-based
approach incorporating principles from solution-focused therapy, cognitivebehavioral therapy, acceptance and commitment therapy, and positive
psychotherapy. He has training and experience working with children, adolescents,
and adults in community mental health centers, juvenile corrections, and inpatient
psychiatric facilities. He works primarily with adolescents and adults coping with
depression, anxiety, self-esteem, and life transitions.
Samantha Ciani, T-LMLP
_________________________
Samantha is currently working on her Master’s degree in Counseling Psychology at
the University of Saint Mary in Overland Park Kansas. She received her
undergraduate degree from the University of Saint Mary with a major in Psychology.
Samantha has experience in community based services working with youth
suffering severe emotional disturbances.
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Theresa Grass, LMLP
_________________________
Theresa completed her Masters in Counseling Psychology at the University of Saint
Mary as well as a Master’s in Business Administration with a concentration in
Management. She has training and experience working with children, adolescents,
and adults in community mental health centers, foster care, and government service
agencies. Theresa has worked with severely and persistently mentally ill adults and
children with severe emotional disorders through individual and group therapies.
Theresa utilizes a strengths-based, holistic approach combining strategies founded
in cognitive-behavioral therapy, mindfulness-based cognitive therapy, and solution
focused therapy. Theresa enjoys being active in local community non-profit
organizations.
Mark Carey, T-LMLP
_________________________
Mark received his undergraduate degree from Coe College, followed by his Master’s
of Counseling Psychology from Avila University. He is currently under supervision
while working towards additional licensure. While at Avila, Mark assisted with
psychological research about learning theories, comparing therapeutic approaches,
and performance anxiety. Mark split his internship between Crittenton Children’s
Center and Clinical Associates. He gained experience working with individuals,
groups, couples, and families. Mark enjoys learning and plans on pursuing his
doctorate in the future. Mark incorporates CBT techniques, skill building, and
positive psychology into sessions. He believes that therapy is about helping others
with their current situations as well as making long lasting improvements. Mark is
also passionate about psychological testing and plans to continue to build his skills
in administering, scoring, and interpreting psychological tests. Mark has experience
with a large array of tests that target personality traits, clinical symptoms, and
cognitive abilities such as achievement or intelligence testing.
Josh Tanguay, LMP
_________________________
Josh Tanguay is a Licensed Master Level Psychologist in the state of Kansas. Josh
provides intensive individual, family and group therapies to address chronic mental
health needs of children and their families. He has worked extensively with
traumatized children of all ages as well as children with different mood,
developmental (e.g. Autism), attachment and behavioral disorders. Josh is
nationally certified in Dialectical Behavior Therapy and soon to be nationally
certified in Trauma Focused CBT. He also has comprehensive training in Trauma
Systems Therapy, which targets the entire social system surrounding a traumatized
child. Josh has experience in leading different facets of the mental health and foster
care systems to coordinate their efforts in targeting specific needs of children and
families. These services can range from consultation on individual treatment plans
to advocacy on a local or state level.
Danille Singer, LMFT
_________________________
Danielle is a Licensed Marriage and Family Therapist (LMFT) in Kansas. She is a
Provisionally Licensed Marriage and Family Therapist in Missouri (PLMFT). She has
served diverse and varied clients and works with families, couples, individuals, and
adolescents. Danielle provides a warm, comforting, non-judgmental environment
where clients feel safe and supported. Utilizing Eye Movement Desensitization and
Reprocessing (EMDR), one of the most widely investigated treatments for posttraumatic stress disorder (PTSD) and trauma, Danielle will help you reprocess
disturbing thoughts and memories which continue to affect your current life. She is
11
also Prepare-Enrich trained and certified, specifically for Premarital couples
work. Her education includes the University of Kansas, where she received her
Bachelor of Arts in Social Welfare. Upon graduating, she attended Friends University
and received her Master of Science in Family Therapy and was trained in Systemic
Therapy. Danielle offers a holistic and integrative approach to therapy. She is
devoted to improving the lives of individuals and to enhancing all facets of human
relationships and families. Danielle believes in systemic therapy, treating the whole
person, not just the symptom. She seeks to help her clients experience positive
changes and gain a greater sense of personal strength and growth in order to help
them develop into the best versions of themselves. She works primarily with
couples, pre-marital couples, adults, and adolescents struggling with trauma, PTSD,
addiction, anxiety, and depression.
Quinn Eggesiecker-Mack, LPC
_________________________
Quinn Eggesiecker-Mack, LPC, is a licensed professional counselor (Kansas) who
specializes in sex therapy and education and is especially passionate about working
with members of the LGBT community. In addition to sex therapy she also enjoys
working with adolescents and individuals who present with mood disorders. She
obtained her Bachelors degrees in Psychology and English from the University of
Mississippi before attending University of Missouri- Kansas City where she received
her Masters in Counselor and Guidance with an emphasis in couples and family
work. Following her Masters, Quinn began an extensive training program through
the University of Michigan for Sex Therapy and Sexuality Education. Quinn currently
works as a community-based therapist for the Sex Offender Treatment Program as
well as an individual, couples and family therapist in the agency setting.
Lisa Bozzoli , LPC
_________________________
Lisa Bozzoli is a Licensed Professional Counselor (LPC) and a Nationally Certified
Counselor (NCC). She received her Education Specialist in Counseling and Guidance
from the University of Missouri - Kansas City. She received her Masters in
Counseling and Guidance from Emporia State University. Her training and
experience includes individual, couples, and family therapies for children,
adolescents, and adults. She uses cognitive - behavioral and solution focused
therapy. She also uses play therapy techniques.
Caryn Hess, T-LPC
_________________________
Caryn Hess is a Licensed Professional Counselor (LPC). She received her Master’s
degree in Counseling Psychology from Avila University in Kansas City, MO. Her
training and experience includes work with adults, adolescents, couples and groups.
She has a special interest in the areas of anxiety and depression, low self-esteem and
life transitions.
Andy Caraway, Associate
_________________________
Andy Caraway graduated from Avila University with a Master’s Degree in
Counseling Psychology and also holds a Master’s Degree from the University of
Kansas in Education. He has training in a number of areas including individual
therapy, group therapy, family and couples counseling. He prefers person centered
therapy while also blending several other therapeutic approaches when working
with clients. He also has training in the treatment of sex offenders. Andy is
interested in working with individuals dealing with anxiety, depression, and a
variety of other psychological issues. He is interested in and has experience in
working on men’s issues and is also interested in working with people in the LGBT
community.
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James McMillian, LPC
_________________________
James McMillian, MA, LPC, NCC is a Licensed Professional Counselor and a National
Certified Counselor. He graduated from Mid America Nazarene University in 2013
with his Masters of Arts in Counseling with a marriage, couples, and family
therapy focus. He completed his graduate internship work at Solace House focusing
on Grief Counseling, and at a private counseling practice working with individuals
suffering from depression and anxiety as well as couples and families with relational
conflict. James is certified to give the Prepare/Enrich pre-marriage assessment
to couples and to conduct Prepare/Enrich pre-marriage counseling sessions. He is
also trained in EMDR therapy for trauma. James also runs intensive outpatient
groups for people suffering from a range of conditions including depression, anxiety,
panic, bipolar, and substance abuse.
Robin Rouse, LAC
_________________________
Robin L. Rouse is a licensed addictions counselor. She has been working in the field
since 2009 writing evaluations and providing individual and group counseling to
adolescents and adults. Robin holds a Bachelor of Science Degree in journalism and
mass communications with an emphasis on social sciences from Kansas State
University. Since 2006 she has facilitated TeenLink, an adolescent group focusing on
community service projects. As the Kansas City Addiction Recovery Examiner for
Examiner.com, Robin has published on-line articles on substance abuse and
prevention. She has served as a member of the Johnson County STOP Underage
Drinking Coalition since 2007 and is currently an active member of the Kansas HCV
Advisory Council.
_____________________________________________________________________
_________
Licensed Psychologists, Licensed Masters Level Psychologists, Licensed Clinical
Psychotherapists, and Social Workers have not attended medical school and are not
authorized to practice medicine or surgery nor are they authorized to prescribe
medication. Please be advised that certain mental disorders can have medical or
biological origins and you should consult with a physician if you have not already
done so. Psychiatrists and Psychiatric Nurse Practitioner Specialists are available to
discuss medical issues. Inpatient referrals can also be facilitated as needed. If our
work together leads to problems beyond our expertise, we will help you to obtain
the necessary services from the appropriate specialist. All vitae are available for
review.
13
Office Policies
APPOINTMENTS
Services are by appointment only. The length of the appointment time varies on the
basis of services provided. Individual therapy is generally scheduled for 45 to 50
minutes and this is known as the "clinical hour." Because the appointment is
reserved for you, it is necessary to charge $85.00 for appointments which are not
canceled 24 hours in advance, unless in fact they are occasioned by circumstances
which we would both define as an emergency. Failure to provide a 24-hour notice
of cancellation generally means that some other person is not able to use that
appointment time.
CONFIDENTIALITY
The law protects the privacy of all communications between a patient and a
provider, psychiatrist and psychologist. In most situations, information can only
be released about your treatment to others if you sign a written authorization
form that meets certain legal requirements imposed by HIPAA. There are other
situations that require only that you provide written, advance consent.
 Occasionally it may be helpful to consult other health and mental health
professionals about a case. During a consultation, every effort will be made
to avoid revealing the identity of a patient. The other professionals are also
legally bound to keep the information confidential. If you don't object, you
will not be told about these consultations unless it is felt that it is important
to our work together. Also, you should be aware that privilege and
confidentiality apply only to the identified patient. If you are seen in an
adjunct or collateral fashion, then you do not have these rights as outlined.
An example would be a patient's spouse who is not an identified patient but
who is seen in session for the benefit and progress of the patient.
 You should be aware that we practice with other mental health professionals
and that we employ an administrative staff. In most cases, protected
information is shared with these individuals for both clinical and
administrative purposes, such as scheduling, billing and quality assurance.
All mental health professionals are bound by the same rules of
confidentiality. All staff members have been given training about protecting
your privacy and have agreed not to release any information outside of the
practice without the permission of a professional staff member.
 Disclosures required by health insurers or to collect overdue fees as
discussed elsewhere in this booklet.
 If a patient threatens to harm himself/herself, our office may be obligated to
seek hospitalization for him/her, or to contact family members or others who
can help provide protection.
There are some situations where we are permitted or required to disclose
information without either your consent or authorization:
 If you are involved in a court proceeding and a request is made for
information concerning the professional services provided, such information
may be protected by patient privilege law. We cannot provide any
information without your (or your legal representative's) written
authorization, or a court order. If you are involved in or contemplating
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


