COUNSELING INFORMATION AND CONSENT TO TREATMENT

1. APPOINTMENTS:

When a counselor sets an appointment with you, that time is yours and yours alone. If you need to cancel your appointment, we require a minimum of 24-hours notice; otherwise, you are subject to a full charge for the missed appointment. Messages may be left on the voice mail, which will accurately record the date and time you called. Our counselors will do their best to be punctual for your appointment unless they have an emergency call. We ask that you be punctual as well. If you are late, for any reason, you will receive the remainder of your scheduled time. This is necessary so we can see following clients at their scheduled times. You will, however, be required to pay the full fee. Of course, in the case of an emergency or illness, late cancellations are acceptable per your counselor's approval.

2. COUNSELING FEES:

Counseling sessions are 60 minutes. The fee per session is $125.00. You are fully responsible for all services rendered. Full payment is expected at the time of service unless other arrangements apply. You may pay by cash, check or debit/credit card. You may submit a claim to your insurance carrier directly. There is no guarantee that your insurance will reimburse you for the service. You're advised to inquire about reimbursement terms with your insurance carrier prior to your initial session.

3. RETURNED CHECKS:

A penalty fee of $35.00 will be assessed on all checks returned by the bank for any reason. Re-payment of the returned check must be made by cash, cashier's check, or money order only.

4. UNPAID BALANCES:

If your account has an unpaid balance any time, it may be necessary to suspend counseling sessions until the account is paid in full.

5. CHILDREN:

Childcare is not provided. Therefore, unless your child(ren) is receiving services, we ask that you not bring them.

6. Legal Limitations:

It is agreed that neither the client nor the client's attorney or anyone acting on behalf of the client will call on the therapist to testify in court or any proceeding including but not limited to divorce, custody disputes, injuries or lawsuits. It is extended to no request being made to disclose psychotherapy records or any communication that took place between the therapist and the client. This is due to the fact that disclosure often includes all records and the nature of the therapeutic process and other confidential matters. We are dedicated to you and your counseling needs and appreciate your cooperation in these matters. Should you have any questions or concerns regarding fees, payments, or policies, feel free to bring them to our attention.

CONFIDENTIALITY STATEMENT

Your therapy records are the property of your counselor and shall be treated as confidential. To comply with state and federal laws your records will not be released without properly executed written consent. Everything about your care will be held in strict confidence (with the exception of those situations in which we are required by law to report). If you choose to have your counselor keep a third party informed of your progress, it is necessary to complete a "Release of Information Form" that will be kept on file. For more information, download our Notice of Privacy Practices in PDF format.

The following circumstances are an exception to keeping confidentiality and are required by law to report:

  1. When a client communicates threat of bodily injury to self another person or is suicidal.
  2. When there is reasonable suspicion of abuse to a child or a dependent adult which has occurred or will occur.
  3. When information is required by law or is ordered by the court.
  4. Counselor Team. Counselors typically work as a team and reserve the right to consult and discuss pertinent information with other counselors and supervisors within the counseling field.

It is important to remember that electronic communication such as e-mail, faxes and cell phone calls are not secure. Please keep this in mind when there is communication with a counselor. If you have any questions about confidentiality, please discuss them with your counselor.

TREATMENT FOR MINOR CHILDREN

Parents give permission to counselors to see my his/her son/daughter for treatment with or without the parent being present in the same session. Counselors must assert confidential privilege - the right to withhold disclosure of private counseling information about the child(ren). However, in the interest of developing a trusting relationship between the counselor and the child(ren), parents give the counselor permission to reveal or withhold information that in his/her clinical judgment is necessary to best help and protect the child(ren).

The only exception would be in the case of:

  1. The child communicates threat of bodily injury to self, another person or is suicidal.
  2. Counselor Team. Counselors typically work as a team and reserve the right to consult and discuss pertinent information with other counselors and supervisors within the counseling field.

LEGAL

Mediation and Arbitration

All disputes that occur as a result of psychotherapy shall first be referred to mediation, before and as a pre-condition, to the initiation of arbitration. The client(s) and counselor shall choose a neutral third party that they both agree upon. Any expenses that occur shall be split equally, unless otherwise agreed by the parties involved. If the mediation is unsuccessful and the matter is taken for arbitration; the arbitrator will determine the expenses to be paid by either party.

Litigation Limitation

It is agreed that neither the client nor the client's attorney or anyone acting on behalf of the client will call on the therapist to testify in court or any proceeding including but not limited to divorce, custody disputes, injuries, lawsuits. It is extended to no request being made to disclose psychotherapy records or any communication that took place between the therapist and the client. This is due to the fact that disclosure often includes disclosing the nature of the therapeutic process and other matters that may be confidential in nature.

Financial Arrangements

  • Payment is expected prior to each session unless other arrangements have been made in advance. Therapy sessions are 60 minutes in length, unless otherwise agreed upon. You are responsible for payment for all services rendered.
  • Cancellation of appointments must be made at least 24 HOURS in advance. Voice mail is reachable 24 hours a day, 7 days a week. Late cancellations will be charged $125.00, the regular direct pay hourly fee. If you are using insurance, the charge will be the amount of your insurance reimbursement for the service, including your co-pay amount. Emergency circumstances are an exception to this policy and shall be approved by your therapist.
  • There is a thirty-five dollar ($35.00 USD) service charge for all checks returned by the bank. If 1 or more session fees are not paid, therapist reserves the right to terminate therapy.
  • If you have an urgent need to speak with your therapist between your scheduled sessions, a brief call or email, not requiring more than 15 minutes to read and respond is appropriate. Should you wish to discuss issues at a greater length, please schedule a session or arrange a time for a telephone consultation, which will be charged at the regular rate.

Therapist's Requests and/or Recommendations

Counseling services are available only during office hours. In the event of a crisis, you may visit the nearest hospital to you. Alternatively, you could call 911. In case of suicide tendencies, another option is 1-800- SUICIDE.

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