Common use of Sessions Clause in Contracts

Sessions. The first few sessions will involve an evaluation of your needs. During this time, we can both decide if I am the best person to provide these services in order to meet your treatment goals. By the end of this period of time, if I have not already done so, I will be able to offer you some impressions of what the work will include if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working in this way. You always maintain the right to ask about other treatments for and about their risks and benefits. Once psychotherapy has begun, I usually schedule one 50-minute session (one appointment hour of 50 minutes duration) per week at a time we agree upon. Based on your needs, some sessions may be longer or more frequent. Missed sessions present a special problem in therapy because the given hour is specifically blocked out for you and often can not be filled on short notice. If you must miss an appointment, please notify me as soon as possible at (▇▇▇) ▇▇▇-▇▇▇▇. I will try to find another time to reschedule the appointment. Unless you give 48 hours notice of your intention to miss the session, you will be billed for the session. Insurance will not reimburse you for missed sessions. Sessions are 50 minutes long and are billed at the rate of $225 for individuals and $250 for couples and families. If this rate should change, you will be given at least 2 months notice. Longer or shorter sessions are pro-rated by prior mutual agreement. You will be expected to pay for each session at the time it is held unless we arrange for monthly ▇▇▇▇▇▇▇▇. If for any reason you should become involved in legal action that requires your therapist or other counseling clinical staff to protect your privilege of confidentiality or testify on your behalf, you must agree to cover legal expenses and the therapist's time. I do not agree to take on any cases where there is an established legal case or where you would expect me to testify in any such case. Our contract is for treatment purposes only. In the rare case of your records being subpoenaed by the courts, you will be expected to cover the cost incurred by me for the processing of the records.

Sessions. The first few sessions will involve We normally conduct an evaluation of your needsthat will last from 1-3 sessions. During this time, we can both decide evaluate if I am the best person to provide these services in order to meet clinician is a good fit for your treatment goals. By the end of this period of timeIf psychotherapy starts, if I have not already done so, I we will be able to offer you some impressions of what the work will include if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working in this way. You always maintain the right to ask about other treatments for and about their risks and benefits. Once psychotherapy has begun, I usually schedule one 50fifty-minute session (one appointment hour of 50 minutes duration) per week at a time we agree upon. Based on your needson, although some sessions may be longer or more frequent. Missed sessions present a special problem in therapy because the given hour Once an appointment is specifically blocked out for you and often can not be filled on short notice. If you must miss an appointment, please notify me as soon as possible at (▇▇▇) ▇▇▇-▇▇▇▇. I will try to find another time to reschedule the appointment. Unless you give 48 hours notice of your intention to miss the sessionscheduled, you will be billed expected to pay for it unless you provide 24 hours advance notice of cancellation, unless it is agreed upon that you were unable to attend due to circumstances beyond your control. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Likewise, if the clinician is unable to keep an appointment with you within the 24-hour cancellation period, you will not be charged for that session, and an attempt will be made to reschedule for the earliest opening. PROFESSIONAL FEES The psychotherapy fee for a fifty-minute session is $225. If you are working with an associate the fee will be different. It will be negotiated in the first session. Insurance will not reimburse you for missed In addition to weekly sessions. Sessions are 50 minutes long and are billed at the rate of $225 for individuals and $250 for couples and families. If this rate should change, you will be given charged for other professional services you may need. These typically include report writing, telephone conversations lasting longer than 15 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other services you may request of the practice. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time, including preparation and transportation costs, even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge a separate fee per hour for preparation and attendance at least 2 months noticeany legal proceeding. Longer TELEPHONE CONTACT Due to our work schedules, we are often not immediately available by telephone. We do not answer the telephone when we are with clients. When we are unavailable, the telephone is answered by voice mail that it monitored frequently. We will make every effort to return your call on the same day you place it. This may not include weekends or shorter sessions holidays. If you have an emergency that cannot reasonably wait until the end of the business day, you are prourged to call 911 or contact the nearest emergency room and ask for the psychiatrist on call. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a client and a psychologist. In most situations, we can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. These are situations that require that you provide written, advanced consent. Your signature on this Agreement provides consent for those activities as follows: It is occasionally helpful to consult other medical and mental health professionals about a case. During a consultation, every effort to avoid revealing the identity of the client. The other professionals are also legally bound to keep the information confidential. Unless you wish that we do so, we will not tell you about these consultations unless it feels important to our work together. We will make note of these consultations in your clinical record. At times it may be necessary to employ administrative staff to help with scheduling and quality assurance practices. We may need to share protected information, such as your name and telephone number, with these individuals for purely administrative purposes. Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in the Agreement. If a client threatens to harm him/herself, we may be obligated to seek hospitalization for him/her or to contact family members or others who can 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 our professional services, such information is protected by the psychologist-rated client privilege law. We cannot provide any information without your written authorization or a court order. If you are involved in, or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. If a government agency is requesting the information for health oversight activities, we may be required to provide it for them. If a client files a complaint or lawsuit against the practice, we may disclose relevant information regarding that client in order to defend ourselves. If a client files a worker’s compensation claim, and one of us is providing treatment related to the claim, we must, upon appropriate request, furnish copies of all psychological reports and bills. There are some situations in which we are legally obligated to take action, and which we believe are necessary, to attempt to protect others from harm. we may have to reveal some information about a client’s treatment. In this practice, such situations are unusual. If we have reason to believe that a child has been abused, the law requires that we file a report with the appropriate governmental agency, usually the Department of Family and Children’s Services. Once such a report is filed, we may be required to provide additional information. If we have reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or elder person, other than by prior mutual agreementaccidental means, or has been neglected or exploited, we must report this to an agency designated by the Department of Human Resources. Once such a report is filed, I may be required to provide additional information. If we determine that a client presents a serious danger of violence to another, we may be required to take protective actions. These actions may include notifying the potential victim, and/or contacting the police, and/or seeking hospitalization for the client. If such a situation arises, we will make every effort to fully discuss it with you before taking any action and will limit our disclosure to what is necessary. 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 consultation may be necessary. PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, we keep Protected Health Information (PHI) about you in two sets of professional records. One set constitutes your clinical record. It includes information about your reasons for seeking therapy, a description of the ways in which your problems impact your life, your diagnosis, the goals we have set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Exceptions to this are unusual circumstances that involve danger to yourself or others, or circumstances that make reference to another person (unless such other person is a healthcare provider), and we believe that access is reasonably likely to cause substantial harm to such other person, or if information is supplied to us confidentially by others. You or your legal representative 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 our presence, or have them forwarded to another mental health professional so you can discuss the contents. The exceptions to this policy are contained in the attached Notice Form. If we refuse your request for access to your records, you have a right of review (except for information provided to me confidentially by others), which we will discuss with you upon request. In addition, we also keep a set of psychotherapy notes. These notes are for our own use and are designed to assist in providing you with the best treatment. While the contents of psychotherapy notes vary from client to client, they can include the contents of our conversations, an analysis of those conversations, and how they impact your therapy. They may also contain particularly sensitive information that you may reveal that is not required to be included in your clinical record, and information supplied confidentially by others. Your psychotherapy notes are kept separate from your clinical record. Your psychotherapy notes are not available to you, and cannot be sent to anyone else, including insurance companies, without your written, signed authorization. Insurance companies cannot require your authorization as a condition of coverage, and they cannot penalize you in any way for your refusal to provide them. PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your clinical record and disclosures of protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your clinical record is disclosed to others; requesting an accounting of most disclosures of protected health information (PHI) that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice Form, and our privacy policies and procedures. We are am happy to discuss any of these rights with you. MINORS AND PARENTS Clients under 18 years of age, who are not emancipated, and their parents should be aware that the law allows parents to examine their child’s treatment records unless we believe that doing so would endanger the child or we agree otherwise. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes our policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment we will provide them with only general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. We will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless we feel that the child is in danger or is a danger to someone else. In those cases, we will notify the parent of the concern. Before giving parents any information, we will discuss the matter with the child, if possible, and do our best to handle any objections he or she may have. BILLING AND PAYMENTS You will be expected to pay for each session all sessions at the time end of each month. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days, and arrangements for payment have not been agreed upon, we have the option of using legal means to secure payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information we release regarding a client’s treatment is his or her name, the nature of the services provided, and the amount due. If such legal action becomes necessary, its costs will be included in the claim. INSURANCE REIMBURSEMENT If you have a health insurance policy, it will usually provide some coverage for mental health treatment. Claims can be provided electronically by the practice. You will need to provide all of your insurance You, not your insurance company is responsible for full payment to the provider. It is very important that you find out exactly what mental health services your insurance policy covers. You should also be aware that your contact with your health insurance company requires that we provide it with information relevant to the services we provide to you. A clinical diagnosis will be required for reimbursement. Sometimes we are required to provide additional clinical information such as treatment plans or summaries, or copies of your entire clinical record. 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’s 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 held unless 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 we arrange for monthly ▇▇▇▇▇▇▇▇submit, if you request it in writing. If for any reason you should become involved in legal action that requires your therapist or other counseling clinical staff to protect your privilege of confidentiality or testify on your behalfBy signing this Agreement, you must agree that we can provide requested information to cover legal expenses and the therapist's time. I do not agree to take on any cases where there is an established legal case or where you would expect me to testify in any such case. Our contract is for treatment purposes only. In the rare case of your records being subpoenaed by the courts, you will be expected to cover the cost incurred by me for the processing of the recordscarrier.

