Intake Online Form
Informed Consent Form
Notice of Privacy Practices Form
Release of Information
1. Appointments are generally made on a regular, weekly basis, with on-going appointments on the same day and time of the week, if and when possible.
a. Appointment reminder texts/email are a courtesy and are generated through Therapy Notes. To cancel or reschedule, please either call or text 317.572.7847.
b. For proper preparation, should you want to bring a spouse/partner etc., to a session, this should be discussed in a session prior to the visit with your guest.
c. If after 60 days since your last visit, your file becomes inactive (i.e. you are no longer considered an active patient of Dr. Grant’s). Should you return after 60 days since your last visit, you will need to complete a new Demographic Form, Informed Consent, and Notice of Privacy Practices.
2. You might wonder what psychotherapy is.
a. Psychotherapy is a process in which the patient explores his or her internal processes (e.g., thoughts and feelings) and behaviors (i.e. overt and covert) with the guidance of the psychotherapist. Psychotherapy can be an enjoyable, rewarding, but difficult process as the person in the process changes and learns things about him or herself. Dr. Grant's philosophy is that you get out of psychotherapy what effort and time you are willing to put into it; commitment and dedication is important in the psychotherapeutic process. Metaphorically as your compass, Dr. Grant assists his patients in finding their own answers to their questions/problems. Dr. Grant firmly believes in the saying that "Life is a journey and only you hold the map."
b. Sometimes patients might may feel worse before they feel better; this is normal but most patients find the process a relief.
3. Please place your cell phone on silence while in session.
4. Payment for the session will be due at the end of the session unless prior arrangements have been made.
a. You may pay in cash, check, HSA, or credit card.
b. There will be a $30.00 charge for all checks that are returned.
c. When paying by credit card, the Pocket Suite platform is utilized to collect for services rendered. When paying by credit card, your credit card will be stored in the Pocket Suite platform to make payment and checkout nice and easy. There's also the option of paying for the cost of your session via an invoice that is sent via text to your cell phone. Please note that message and data rates may apply.
d. If applicable, your co-pay or co-insurance or deductible will be due at the end of each session; using your health insurance is not a guarantee of payment for services rendered.
a. Diagnostic Interview (i.e. first session up to 60 minutes) $175.00
b. Individual Psychotherapy (i.e. follow-up) $125.00 for 20 to 30 minutes
c. Individual Psychotherapy (i.e. follow-up) $150.00 for 31 to 59 minutes
d. Individual Psychotherapy (i.e. follow-up) $175.00 for 60+ minutes
e. Couples Psychotherapy $150.00 an hour (i.e. usually 55 to 60 minutes)
f. Group Psychotherapy $30.00 (i.e. usually 1-1.5 hours)
6. Please arrive, if possible, 5 minutes prior to your scheduled appointment.
a. When late, please note: if you have a 45 minute appointment starting at 9:00am and you show up at 9:20am, you have 25 minutes left in your session.
b. Failing to cancel your scheduled appointment within 24 hours:
• If you miss an appointment or cancel less than 24 hours prior to your appointment, you will be charged $75.00; this fee is waived if you’re able to be seen the same week. Dr. Grant allows ONE FREE late cancellation per year from the start date of your first appointment. Appointments that are not kept due to inclement weather are waived.
- Please note that Dr. Grant is unable to bill your health insurance for missed sessions or sessions less than 20 minutes.
• If you have failed to cancel, have not shown for your appointment, or cancelled 2 or more times consecutively, Dr. Grant may decline to schedule future appointments. In this case, appropriate referrals will be made.
7. Please do not bring weapons to the session (i.e. guns, knives etc).
8. Please do not arrive intoxicated and/or high.
Arriving in this condition does not provide an environment to actively participate in the therapeutic process. If warranted, Dr. Grant will call your emergency contact and have you picked-up.
9. Please do not bring children under the age of 13 years-old unless you are participating in family therapy.
Unfortunately, children under this age should not be unsupervised at Dr. Grant’s office.
10. Because Dr. Grant is unable to provide emergency services, should you have a psychiatric emergency (i.e. you have a plan or method of how you might hurt/kill yourself or someone else), please dial 911 or go to your nearest emergency room.
Should you go to the emergency room or to an inpatient psychiatric facility, to ensure confidentiality, Dr. Grant does not make hospital visits and he does not have hospital privileges. If you are not at imminent risk of hurting yourself or someone else, and you desire to speak with someone and you're unable to get in contact with Dr. Grant and/or it's after Dr. Grant's office hours, please call one of the Hotline numbers below:
• The National Suicide Prevention Lifeline, please call (800) 273-8255
• The local Suicide & Crisis Intervention, Indianapolis, please call (317) 251-7575
11. When contacting Dr. Grant by phone or email, please limit your conversation needs to appointment scheduling and emergencies.
a. Dr. Grant is unable to accept requests to connect via his personal Facebook and LinkedIn pages. Should you leave comments on Dr. Grant's Blog, The Navigateur, you're identity will be unknown.
b. Dr. Grant attempts to return all voicemails and emails within a 24 hour period.