litigation, you should consult with your attorney to determine whether a
court would be likely to order our office to disclose information.
If a government agency is requesting the information for health oversight
activities or related to national security, our office may be required to
provide it for them.
If a patient files a complaint or lawsuit against our office, we may disclose
relevant information regarding that patient in order to defend the practice.
If you file a worker's compensation claim, and we have examined or treated
you in regard to such claim, we must, upon appropriate request, provide a
report to the patient's employer or the employer's insurance company.
There are some situations in which we are legally obligated to take actions, which
we believe are necessary to attempt to protect others from harm and we may have
to reveal some information about a patient's treatment.
 If we have reason to suspect that a child under 18 has been injured as a
result of physical, mental or emotional abuse or neglect or sexual abuse, or
that an adult has been or is being abused, neglected or exploited or is in
need of protective services, the law requires that we file a report with the
appropriate government agency, usually the Department of Social and
Rehabilitation Services. Once such a report is filed, we may be required to
provide additional information.
 If a patient communicates an imminent, specific threat of harm against a
specific individual and we believe that there is a substantial risk that the
patient will act on that threat in the foreseeable future, we may be required
to take protective actions. These actions may include notifying the
potential victim, contacting the police, or seeking hospitalization for the
patient.
 If such a situation arises, we will make every effort to fully discuss it with
you before taking any action and we will limit our disclosure to what is
necessary.
A law in Kansas may allow, under certain circumstances, disclosure of records to
the Behavioral Sciences Regulatory Board under subpoena if there were to be
serious misbehavior or illegal activity by anyone in our group. You should be
aware that we will always try to preserve your confidentiality rights and specific
questions can be addressed with your provider or Dr. Cappo in this regard. This
information is provided to keep you as fully informed as possible of any potential
limitations of confidentiality. While this written summary of exceptions to
confidentiality should prove helpful in informing you about potential problems, it is
important that we discuss any questions or concerns that you may have now or in
the future. The laws governing confidentiality can be quite complex. In situations
where specific advice is required, formal legal advice may be needed.
I understand that my treatment provider generally may not condition mental health
services upon my signing an authorization unless the mental health services are
provided to me for the purpose of creating health information for a third party.
I understand that information used or disclosed pursuant to a release authorization
may be subject to re-disclosure by the recipient of your information and no longer
protected by the HIPAA Privacy Rule.
15
Our building uses video surveillance for security. Some images are viewable by our
staff and employees and are not recorded in any form. Some images are stored
electronically on a hard disk that is then overwritten when full. Only in the case of
an incident of some type are the stored images reviewed. If you have any questions
or concerns in this area please talk to Dr. Cappo.
MESSAGES
During regular office hours, calls are answered by the receptionists in the office. In
the evening, calls are answered by an answering service and if there is an
emergency they will contact your practitioner. If it is a life-threatening emergency,
go to the nearest hospital emergency room. Please be aware that if you subscribe to
certain telephone features, this may affect confidentiality or our ability to contact
you. If you have Caller-ID services and we phone from the office, then our practice
name may show up on your Caller ID and be available to others in the household.
We do not block the Caller ID signal in outgoing calls from our office. Also, please be
aware that should your telephone not accept any blocked calls, then it may limit our
ability to contact you at times. There are times when only blocked calls may be
available from specific locations. If we are calling from one of those locations and
your telephone does not accept blocked calls, there will be a delay in eventually
contacting you. If you have concerns along these lines, please discuss this with your
practitioner. Unless you tell us otherwise, we may attempt to contact you at any of
the numbers you have provided us. Please do not email your provider unless your
provider has agreed to this with you. Emails are not read timely by all providers
and time sensitive information should not be conveyed in an email.
INITIAL CONTACT
Your initial appointment is often called an "initial evaluation." This appointment is
scheduled for you to discuss your concerns and problems from your point of view.
There may be time during this appointment to obtain historical and other
background data or this information may be gathered at subsequent sessions. In
situations of crisis, the usual format of an "initial evaluation" is not followed in the
hope that the time might be used to resolve or relieve the immediate crisis. As part
of the "initial evaluation" new patients are sometimes requested to complete at least
one questionnaire concerning their beliefs, experiences, thoughts and feelings which
will then be scored using statistical norms. The results of this "psychological test"
will allow us to "measure" your concerns and problems. This booklet contains a
copy of our Policies and Practices to Protect the Privacy of Your Health Information.
You should review this information and ask any questions of your provider or Dr.
Cappo. Under certain conditions a provider-patient relationship may not exist. This
may include some forensic evaluations or evaluations/treatment at the request of a
third party such as an employer, state or federal agency, court or insurer. The
agency will pay for the service and may control access to reports or records. In such
cases, the relationship actually exists between our practice and the referring agency
rather than between you and your provider.
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Treatments
We expect and encourage you to obtain knowledge of the procedures, goals, and
possible side effects of psychotherapy. We expect to make our professional contact
one where you receive the maximum benefit, and we will also keep you informed
about alternatives to psychotherapy. Psychotherapy may be tremendously
beneficial for some individuals while, at the same time, there are some risks. The
risks may include the experience of intense and unwanted feelings, including:
sadness, anger, fear, guilt or anxiety. It is important to remember that these feelings
may be natural and normal and are an important part of the therapy process. Other
risks of therapy might include: recalling unpleasant life events, facing unpleasant
thoughts and beliefs, increased awareness of feelings, values and experiences,
alteration of an individual's ability or desire to deal effectively and harmoniously
with others in relationships, changing employment settings and changing lifestyles.
These decisions are a legitimate outcome of the therapy experience as a result of an
individual's calling into question many of their beliefs and values. Your provider
will be available to discuss any of your assumptions, problems, or possible negative
side effects of your work together.
MEDICATION TREATMENT AND MEDICATION REFILL PROTOCOL
Allow 48 hours for refills to be processed. No refill will be provided between 5:00
p.m. and 8:00 a.m., Monday through Friday or on weekends. In order to continue to
receive medication services, you must be seen a minimum of once every six months.
INDIVIDUAL, FAMILY AND COUPLES TREATMENT
CA offers individual, family and couples psychotherapy focusing on depression,
anxiety, stress, anger, self-esteem, communication, substance abuse and other
issues. This treatment starts with an initial diagnostic and treatment planning
session. The treatment provider and the patient(s) will decide together in that
session how to proceed with the course of treatment and will regularly re-evaluate
this throughout the treatment process.
GROUP THERAPY
All of our groups are open which means that individuals can begin their attendance
in group at any time.
ADULT ANGER CONTROL GROUP
The Adult Anger Control Group is offered on a weekly basis. We ask participants to
make a commitment for a minimum of twelve (12) weekly sessions and
recommended aftercare sessions. The emphasis is on issues of identifying and
dealing with anger and violence, as well as dealing with these issues in conjunction
with substance abuse. This group meets the criteria for the Johnson County
Domestic Violence Diversion Program as well as some other local court programs.
Please check with the Court of Jurisdiction if other than Johnson County.
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ADULT SUBSTANCE ABUSE GROUP
CA is a Kansas Department for Aging and Disability Services State Certified agency
for outpatient substance abuse. We are also approved through the Johnson County
Courts, as well as some other courts and municipalities, to provide evaluation and
diagnosis, psychoeducational intervention, brief treatment and intensive treatment
including family sessions. We do not offer inpatient, residential or detoxification
treatment.
AFTERCARE FOR ADULT ANGER GROUP AND
ADULT SUBSTANCE ABUSE GROUPS
Aftercare for Adult Anger Control Group and Adult Substance Abuse Group is
recommended once a month for the duration of probation or diversion program.
ADOLESCENT GROUPS
These are weekly coeducational and/or therapy groups for teens ages 12 to 18.
Issues concerning behavior, family, relationships, substance use, self-esteem, anger,
communication and other general topics are addressed in an environment that is
supportive yet can also be confrontive. Peer feedback is an important aspect of the
group process.
 "COPING" is an Adolescent Group for teens ranging in age from 12 to 18 who
are experiencing some difficulties with their emotions. The group focuses
on developing positive coping strategies to more effectively deal with the
day-to-day stressors that occur in a teen’s life. Teens suffering from
depression, anxiety, low self-esteem, difficulty in interpersonal
relationships, school stress or grief and loss, benefit from a group setting
where support and feedback is offered.
 "DECISION-MAKING" is an Adolescent Group for teens ranging in age
from12 to 18 who are faced with past choices that have had a negative
impact on their lives. The group uses the setting of a supportive, yet
confrontive atmosphere to address issues such as alcohol and/or drug use,
anger, poor communication, school difficulties, family conflict or behavioral
difficulties. Some teens may be involved in the juvenile legal system and
are desiring to address the behaviors/choices that led to the legal
consequences.
ANGER CONTROL GROUP FOR ADOLESCENTS
The primary goal of this group is to prevent physical, sexual, property and or
psychological violence by helping adolescents learn to cope with anger, stress,
frustration and anxiety in positive and constructive ways. A secondary goal is to
work on the related issues of substance use/abuse which facilitate such violence as
well as self-esteem issues.
ADOLESCENT SUBSTANCE ABUSE GROUP
CA is a Kansas Department for Aging and Disability Services State Certified agency
for outpatient substance abuse. We are also approved to offer Options 1, 2, 3 and 4
through the Johnson County Courts, which address evaluation and diagnosis,
psychoeducational intervention, brief treatment and intensive treatment including
family sessions. We do not offer inpatient, residential or detoxification treatment.
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ADOLESCENT SUBSTANCE ABUSE AFTERCARE GROUP
___________
Aftercare for Adolescent Substance Abuse Group is recommended once a month for
six months or for the duration of probation or diversion program.
IMMIGRATION EVALUATIONS
The U.S. Citizenship and Immigration Services (USCIS) require that applicants for
naturalization demonstrate the ability to read, write and speak basic English and to
answer basic questions about the history and government of the United States. This
evaluation determines whether an individual meets specific criteria based on
developmental or mental impairment. The required forms: N-648, Part II-2, 3, 4 & 5
will be completed as part of the assessment but USCIS will determine whether to
grant the waiver.
SEX OFFENDER GROUP
The Sex Offender Group is offered on a weekly basis to persons 18 years of age and
older. Participants are both court ordered and self-referred. This interactional
program is empirically based and has a cognitive-behavioral focus. The curriculum
examines and treats the root causes of offending as well as presenting relapse
prevention skills.
SEX OFFENDER TREATMENT PROGRAM
Clinical Associates, P.A. offers evidence-based sex offender evaluation and treatment
services throughout the State of Kansas. Clinical Associates is the contracted
provider for sex offender treatment for the Kansas Department of Corrections. We
offer evaluation, assessment, and treatment at correctional facilities, parole and
probation offices, and at Clinical Associates’ offices within the state. Clinical
Associates’ sex offender treatment program utilizes evidence-based measures to
assess the risk, needs, and responsivity issues of clients. Treatment is focused on a
decrease in client risk to the community, and an increase in pro-social behaviors. At
the conclusion of services, we want clients to have developed the ability to intervene
prior to potential problematic behaviors, and be better able to display appropriate
responses to stressful life events. Clinical Associates believes that patient success
depends on the successful interaction between the referral source, the client, and
the treatment team. We understand the importance of providing high-quality,
evidence-based services to clients and make available to those with whom we work
our collective experience in a professional manner.
GROUP LOCATIONS AND CONTACT INFORMATION
Clinical Associates, PA
8629 Bluejacket, Suite 100
Lenexa, KS 66214
(913) 677-3553
(913) 677-3282 Fax
Emporia Parole Office
Supervising Chase, Coffey and Lyon Counties
430 Commercial
Emporia, KS 66801
(620) 341-3294
(620) 341-3456 Fax
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Garden City Parole Office
Supervising Finney, Grant, Greeley, Hamilton, Haskell, Hodgeman, Kearny, Lane,
Morton, Ness, Scott, Seward, Stanton, Stevens and Wichita Counties
601 N. Main, Suite A
Garden City, KS 67846
(620) 272-3878
(620) 272-3635 Fax
Great Bend Parole Office
Supervising Barton, Pawnee and Rush Counties
1806 12th
Great Bend, KS 67530
(620) 792-3549
(620) 792-3540 Fax
Hayes, Kansas Office
205 E. 7th St. Suite 223
Hays, KS 67601
913-677-3553
Hutchinson Parole Office
Supervising Barber, Comanche, Edwards, Harper, Harvey, Kingman, Kiowa, Marion,
Pratt, Reno and Stafford Counties
113 W. 1st St.
Hutchinson, KS 67501
(620) 669-0175
(620) 669-1017 Fax
Junction City Parole Office
Supervising Dickinson, Geary, Marshall, Wabaunsee, and Washington Counties
Pennell Building, 801 N. Washington
Junction City, KS 66441
(785) 238-1911
(785) 762-8660 Fax
Kansas City Parole Office
Supervising Wyandotte County
155 South 18th St., Suite 213
Kansas City, KS 66102
(913) 621-1830
(913) 621-0201 Fax
Kansas City Kansas Satellite Office
1225 N. 78th St., Suite J
Kansas City, KS 66112
(913) 299-9255
20
Lawrence Parole Office
Supervising Douglas, Jefferson and Osage Counties
1800 E. 23rd St., Suite K
Lawrence, KS 66046
(785) 842-2926
(785) 842-3905 Fax
Leavenworth – Clinical Associates Office
3601 S. 4th St., Suite 2
Leavenworth, KS 66048
(913) 677-3553
(913) 677-3282 Fax
Northwest Kansas Community Corrections (NWKSCC)
Supervises the following counties by contract: Cheyenne, Decatur, Ellis, Gove,
Graham, Logan, Norton, Osborne, Phillips, Rawlins, Rooks, Sheridan, Sherman,
Smith, Thomas, Trego and Wallace
1011 Fort
Hays, KS 67601
(785) 625-9192
(785) 625-9194 Fax
Norton County Probation Office
101 S. Kansas Ave.
Norton, KS 67654
(785) 877-5775
Olathe Parole Office
Supervising Johnson County
804 North Meadowbrook Dr., Suite 100
Olathe, KS 66062
(913) 829-6207
Pittsburg Parole Office
Supervising Allen, Bourbon, Cherokee, Crawford, Labette and Neosho Counties
1008 W. 4th
Pittsburg, KS 66762
(620) 232-9550
(620) 232-6028 Fax
Salina Parole Office
Supervising Cloud, Ellsworth, Jewell, Lincoln, McPherson, Mitchell, Ottawa, Republic,
Rice, Russell and Saline Counties
128 N. Santa Fe, 2A
Salina, KS 67401
(785) 827-2584
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Topeka Parole Office
Supervising Jackson and Shawnee Counties
1430 SW Topeka Blvd., 3rd Floor
Topeka, KS 66612
(785) 296-3195
(785) 297-0744 Fax
Wichita Parole Office
Supervising Butler, Cowley, Sedgwick and Sumner Counties
212 S. Market
Wichita, KS 67202
(316) 262-5127
(316) 262-0330 Fax
OTHER AREAS OF EMPHASIS
CA offers Attention-Deficit Disorder evaluations and treatment, intellectual
functioning and achievement, court-involved domestic violence and sex offender
evaluations and treatments, and forensic and court ordered evaluations. CA is a
Kansas Department for Aging and Disability Services licensed outpatient treatment,
diagnostic and referral service as well as Juvenile Court Services and Johnson
County Drug/Alcohol Board service provider.
OTHER PSYCHOLOGICAL SERVICES
Infrequently, a patient's distress remains or becomes so high that hospitalization or
the use of medication must be considered. CA has several prescribing practitioners
(psychiatrists & nurse practitioners) although psychologists and social workers are
not physicians, and consequently do not prescribe medication; however, at times
psychologists and social workers may treat patients in hospitals. In cases where
medications or hospitalization may be required, this will be discussed in advance
with the patient and, if necessary, with other responsible individuals. LMLPs and
LPCs are licensed professionals who practice under direction of our Clinical Director.
TERMINATION
Termination of psychotherapy may occur at any time and may be initiated by either
the patient or the provider. We request that if a decision is being made to terminate,
that a final termination session be scheduled to explore the reasons for termination.
Termination itself can be a constructive, useful process. If any referral is warranted,
it will be made at that time.
PATIENTS WHO ARE DEPENDENTS
If you are requesting our services as the guardian or parent of a child, or the
guardian of a dependent adult, the same general practice as outlined above will
apply. However, as your child's provider, it is important that your child is able to
completely trust us. As such, we keep confidential what your child says in the same
way that we keep confidential what an adult says. As the parent or guardian, you
have the right and responsibility to question and understand the nature of our
activities and progress with your child, and we must use our clinical discretion as to
what is an appropriate disclosure. In general, we will not release specific
information that the child provides. However, we may deem it appropriate to
discuss with you, the parent or guardian, your child's progress and your
participation in their treatment. Children over the age of 13 have specific rights and
should sign pertinent forms in addition to their parent or guardian.
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Patient’s Rights
HIPAA provides you with several new or expanded rights with regard to your
clinical records and disclosures of protected health information. These rights
include requesting that we amend your record; requesting restrictions on what
information from your files is disclosed to others; requesting an accounting of most
disclosures of protected health information that you have neither consented to nor
authorized; determining the location to which protected information disclosures are
sent; and, having any complaints you make about our policies and procedures
recorded in your file. At any time, our patients may question and/or refuse
therapeutic or diagnostic procedures or methods, or gain whatever information
they wish to know about the process and course of therapy. You may examine
and/or receive a copy of your clinical record, if you request it in writing. Because
these are professional records, they can be misinterpreted and/or upsetting to
untrained readers. For this reason, we recommend that you initially review them in
the presence of your provider, or have them forwarded to another mental health
professional so you can discuss the contents. You should also be aware that some of
these rights may be limited in specific situations or that invoking some of these
rights could result in other consequences (such as refusing to participate in a court
ordered or employer required visit which might bring about legal or work
consequences). If your request for access to your records is refused, you have a
right of review (except in specific cases where information has been supplied to CA
confidentially by others), which will be discussed with you upon request.
Patients are also assured of confidentiality which is protected by both ethical
practice and by state law. There are, however, important exceptions to
confidentiality that are legally mandated. In general terms, these exceptions
include: (1) Possible notification of relevant others if we judge that a patient has an
intention to harm another individual or themselves. (2) We are also obliged by the
law to report any incidence of suspected child abuse, neglect, or molestation in
order to protect the children involved. (3) In legal cases, we or our records may be
subpoenaed by the court. Confidentiality will be respected in all cases, except as
noted above, and in those additional cases where in our clinical judgment the
maintenance of confidentiality is, in fact, destructive to the individual. In those
situations, we will inform our patients of our judgment and they will have the final
decision as to whether we maintain confidentiality. Please understand that all files
are kept confidential in their use by the staff of CA. Your written consent is required
for any release of information by CA staff to other persons, organizations or
agencies except in the rare cases of court orders, child abuse, life threatening
situations and national security issues. If you provide us a fax number with
instructions to fax information to you, we cannot assure confidentiality or security
at the receiving end. Also, be aware that while your provider may be available to
you by e-mail, this also is not a secure or confidential form of communication. If you
receive a response by e-mail, then such information should not be forwarded to
others and should be considered specific to your private use.
23
Additionally, a Kansas Department for Aging and Disability Services you are entitled
to the following rights and privileges without limitations:
1. To be treated with dignity and respect,
2. To be free from:
a. Abuse,
b. Neglect,
c. Exploitation,
d. Restraint or seclusion, of any form, used as a means of coercion,
discipline, convenience, or retaliation,
3. To a safe, sanitary, and humane living environment that:
a. Provides privacy, and
b. Promotes dignity,
4. To receive treatment services free of discrimination based on the client’s
race, religion, ethnic origin, age, disabling or a medical condition, and
ability to pay for the services,
5. To privacy in treatment, including the right not to be fingerprinted,
photographed, or recorded without consent, except for:
a. Photographing for identification and administrative purposes, as
provided by R03-602, or
b. Video recordings used for security purposes that are maintained
only on a temporary basis,
6. To receive assistance from a family member, designated representative, or
other individual in understanding, protecting, or exercising the client's
rights,
7. To confidential, uncensored, private communication that includes letters,
telephone calls, and personal visits with:
a. An attorney,
b. Personal physician,
c. Clergy,
d. Department of Social and Rehabilitation Services Staff, or
e. Other individuals unless restriction of such communication is
clinically indicated and is documented in the client record,
8. To practice individual religious beliefs including the opportunity for
religious worship and fellowship as outlined in program policy,
9. To be free from coercion in engaging in or refraining from individual
religious or spiritual activity, practice, or belief,
10. To receive an individualized treatment plan that includes the following:
a. Client participation in the development of the plan,
b. Periodic review and revision of the client’s written treatment plan,
11. To refuse treatment or withdraw consent to treatment unless such
treatment is ordered by a court or is necessary to save the client’s life or
physical health,
12. To receive a referral to another program if the licensee is unable to
provide a treatment service that the client requests or that is indicated in
the client’s assessment or treatment plan,
13. To have the client’s information and records kept confidential and released
according to R03-602,
14. To be treated in the least restrictive environment consistent with the
client’s clinical condition and legal status,
24
15. To consent in writing, refuse to consent, or withdraw written consent to
participate in research, experimentation, or a clinical trial that is not a
professionally recognized treatment without affecting the services
available to the client,
16. To exercise the licensee’s grievance procedures,
17. To receive a response to a grievance in a timely and impartial manner,
18. To be free from retaliation for submitting a grievance to a licensee, the
Department of Social and Rehabilitation Services, or another entity,
19. To receive one’s own information regarding:
a. Medical and psychiatric conditions,
b. Prescribed medications including the risks, benefits, and side
effects,
c. Whether medication compliance is a condition of treatment, and
d. Discharge plans for medications,
20. To obtain a copy of the client’s clinical record at the client’s own expense,
21. To be informed at the time of admission and before receiving treatment
services, except for a treatment service provided to a client experiencing a
crisis situation, of the:
a. Fees the client is required to pay, and
b. Refund policies and procedures, and
22. To receive treatment recommendations and referrals, if applicable, when
the client is to be discharged or transferred.
SUBSTANCE ABUSE GRIEVANCE PROCEDURE
__
If there are any concerns or complaints regarding substance abuse treatment
and/or services received, they can be directed to:
Bruce Michael Cappo, Ph.D.
Director
Clinical Associates, P.A.
8629 Bluejacket Street, Suite 100
Lenexa, Kansas 66214-1700
913-677-3553
913-677-3282 (Fax)
Kansas Department for Aging and Disability Services
Behavioral Health Services Commission
503 S. Kansas Avenue
Attn: Stacey Chamberlain
Topeka, Kansas 66603-3404
785-296-6807
A review will be completed within 30 days
There may be other relevant exceptions to confidentiality which are not included
here or that arise following printing of this document. Please ask your provider or
Dr. Cappo any questions you may have in this area.
You have the right to discontinue treatment at any time, except in cases where the
treatment or assessment has been ordered by the court. CA may discontinue
treatment if it becomes reasonably clear that you are not benefiting from treatment.
Disclosing information received from other agencies or doctors is subject to the
Drug Abuse Office and Treatment Act of 1972 (21 USC 1175) Comprehensive
25
Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of
1970 (42 USC 4582) as follows:
Prohibition on Re-disclosure: This information has been disclosed to you from
records whose confidentiality is protected by federal law. Federal regulations (42
CFR Part 2) prohibit you from making any further disclosure of this information
except with the specific written consent of the person to whom it pertains. A
general authorization for the release of medical or other information if held by
another party is not sufficient for this purpose. Federal regulations state that any
person who violates such provision of this law shall be fined not more than $500 in
the case of a first offense, and not more than $5,000 in the case of each subsequent
offense.
26
Financial Obligations and Responsibilities
CHARGES
Prices subject to change. Please call office to confirm pricing.
Fees are charged differently for specific groups of providers as follows:
EVALUATION AND TREATMENT
Psychiatrist
CPT
90791
90792
90832
90833
90834
90837
90846
90847
90853
96101
99212
99213
99214
99215
Description
Initial Evaluation
Initial Intake
Psychotherapy 30 min.
Psych w/E&M service 30
min. ADD ON
Psychotherapy 45 min.
Psychotherapy 60 min.
Family Counseling w/o
Patient
Family Counseling
Group Psychotherapy
Testing
Est. Pt. Minor Complexity
10 min.
Medication Check
Est. Pt. Moderate
Complexity
Est. Pt. High Complexity
Charge
N/A
$375.00
N/A
N/A
Nurse
Practitioner
Psychologist/
Therapist
Charge
N/A
$300.00
N/A
N/A
Charge
$225.00
N/A
$110.00
$140.00
N/A
N/A
N/A
$180.00
N/A
N/A
$185.00
$270.00
$205.00
N/A
N/A
N/A
$125.00
N/A
N/A
N/A
$125.00
$205.00
$140.00
$360.00
N/A
$175.00
$200.00
$125.00
$200.00
N/A
N/A
$225.00
$225.00
N/A
TESTING AND FORENSICS (Psychologists/Therapists)
Description
Psychological Testing
Consultation per hour
Forensic Time per hour
Level I Evaluation
Level II Evaluation
Level III Evaluation
Competency to Stand Trial
Bariatric Evaluation
Parenting Evaluation
Sex Offender Evaluation
Juvenile Waive to Adult
Charge
$360.00
$360.00
$360.00
$225.00
$1,300.00
$1,600.00
$475.00
$1150.00
$1,500.00
$1,900.00
$1,600.00
SCHOLARSHIP FEES (Psychologists/Therapists)
Description
WJ III or WIAT-II
WISC IV or WAIS IV
IQ & Achievement
Group Fee
Aftercare (adult and teen)
Aftercare (adult)

27
Charge
$425.00
$425.00
$850.00
$40.00
$23.00
$23.00
For any appointment not canceled 24-hours in advance $85.00.
For particular services, some individuals may qualify for a scholarship agreement as
noted above. We also sometimes have available particular programs offering
services to persons who meet particular qualifications (such as deaf or hard of
hearing persons with substance abuse issues) at reduced fees or fees paid by grant
or subsidy. Court-related travel, preparation time and appearances are $360.00 per
hour. The fee includes our time on your behalf for record keeping and preparation.
There will be a charge for filling out special forms such as FMLA forms, disability
letters and forms, etc. Allow five (5) business days for completion of all forms and
letters. We encourage you to discuss fees at any time, and our patients are expected
to pay for services when provided unless arrangements have been made in advance.
With limited exceptions, when our psychological reports are sent to a third party,
payment in full is necessary prior to release of our findings. For your convenience,
we accept cash, personal check, Mastercard, Visa, Discover, and American Express.
Please feel free to discuss any concerns about fees with your provider directly.
In certain situations such as a forensic, court ordered, mandated, or recommended
evaluation or treatment, the services requested may not meet the eligibility
requirements of medical necessity as defined by your insurance company. At times,
CA may have an agreement with specific insurance companies to not require
payment for services deemed not medically necessary. Our agreement allows us to
inform you that we will not provide such services to you under these conditions. If
you choose to have such services performed, even if they are not found to be of
medical necessity, you agree to be responsible for the charges involved. CA will be
happy to bill your insurance company as a courtesy although such action would not
constitute a change in the above agreement.
Payment is expected at the time services are rendered unless other specific
arrangements have been made. Payment of fees is an important part of our work
together. Please discuss fee issues with your provider directly should you have
difficulties or concerns. Dr. Cappo is always available to discuss fees with you
personally.
Please understand that failure to pay your bill may result in specific information
being disclosed to a collection agency to facilitate payment. This information would
include demographic information including your name, how you might be contacted,
the amount you owe and for what specific services. Specific clinical information
about your problems will remain confidential. You will receive written notification
that this will happen at the address supplied to CA. You will be notified of a date by
which you must contact the office to make arrangements for payment or have your
account turned over to collection. It is your responsibility to maintain accurate
phone and mailing contact information with our office.
RESTRICTIVE LEGENDS
We are not required to honor any restrictive legend on checks you write unless we
have agreed in writing to the restriction. Examples of restrictive legends are “must
be presented within 90 days” or “constitutes agreement for payment in full.”
28
BILLING AND TRANSCRIPTION
Our office contracts with reputable third parties at times to provide various support
services and, as required by HIPAA, we have formal business associate contracts
with these businesses. Such services could include, but are not limited to,
transcription or billing. Any vendor who provides such services to us is committed
to the same levels of confidentiality that we apply here in our practice.
INSURANCE
If you have a health insurance plan, your visits may be reimbursed by your
insurance company. Your signature on the appropriate form allows our office to
release relevant information to facilitate reimbursement. In order for us to set
realistic treatment goals and priorities, it is important to evaluate what resources
you have available to pay for your treatment. If you have a health insurance policy,
it will usually provide some coverage for mental health treatment. We will fill out
forms and provide you with whatever assistance we can in helping you receive the
benefits to which you are entitled; however, you (not your insurance company) are
responsible for full payment of fees. It is very important that you find out exactly
what mental health services your insurance policy covers.
You should carefully read the section in your insurance coverage booklet that
describes mental health services. If you have questions about the coverage, call
your plan administrator. Many individuals are members of preferred provider plans
or health maintenance organizations with whom we have contractual obligations.
Please inform us in advance should you be eligible for these contracted services. It
is the patient's responsibility to obtain insurance preauthorization for all office
visits. Failure to do so may result in out-of-pocket expense. Of course, we will
provide you with whatever information we can based on our experience and will be
happy to help you in understanding the information you receive from your
insurance company. If it is necessary to clear any confusion, we will be willing to
call the company on your behalf.
Due to the rising costs of health care, insurance benefits have increasingly become
more complex. It is sometimes difficult to determine exactly how much mental
health coverage is available. "Managed Health Care" plans such as HMOs and PPOs
often require authorization before they provide reimbursement for mental health
services. These plans are often limited to short-term treatment approaches
designed to work out specific problems that interfere with a person's usual level
of functioning. It may be necessary to seek approval for more therapy after a
certain number of sessions. While much can be accomplished in short-term
therapy, some patients feel that they need more services after insurance benefits
end. Some managed care plans will not allow us to provide services to you once
your benefits end. If this is the case, we will do our best to find another provider
who will help you continue your psychotherapy.
You should also be aware that 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 clinical diagnosis. Sometimes we are
required to provide additional clinical information such as treatment plans or
summaries, or copies of your entire file. In such situations, we will make every
effort to release only the minimum information about you that is necessary for the
purpose requested. This information will become part of the insurance company
29
files and will probably be stored in a computer. Though all insurance companies
claim to keep such information confidential, we have no control over what they do
with it once it is in their hands. In some cases, they may share the information with
a national medical information databank. We will provide you with a copy of any
report submitted, if you request it.
Once we have all of the information about your insurance coverage, we will discuss
what we can expect to accomplish with the benefits that are available and what will
happen if they run out before you feel ready to end your sessions. It is important to
remember that you always have the right to pay for services yourself to avoid the
problems described above [unless prohibited by contract]. If you prefer that we do
not release information to your insurance carrier for reimbursement purposes, or if
your insurance carrier fails to reimburse you in a manner which you expected, you
will remain responsible for the fee for services.
Disclosures

Dr. Cappo has a financial interest in STAT Corporation which provides
support services, including transcription, to our practice. He also has a
financial interest in Midwest Behavioral Health which has an interest in
Signature Behavioral Healthcare. Additionally, he is a consulting
psychologist for the Overland Park Police Department and several other area
police departments. He performs work on a regular basis for Elizabeth
Layton Center in Paola. He also has contracts with the Federal Bureau of
Prisons and the Federal Drug & Alcohol Prevention Services Program to
provide both mental health and substance abuse evaluations and treatment.
He provides services to the Drug Enforcement Agency (DEA), Immigration &
Customs Enforcement (ICE), National Oceanic and Atmospheric
Administration (NOAH) and Department of Energy (DOE) and may provide
services to other governmental entities or agencies which may not allow
affiliation disclosure by name.

Dr. Lieberman is associated with Jewish Family Services. She provides
services to Immigration & Customs Enforcement (ICE) and may provide
services to other governmental entities or agencies which may not allow
affiliation disclosure by name.

Lila Peckham-Wickman is affiliated with Sharon Lane Nursing Home,
Richmond Nursing Home and Golden Living Nursing Home facilities.

Jeff Cowan is affiliated with Corrections Corporation of America and Shawnee
Mission Medical Center.
It may be that you would qualify for services under these programs at a different
rate than you would be charged through our practice. It may be that you would be
eligible for different rates from our providers at the various other organizations
with which they are involved. If you believe this may be the case, you should discuss
this with your provider, the front office staff or Dr. Cappo.
30
Reference Forms
The following forms are provided for you here for your reference. You may be asked to
complete some or all of them for our records. These will be provided for you as
separate sheets to sign.
GENERAL CONSENT FOR TREATMENT
Name (printed): ___________________________________________________________________________