Sessions. The first few sessions will involve We normally conduct an evaluation of your needsthat will last from 1 to 2 sessions. During this time, we can both decide if I am your therapist is the best person to provide these the services that you need in order to meet your treatment goals. By the end of this period of time, if I have not already done so, I will be able to offer you some impressions of what the work will include if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working in this way. You always maintain the right to ask about other treatments for and about their risks and benefits. Once If psychotherapy has is begun, I we will usually schedule one 50-minute session (one appointment hour of 50 minutes duration) per week at a time we agree uponon. Based on your needs, some sessions may Please notify us as soon as you know that you will be longer or more frequentunable to keep a scheduled session. Missed sessions present a special problem in therapy because the given hour Our posted fee is specifically blocked out $225 for you an initial assessment and often can not be filled on short notice$150 for subsequent sessions. If you must miss an appointmenthave insurance, please notify me these fees will be reduced to the rates we have agreed to as soon as possible at (▇▇▇) ▇▇▇-▇▇▇▇a contracted provider to your insurance company. I will try to find another time to reschedule the appointment. Unless If you give 48 hours notice of have questions about your intention to miss the sessioncoverage, you should contact your insurance company. In addition to weekly appointments, we charge $150 per hour for other professional services you may need, though we will be billed break down the hourly cost if we work for less than an hour. Other services include report writing, telephone conversations lasting longer than 10 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the session. Insurance will not reimburse time spent performing any other service you for missed sessions. Sessions are 50 minutes long and are billed at the rate may request of $225 for individuals and $250 for couples and familiesus. If this rate should changeyou become involved in legal proceedings that require our participation, you will be given at least 2 months notice. Longer or shorter sessions are pro-rated by prior mutual agreement. You will be expected to pay for each session at the time it is held unless all of our professional time, including preparation and transportation costs, even if we arrange for monthly ▇▇▇▇▇▇▇▇. If for any reason you should become involved in legal action that requires your therapist or other counseling clinical staff to protect your privilege of confidentiality or testify on your behalf, you must agree to cover legal expenses and the therapist's time. I do not agree to take on any cases where there is an established legal case or where you would expect me are called to testify by another party. Due to our work schedule, we often are not immediately available by telephone. Generally we will not answer the phone when we are in any such casesession. Our contract When unavailable, our calls will be routed to a voice mail service that is for treatment purposes onlymonitored frequently, and we will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. In the rare case Please inform us of your records being subpoenaed by the courts, some times when you will be expected available if you are difficult to cover reach. If you are unable to reach us and feel that your situation is life threatening, contact your family physician or the cost incurred by me nearest emergency room. If we will be unavailable for an extended time, we will provide you with the processing name of the recordsa colleague to contact, if necessary.

Sessions. The first few sessions will involve an evaluation of your needs. During this time, we can both decide if I am the best person to provide these services in order to meet your treatment goals. By the end of this period of time, if I have not already done so, I will be able to offer you some impressions of what the work will include if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working in this way. You always maintain the right to ask about other treatments for and about their risks and benefits. Once psychotherapy has begun, I usually schedule one 50-minute session (one appointment hour of 50 minutes duration) per week at a time we agree upon. Based on your needs, some sessions may be longer or more frequent. Missed sessions present a special problem in therapy because the given hour is specifically blocked out for you and often can not be filled on short notice. If you must miss an appointment, please notify me as soon as possible at (▇▇▇) ▇▇▇-▇▇▇▇. I will try to find another time to reschedule the appointment. Unless you give 48 hours notice of your intention to miss the session, you will be billed for the session. Insurance will not reimburse you for missed sessions. Sessions are 50 minutes long and are billed at the rate of $225 for individuals and $250 for couples and families$ . If this rate should change, you will be given at least 2 months notice. Longer or shorter sessions are pro-rated by prior mutual agreement. You will be expected to pay for each session at the time it is held unless we arrange for monthly ▇▇▇▇▇▇▇▇. If for any reason you should become involved in legal action that requires your therapist or other counseling clinical staff to protect your privilege of confidentiality or testify on your behalf, you must agree to cover legal expenses and the therapist's time. I do not agree to take on any cases where there is an established legal case or where you would expect me to testify in any such case. Our contract is for treatment purposes only. In the rare case of your records being subpoenaed by the courts, you will be expected to cover the cost incurred by me for the processing of the records.