12. There is legal privilege in this state protecting the confidentiality of the information you share with me. As a professional, Dr. Grant can assure you that he strives to maintain the strictest standards of confidentiality.
a. There are legal exceptions to confidentiality. The following situations are those in which the information you have shared with me may be shared with others.
i. You provide written permission to share confidential information.
ii. When Dr. Grant suspect child/elderly adult abuse or neglect.
iii. Dr. Grant believes that you are at imminent risk of hurting yourself or someone else.
• Here, law enforcement and potential victim is contacted.
iv. You file a complaint against Dr. Grant.
v. In response to a subpoena.
vi. You’re under the age of 18 years-old and dependent on an adult.
13. Dr. Grant regularly consults with other professionals to gain other perspectives and ideas as to how to best help you reach your goals.
These consultations are obtained in such a way that confidentiality is maintained. In addition, Dr. Grant may use your clinical material for educational purposes for the students he teaches; your information would be de-identified and confidentiality would be maintained.
14. Please feel free to bring a beverage to session with a lid, but unfortunately food is not permitted.
15. There may be times when you need Dr. Grant to fill out paperwork (e.g., for disability).
Please note that disability paperwork is completed during your session. To obtain an accurate picture of who you are, Dr. Grant does not complete disability paperwork unless he has met with you for a minimum of 6 sessions.
16. As a courtesy to you, Dr. Grant or Express Billing Solutions, Inc. on behalf of Dr. Grant will check your mental health insurance benefits; however, it is your responsibility to know and understand the limits of your coverage. You agree to be responsible for all charges, even those denied for coverage by your insurance company.
a. Please call 317.572.7847 should you have questions concerning your insurance benefits or account balance.
b. If there have been multiple attempts to collect your unpaid balance, and a prior arrangement/agreement has not been made to collect your unpaid balance, Dr. Grant will be unable to see you until your account has been brought current or a payment agreement has been made. This doesn’t apply in emergency cases.
c. If 90 days have passed since your last visit or last payment without making any arrangement/agreement to pay your balance, Dr. Grant will provide permission to Express Billing Solutions, Inc., to turn your account over to a collection agency to collect your unpaid balance on behalf of Dr. Grant. Should this happen, please know that your credit score could be impacted.
d. Should you have an HMO and want to file a complaint or a grievance with your health insurance company, please call their toll free number. You may also file a complaint with the Indiana Department of Insurance at 1-800-622-4461.
17. Please make a note of the following professional services that cannot be billed to your insurance company and for which you are responsible:
a. Phone consultations to an attorney, a physician, or any other provider with whom you receive services from.
b. Providing your physician or psychiatrist a brief note of your progress is and can be expected; however, please make sure to complete the Release of Information Form. However, you will retain the costs for letters that you have authorized to provide to courts, attorneys, employers, schools etc.
c. Time spent conducting psychological testing, report writing, reviewing records, and record copying. Please consult on pricing. Please inquire about the cost of these services.
d. Costs of the above services (i.e. a, b) are based on Dr. Grant's standard session fee. For instance, if Dr. Grant charges $100.00 per 45 minute session, and you need him to write a letter that takes him 20 minutes to write, your charge would be $ 44.44.
e. Court attendance. Should Dr. Grant appear on your behalf in court, the cost out-of-pocket per hour (i.e. 60 minutes) is $300.00. You’re also required to pay for costs of travel to and from court at $.60 per mile.
18. Contact information is updated annually at the beginning of each year. Thus, should you have any changes to your address, phone number, etc., it is your responsibility to make Dr. Grant aware of these changes.
19. Consent for treatment.
PLEASE CHECK THE BOX! I have read and agree with the above Office Policies. I further consent voluntarily to receive treatment and services from Matthew Grant, Psy.D. HSPP. By signing below, I acknowledge that treatment and services, given or performed by Matthew Grant, Psy.D., HSPP cannot make or offer a guarantee or warranty. I understand that I am consenting to those services that Matthew Grant, Psy.D., HSPP is qualified to provide within the scope of his license and training. You have the right to withdraw your consent for treatment at any time and for any reason. I'm aware that Dr. Grant only provides clinical services, and will refer patients to other providers for forensic services.
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429 E. Vermont Street
Indianapolis, IN 46202
317-572-7847 (ST4R) Call/Text