I understand that all files are kept confidential in their use by the staff of Clinical
Associates, P.A. My written consent is required for any release of information
by Clinical Associates, P.A.’s staff to other persons, organizations or agencies
except in the rare cases of court orders, child abuse, life threatening situations
and national security issues. There may be other occasions where a third party
is responsible for contracting with CA and they are actually the client and
control access to the information.
I consent to participate in the necessary psychological testing, therapy,
medication management, recommended medical tests or follow up, or other
procedures in the course of assessment and treatment regarding my concerns
by the staff of Clinical Associates, P.A.
I am aware that I have the right to discontinue at any time, except in cases
where the treatment or assessment has been ordered by the court. There are
also times when discontinuation of services may result in negative
consequences related to employment or other areas of life. My provider may
discontinue treatment if it becomes reasonably clear that I am not benefiting
from treatment.
I am aware that the practice of psychotherapy, medication management and
related disciplines is not an exact science and I acknowledge that no guarantees
have been made to me as a result of assessment, consultation or treatment.
Exceptions or additions to the above are as follows: ____________________________________
______________________________________________________________________________
______________________________________________________________________________
Your own effort will play an important role in determining how much benefit you receive
from coming here. Another important part of treatment is honest communication between
you and your provider. If you have concerns about any items on this page, you should
feel free to discuss them with your provider. Thank you.
31
FORENSIC INFORMED CONSENT CONTRACT
This Forensic Psychological Evaluation is being conducted at the request of:
____________________________________________________________________________________________________________________
and is therefore somewhat different than other psychological services. It is important for you to
understand how a forensic evaluation differs from more tradition psychological evaluations.
While the results of this evaluation may or may not be helpful to you personally, the goal of this
evaluation is to provide information about how you are functioning psychologically to the individual
or agency requesting the evaluation. In most cases, this evaluation is intended for use in some type of
a legal proceeding. As such, the confidentiality of the evaluation and the results are determined by
the rules of that legal system. If your attorney has requested this evaluation, he/she will receive a
copy of my report and will control how it is to be used and who has access to it. Normally, the results
of this evaluation are protected by the attorney-client privilege. Exceptions to this might include a
determination on my part that you are dangerous to another person or if you reveal information that
a child has been abused. I would also have to release this information if a court orders me to do so.
There may be other examples where the laws require me to release the information obtained during
the evaluation. We will discuss these situations on a case-by-case basis.
Once a decision has been made to use the report in a legal proceeding, the report and any
information pertaining to it will probably be admissible into evidence as well as any other
information that was provided concerning your mental health and functioning. If you have any
concerns about the use or distribution of my report, you should discuss these issues carefully with
your attorney. If someone other than your attorney requested the evaluation, that individual is my
client and he/she has complete authority over the results, including whether or not any information
will be released to you or to anyone else. In addition, because the evaluation was requested by
another party, and is not for the purpose of treatment or counseling, the confidentiality may have
fewer legal protections. I will not release the information unless instructed to do so by the person or
entity that hired me or when I am legally required to do so.
Your participation in this evaluation is voluntary. I will not conduct the evaluation without your
signature on this document. You also have the right to stop the evaluation at anytime. There may be
legal consequences if you stop the evaluation; therefore, it would be in your best interest to consult
with an attorney before doing so. In addition, if appointments are not kept or are canceled within 24
hours of the appointment time, the person requesting the evaluation will incur charges for the
unused time that has been set aside for these services. The evaluation itself consists of two separate
parts: an oral interview and psychological testing. In addition, it may be necessary for me to review
other related materials such as court records, depositions, transcripts, medical records, etc. If at any
time you have a question about any aspect of the evaluation or these procedures, please feel free to
ask me. In addition, if at any time you need a break from the evaluation, please let me know and we
will stop. Once the evaluation is completed, and with the permission of the requesting party, I may be
able to have a meeting with you to explain the results and answer any questions you might have.
I have read and agree to the above: _______________________________________________
(Signature)
_____________________
(Date)
Witness: ____________________________________________
Date: _____________________________
32
CONSENT TO RELEASE INFORMATION
I, __________________________________________ authorize ________________________________________
________________________________________________________________________________________________
to disclose to Clinical Associates, P.A. progress notes, medication records, treatment
plan, laboratory results, evaluation and status of treatment from my records. The
purpose or need for such disclosure is to facilitate treatment, assessment and case
disposition.
I further authorize Clinical Associates, P.A. to disclose to:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
medication records, psychiatric evaluation and treatment records, laboratory
results and other medical tests, progress notes, treatment plan, evaluation and
status of treatment from my records. The purpose or need for such disclosure is to
facilitate treatment, assessment, and case disposition.
I understand that my medical records (including any alcohol, drug or psychiatric
information) may be protected by Federal Regulations. This consent to disclose may
be revoked by me in writing at any time except to the extent that action has already
been taken in reliance thereon. This consent expires one year following termination
of the case.
I indemnify and hold Clinical Associates, P.A. harmless from any and all damages or
prejudice which might result to myself, relatives or heirs from the use or misuse of
the information furnished by the agency pursuant to this authorization.
THIS IS YOUR COPY. YOU MAY BE ASKED TO SIGN A DUPLICATE FORM FOR OUR
RECORDS.
Signature of Patient _______________________
Date ___________
Signature of Witness _______________________
Date ___________
Signature of Parent, Guardian or legal representative (specify relationship)
________________________________________
Date ___________
PROHIBITION ON REDISCLOSURE: This information has been disclosed to you from records whose
confidentiality is protected by federal law. Federal regulations (42 CFR Part 2) prohibit you from
making any further disclosure of this information except with the specific written consent of the
person to whom it pertains. A general authorization for the release of medical or other information if
held by another party is not sufficient for this purpose. Federal regulations state that any person who
violates such provision of this law shall be fined not more than $500, in the case of a first offense, and
not more than $5,000 in the case of each subsequent offense. Drug Abuse Office and Treatment Act of
1972 (21 USC 1175) Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and
Rehabilitation Act of 1970 (42 USC 4582)
33
CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE
PATIENT RECORDS
The confidentiality of alcohol and drug abuse patient records maintained by this
program is protected by Federal law and regulations. Generally, the program may
not say to a person outside the program that a patient attends the program, or
disclose any information identifying a patient as an alcohol or
drug abuser unless:
(1)
The patient consents in writing;
(2)
The disclosure is allowed by court order; or
(3)
The disclosure is made to medical personnel in a medical emergency or to
qualified personnel for research, audit, or program evaluation.
Violation of the Federal law and regulations by a program is a crime. Suspected
violations may be reported to the United States attorney in your district or
SRS/Alcohol and Drug Abuse Services.
Federal law and regulations do not protect any information about a crime
committed by a patient either at the program or against any person who works for
the program or about any threat to commit such a crime.
Federal law and regulations do not protect any information about suspected child
abuse or neglect from being reported under State law to appropriate state or local
authorities.
See 42 U.S.C. 29Odd-3 and 42 U.S.C. 290ee-3 for Federal laws and 42 CFR, Part 2 for
Federal regulations.
My signature on the agreement form certifies I have been given a copy of this
information on confidentiality.
34
GROUP THERAPY POLICIES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Meeting Time: The group begins and ends on time. You are expected to stay for the entire
session.
Attendance: You are encouraged to attend on a weekly basis and stay in the group until the
problems that brought you into treatment are dealt with. Vacation plans that prevent attendance
at a session(s) should be brought to the group's attention prior to your vacation. If sickness
occurs, please contact or leave a message for one of the group therapists before the session;
otherwise you will be billed for that session. If you miss sessions and you are court ordered to
attend, the courts will be notified of your missed attendance. Group sessions may be canceled
for the following reasons: (a) bad weather, (b) official holidays, or (c) if the therapist is on
vacation or unavailable. Every effort is made to have another practitioner cover the group if a
therapist is absent for vacation or illness. If the weather conditions are uncertain or threatening,
please check to see if evening classes at Johnson County Community College (JCCC) are cancelled.
CA closes for weather when JCCC cancels for weather. If JCCC classes are held then CA is open.
Primary Therapist: You may be engaged in individual psychotherapy, in addition to this group. If
you see someone outside of our practice, you are expected to sign a "release of information" form
to allow us to communicate with your individual psychotherapist for purposes of coordinating
treatment. If you terminate or change individual therapists, notify the group leader immediately.
Group Discussions: The group's focus is on verbal interactions. You are encouraged to express
your feelings openly and freely. Interruptions not usually acceptable in social gatherings are
often desirable.
Confidentiality: Strict group confidentiality must be maintained. This means that group issues,
conversations, and membership identities are not to be conveyed by members to people outside
of the group. There are times when the group leaders may discuss group-related information
with other persons. This includes the following situations: (a) sharing information about your
progress in group therapy with your individual psychotherapist, and (b) if it is believed that you
are harmful or potentially harmful to yourself or someone else, appropriate people need to be
informed.
Violence: Violence of any kind in the group is forbidden. You may say anything. However,
physical contact that is sexual, aggressive and/or threatening is prohibited in the group.
Termination: Reasons for termination vary and include completion of group therapy or violation
of group policies. If you are leaving the group for reasons other than having to do with violation
of policies, it is requested that you plan to attend at least one additional session following
announcement of your intent to terminate. The purpose of this additional session is for you and
the group to address issues related to your leaving.
Smoking, Eating, and Drinking: Smoking and eating (including chewing gum) are not allowed
during group. Drinking of nonalcoholic beverages is permissible.
Homework: On occasion, therapeutic "homework" projects may be assigned.
Substance Abuse: Arriving to group under the influence of any non-prescribed substance,
including alcohol, is grounds for termination and/or referral.
Individual Sessions: There are times when it may be necessary for you to meet individually with
the group therapist. Either you or a group leader may request an individual session. Individual
session(s) may be appropriate for group-related situations that do not lend themselves to group
discussion. Whenever possible, issues pertaining to group will be dealt with in group. Individual
sessions are billed at the individual therapy rate.
Breaches of Group Policy: Not abiding by these policies may lead to termination or referral.
Fees: Fees are due at each group session. You may pay either in cash or by check (payable to
Clinical Associates, P.A.) or credit card.
My signature on the agreement form certifies that I have read the above GROUP THERAPY
POLICIES and agree to abide by them. This information is supplied to patients as a public service
and meets part of our education requirements as a participating agency in Substance Abuse
Treatment & Recovery.
35
INFECTIOUS DISEASES
What is HIV/AIDS? The human immunodeficiency virus (HIV), which causes acquired
immunodeficiency syndrome (AIDS), is a virus that lives and multiplies primarily in white blood
cells, which are part of the immune system. HIV ultimately causes severe depletion of these
cells. An HIV-infected person may look and feel fine for many years and may therefore be
unaware of the infection. However, as the immune system weakens, the individual becomes
more vulnerable to illnesses and common infections. Over time, a person with untreated HIV is
likely to develop AIDS and succumb to multiple, concurrent illnesses.
How Is HIV/AIDS Spread? HIV can be transmitted by contact with the blood or other body
fluids of an infected person. In addition, infected pregnant women can pass HIV to their infants
during pregnancy, delivery, and breastfeeding. Among drug users, HIV transmission can occur
through sharing needles and other injection paraphernalia such cotton swabs, rinse water, and
cookers. However, another way people are at risk for HIV is simply by using drugs, regardless of
whether a needle and syringe is involved. Drugs and alcohol can interfere with judgment and
can lead to risky sexual behaviors that put people in danger of contracting or transmitting HIV.
What Other Infectious Diseases are Associated with HIV/AIDS? Besides increasing their risk
of HIV infection, individuals who take drugs or engage in high-risk behaviors associated with
drug use also put themselves and others at risk for contracting or transmitting hepatitis C
(HCV), hepatitis B (HBV), tuberculosis (TB), as well as a number of sexually transmitted
diseases, including syphilis, chlamydia, trichomoniasis, gonorrhea, and genital herpes. Injecting
drug users (IDUs) are also commonly susceptible to skin infections at the site of injection and to
bacterial and viral infections, such as bacterial pneumonia and endocarditis, which, if left
untreated, can lead to serious health problems.
HCV, HBV, and HIV/AIDS HCV, the leading cause of liver disease, is highly prevalent among IDUs
and often co-occurs with HIV; HBV is also common among drug abusers. These are two of
several viruses that cause inflammation of the liver. Chronic infection with HCV or HBV can
result in cirrhosis (liver scarring) or primary liver cancer. A vaccine does not yet exist for HCV;
however, HBV infection can be prevented by an effective vaccine. HCV is highly transmissible
through blood-borne exposure. NIDA-funded studies have found that, within 3 years of
beginning injection drug use, most IDUs contract HCV—and up to 90 percent of HIV-infected
IDUs may also be infected with HCV. The effects of HCV infection on HIV disease are not well
understood; however, the course of HCV infection is accelerated in dually infected individuals,
with higher rates of progressive liver disease and death in those with both HIV and HCV than in
those with HCV alone. While treatment can be effective, management of co-occurring HIV and
HCV presents certain challenges. HIV therapy can slow progression of liver disease in coinfected persons, but treatment response rates to HCV therapy in these individuals are reduced.
Assessment of stage of disease is important to the timing of therapy initiation for both
infections, as is long-term medical follow up in order to improve quality of life.
TB and HIV/AIDSTB is a chronic and infectious lung disease. Through major public health
detection and treatment initiatives, its prevalence declined in the United States for several
years—in 2005, 14,000 cases were reported, the lowest number since surveillance began in
1953. However, the decline of TB prevalence has slowed by half in recent years, and TB
infection remains intertwined with HIV/AIDS and drug abuse.
People with latent TB infection do not have symptoms, may not develop active disease, and
cannot spread TB. However, if such individuals do not receive preventive therapy, they may
develop active TB, which is contagious. NIDA research has shown that IDUs have high rates of
latent TB infection. Because HIV infection severely weakens the immune system, people
infected with both HIV and latent TB are at increased risk of developing active TB and becoming
highly infectious. Effective treatment for HIV and TB can reduce TB/HIV-associated disease and
the risk of transmission to others.
To learn more about these infectious diseases go to www.drugabuse.gov
36
Child Therapy Agreement

If you decide to terminate treatment, I have the option of having a few closing sessions with
your child to properly end the treatment relationship.