Sessions. The first few Each individual session lasts 60 minutes and family sessions will involve an evaluation of are 75-90 minutes. If you are late for a session, that time is lost from your needssession. During this timeIf I am late for a session, we can both decide will extend the session if you are willing to do so or we will make other arrangements by mutual consent. Since a time slot is reserved for you that cannot be offered to anyone else, you will be charged for all missed appointments not cancelled 24 hours in advance. Please note my snow policy: I am do not follow Montgomery County’s snow policy. Unless you hear from me in the best person to provide these services in order to meet your treatment goals. By the end of this period of time, if I have not already done somorning, I will assume that we will be able to offer you some impressions of what the work will include if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working in this way. You always maintain the right to ask about other treatments for and about their risks and benefits. Once psychotherapy has begun, I usually schedule one 50-minute session (one appointment hour of 50 minutes duration) per week at a time we agree upon. Based on your needs, some sessions may be longer or more frequent. Missed sessions present a special problem in therapy because the given hour is specifically blocked out for you and often can not be filled on short noticemeeting. If you must miss an appointmentcannot make it to the appointment for weather reasons, please notify call or email me as soon as possible at by 8:00 a.m. (▇▇▇) ▇▇▇-▇▇▇-▇. I will try to find another time to reschedule the appointment. Unless you give 48 hours notice of your intention to miss the session, you will be billed for the session. Insurance will not reimburse you for missed sessions. Sessions are 50 minutes long and are billed at the rate of $225 for individuals and $250 for couples and families. If this rate should change, you will be given at least 2 months notice. Longer ▇▇▇ or shorter sessions are pro-rated by prior mutual agreement. You will be expected to pay for each session at the time it is held unless we arrange for monthly ▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇) and I will waive the 24-hour cancellation fee. If you do not reschedule an appointment within one month of our last session, I will assume that you have decided to discontinue treatment with me. Please be assured that you are always welcome to return regardless of how much time has lapsed since our last session. You are responsible for any reason payment for each therapy session at the time of the session by cash, check or credit card. I do not participate in health insurance programs however I will provide you with an invoice with all the information needed should you wish to file a claim directly with the insurance company. It is your responsibility to contact your insurance company to determine if an authorization for treatment is required and to communicate that requirement to me. A fee of $60 per quarter hour is billed for services such as telephone calls not related to scheduling, special reports, and collateral consultation. During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. If you become involved in legal action proceedings that requires your therapist or other counseling clinical staff to protect your privilege of confidentiality or testify on your behalf, you must agree to cover legal expenses and the therapist's time. I do not agree to take on any cases where there is an established legal case or where you would expect me to testify in any such case. Our contract is for treatment purposes only. In the rare case of your records being subpoenaed by the courtsrequire my participation, you will be expected to cover pay for all of my professional time and expenses, including preparation costs, transportation costs, and attorney’s fees, even if I am called to testify by another party. My professional time related to these activities is $425 per hour. Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail that I monitor. I will make every effort to return your call on the cost incurred by same day you make it, with the exception of weekends and holidays. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the processing psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. It is very important to be aware that computers and email and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise the recordsprivacy and confidentiality of such communication. If you communicate confidential or private information via email or text, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via email or text. Please do not use email or text for emergencies. Due to computer or network problems, emails and texts may not be deliverable, and I may not check my emails or faxes frequently.

Sessions. The first few Each individual session lasts 45 or 60 minutes and family sessions will involve an evaluation of your needs. During this time, we can both decide if I am the best person to provide these services in order to meet your treatment goals. By the end of this period of time, if I have not already done so, I will be able to offer you some impressions of what the work will include if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working in this way. You always maintain the right to ask about other treatments for and about their risks and benefits. Once psychotherapy has begun, I usually schedule one 50-minute session (one appointment hour of 50 minutes duration) per week at a time we agree upon. Based on your needs, some sessions may be longer or more frequent. