PSYCHOLOGICAL SYSTEMS LTD - RICHARD SHERRY
TERMS AND CONDITIONS

APPOINTMENTS

Depending on the treatment type, it may be necessary to include a ‘homework’ element.  I would be grateful if this could please be completed as required in order to move the treatment forward.

SETTLEMENT OF ACCOUNT
Invoices are payable on presentation please and will be sent to you by email (preferred) or to your home address unless you indicate an alternative address.
Overdue Accounts are routinely passed to our collection agent where payments fail or are omitted and, at 30days, if arrears remain on the account. The agent may levy additional charges for chasing and collecting payment.  If you are having difficulties with payment, please contact me as soon as possible so that we may assess the available options.

REIMBURSEMENT OF FEES BY HEALTH INSURANCE COMPANIES 
My invoices will be submitted weeklyand are payable on presentation please, by bank transfer, credit card or cheque.  My preference and policy is for you, my patient, to pay my bill directly and make your own claims submission to any insurance policy you may hold.
Please also note that whilst it may well be the case that your fees will be covered by your health insurance company, any reimbursement to you of my fees is subject to your agreement with your health insurer according to your contract with them and you remain responsible for the full payment of my fees on presentation of my invoice, whether or not they are reimbursed to you by your health insurer.

AMENDING OR CANCELLING APPOINTMENTS

CODE OF PRACTICE
I am a Trauma Specialist, a Clinical and Counselling Psychologist and Psychoanalytic Psychotherapist and, as such, I abide by the professional code of practice required by the Health Professionals Council (HCPC), the British Psychological Society (BPS) and British Association of Counsellors & Psychotherapists (BACP) and I am registered with the British Psychoanalytic Council (BCP) and traumatology with the ESTSS.

CONFIDENTIALITY
All information imparted to me during a session is confidential. It is standard practice however to inform others involved in your care, such as your referring psychiatrist and/or your GP, of your attendance, including a summary of the themes addressed in therapy. Please indicate if you do not wish me to disclose any such information; as in the majority of cases it may notalways be essential for me to do so. Supervision of my work is a professional requirement and standard practice. I might occasionally choose to discuss your progress with my supervisor but I do not disclose any information that would identify you.

AGREEMENT:I have read and agree to the terms and conditions outlined above.DATE …...….…………

 

YOUR NAME: Please PRINT………………………… YOUR SIGNATURE………………………….   

 

PSYCHOLOGICAL SYSTEMS LTD - RICHARD SHERRY
Psychological Systems Limited is a company registered in England and Wales - Registered Number: 08109577
Consulting Rooms and Registered Office : 62 Wimpole Street London W1G 8AJ

Richard Sherry : B.Sc (Psych.) | M.Sc (Lon) | Ad. Dip. (Mental Health) | Dip. (Psych) | PG Dip. (Lon) | MBACP Accred. | MSc (CAPs) Clinical and Counselling Psychologist (HPC Reg.) | Psychoanalytic Psychotherapist (UKCP Reg.) | EMDR Consultant Trauma Specialist | Organisational Consultant
Tel: 07863 145 386      Email: richardcsherry@yahoo.co.uk

PATIENT REGISTRATION DETAILS
(**Please complete all fields as this is a requirement for treatment)

 

NAME …………………………………………     DATE OF BIRTH……/………/……

HOME ADDRESS………………………………………………………………............................................
.……………………………………………………………………….…………………..………………………………………………………………………………………..…………………………………………………..

TELEPHONE CONTACT DETAILS: (please indicate your preferred contact number)

Work ..…………………………..         Please indicate your preferred number    Yes / No        
Home ..………………….…….…                    Please indicate your preferred number    Yes / No
Mobile  ……………………….…         Please indicate your preferred number    Yes / No 

EMAIL (essential for billing please)
 



Email:  ________________________@_______________ . ____________  (home/personal)

*Or        ________________________@_______________ . ____________  (work)

 

WHO REFERRED YOU?   …………………………………………...……….………

DOCTOR’S DETAILS
General Practitioner         Name………….……………………………………….……..  
Practice Address …….……………………………….………
                                        .….………………………………………………….……..…
                                        .……………………………………………………….………
                                        Telephone No ………….……………………………….……
                                        May I provide details of your attendance?                 Yes / No                                    

Consultant Psychiatrist     Name….….…………………………………………………...
                                        Practice Address……….……………………………………..
                                        .……………………………………………………………….
                                        .……………………………………………………………….
                                        Telephone No ………………..………………………………
                                        May I provide details of your attendance?                 Yes / No

INSURANCE DETAILS: if applicable – for reference/patient reports

Medical Insurance: Yes/No 

Membership or Policy No. ………………………………………………

Authorisation No:………..………………………………………………

 

Please Ensure That You Have Read And Signed My Terms And Conditions Overleaf
Thank You


The only exception, besides you requesting my having communication with someone of your choosing, would be that is it is understood you may be a danger to yourself or to someone else.  This risk mitigation would necessitate an intervention to ensure safety and well-being.