You are waiving your right to access to your child’s treatment records.

I will inform you if your child does not attend the treatment sessions.

At the end of treatment, I will provide you with a summary that includes a general description
of goals, progress made, and potential areas that may require intervention in the future.

If necessary to protect the life of your child or another person, I have the option of disclosing
information to you without your child’s consent.

You agree that my role is limited to providing treatment and that you will not involve me in
any legal dispute, especially a dispute concerning custody or custody arrangements
(visitation, etc.).

You also agree to instruct your attorneys not to subpoena me or to refer in any court filing to
anything I have said or done.

If there is a court appointed evaluator, and if appropriate releases are signed and a court order
is provided, I will provide general information about the child which will not include
recommendations concerning custody or custody arrangements.

If, for any reason, I am required to appear as a witness, the party responsible for my
participation agrees to reimburse me at the rate of $250 per hour for time spent traveling,
preparing reports, testifying, being in attendance, and any other case-related costs.

Should you have concerns about any of the above please discuss this with your child’s
therapist or with Dr. Cappo.
Parent or Guardian ____________________________________
37
Date _______________
OUTPATIENT SERVICES AGREEMENT FOR COLLATERALS
INTRODUCTION
I want to thank you for accepting the invitation to assist in ____________________’s psychotherapeutic
treatment. Your participation is important, and is sometimes essential to the success of the treatment. This
document is to inform you about the risks, rights and responsibilities of your participation as a collateral
participant.
WHO IS A COLLATERAL?
A collateral is usually a spouse, family member, or friend, who participates in therapy to assist the identified
patient. The collateral is not considered to be a patient and is not the subject of the treatment. Psychiatrists,
psychologists & therapists have certain legal and ethical responsibilities to patients, and the privacy of the
relationship is given legal protection. Your practitioner’s primary responsibility is to the patient and their
interests are placed first. You also have less privacy protection.
THE ROLE OF COLLATERALS IN THERAPY
The role of a collateral will vary greatly. For example, a collateral might attend only one session, either alone or
with the patient, to provide information to the therapist and never attend another session. In another case a
collateral might attend all of the patient’s therapy sessions and his/her relationship with the patient may be a
focus of the treatment. We will discuss your specific role in the treatment at our first meeting and other
appropriate times.
BENEFITS AND RISKS
Psychotherapy often engenders intense emotional experiences, and your participation may engender strong
anxiety or emotional distress. It may also expose or create tension in your relationship with the patient. While
your participation can result in better understanding of the patient or an improved relationship, or may even help
in your own growth and development, there is no guarantee that this will be the case. Psychotherapy is a
positive experience for many, but it is not helpful to all people.
MEDICAL RECORDS
No record or chart will be maintained on you in your role as a collateral. Notes about you may be entered into
the identified patient’s chart. The patient has a right to access the chart and the material contained therein. It is
sometimes possible to maintain the privacy of our communications. If that is your wish, we should discuss it
before any information is communicated. You have no right to access that chart without the written consent of
the identified patient. You will not carry a diagnosis, and there is no individualized treatment plan for you.
FEES
As a collateral you are not responsible for paying for professional services unless you are financially responsible
for the patient.
CONFIDENTIALITY
The confidentiality of information in the patient’s chart, including the information that you provide me, is
protected by both federal and state law. It can only be released if the identified patient specifically authorizes
this happen. There are some exceptions to this general rule:
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If there is a suspicion that you are abusing or neglecting a child or a vulnerable adult, your
practitioner is required to file a report with the appropriate agency.
If your practitioner believes that you are a danger to yourself (suicidal) then actions will be taken
to protect your life even if your identity must be revealed to do so.
If you threaten serious bodily harm to another your practitioner will take necessary actions to
protect that person even if your identity must be revealed to do so.
If you, or the patient, is involved in a lawsuit, and a court requires that information or testimony be
provided then your practitioner will comply.
If insurance is used to pay for the treatment, the patient’s insurance company may require
submission of information about the treatment for claims processing purposes or for utilization
review.
You are expected to maintain the confidentiality of the identified patient (your spouse, friend, or child) in your
role as a collateral.
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DO COLLATERALS EVER BECOME A FORMAL PATIENT?
Collaterals may discuss their own problems in therapy, especially problems that interact with issues of the
identified patient. The therapist may recommend formal therapy for a collateral. These are some examples of
when this might occur.
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It becomes evident that a collateral is in need of mental health services. In this circumstance the
collateral needs to have a clinician, diagnosis, and chart records kept.
Parents, being seen as collaterals as their child is being treated, need couples therapy to improve
their relationship so they can function effectively as parents.
Most often, but not always, your clinician will refer you to another clinician for treatment in these situations.
There are two reasons the referral may be necessary:
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Seeing two members of the same family, or close friends, may result in a dual role, and potentially
cloud the clinician’s judgment. Making a referral helps prevent this from happening.
The clinician must keep a focus on the original primary task of treatment for the identified patient.
For example, if the clinician started treating a child’s behavioral problem, then takes on couples
therapy with mom and dad to address their relationship problems, the original focus of therapy
with the child may be lost. A referral helps the clinician to stay focused.
One exception to these guidelines is when a family therapy approach can be effectively and ethically used to
treat all members of the family, or each of the couple.
RELEASE OF INFORMATION
The identified patient is not required to sign an authorization to release information to the collateral when a
collateral participates in therapy. The presence of the collateral with the consent of the patient is adequate. This
provides some assurance that full consent has been given to the clinician for the patient’s confidential
information to be discussed with the collateral in therapy. The Release of Information Form is also helpful to
the clinician on those occasions when receiving a telephone call from a collateral or when the clinician calls a
collateral for one reason or another. In most instances the clinician cannot take a call from a collateral without a
Release of Information Form.
PARENTS AS COLLATERALS
Clinicians specializing in the treatment of children have long recognized the need to treat children in the context
of their family. Participation of parents, siblings, and sometimes extended family members, is common and
often recommended. Parents in particular have more rights and responsibilities in their role as a collateral than
in other treatment situations where the identified patient is not a minor.
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In treatment involving children and their parents, access to information is an important and
sometimes contentious topic. Particularly for older children, trust and privacy are crucial to
treatment success. But parents also need to know certain information about the treatment. For this
reason, we need to discuss and agree about what information will be shared and what information
will remain private. Your clinician generally requires a written contract signed by both you and
your child/children concerning access to a child’s record and once that contract is made, it as
legally binding, although it sometimes may be overridden by a judge. In general, parents should be
informed about the goals of treatment and how the treatment is going and whether the child comes
to his/her appointments. Your clinician will always inform you if he/she thinks that your child is
in danger or if he/she is endangering others. One of your first tasks is to discuss this shared
definition of dangerousness if you choose, so that everyone is clear about what will be disclosed.
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If you are participating in therapy with your child, you should expect the clinician to request that
you examine your own attitudes and behaviors to determine if you can make positive changes that
will be of benefit to your child.
SUMMARY
If you have questions about therapy, procedures, or your role in this process, please discuss them with your
therapist. Remember that the best way to assure quality and ethical treatment is to keep communication open
and direct with your clinician. By signing below you indicate that your have read and understood this
document.
_____________________________________
____________________
Signature
Date
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Acknowledgement
of Receipt and Agreement
I have received and read the New Patient Welcome materials (version 16.7) that
describes the practice and CA policies as well as the Health Insurance Portability and
Accountability Act (HIPAA) and its application to my personal health information. I
have discussed any questions I had and agree to abide by the terms as stated.
My signature below indicates that I, __________________________________________
have received a written copy and a verbal explanation of the following documents from
Clinical Associates, P.A.
1. Written summary of the Federal Regulations on confidentiality
2. Client’s Rights
3. Grievance Policy and Procedure
4. Client responsibilities
5. Treatment Service Fees
6. Infectious Diseases to include AIDS, HIV, STI and HCV
7. Group Therapy Policies
_______(initial) I authorize Clinical Associates, P.A. (CA) to leave me messages regarding
my appointment times or other relevant information that may contain protected health care
information on my voice mail, answering machine or with any person answering the phone
numbers I have provide to CA.
Patient Signature:_____________________________________
Date: _____________
Patient/Legal Guardian Signature:__________________________ Date: _____________
Witness Signature:_____________________________________ Date: _____________
Version 16.7 04-05-16
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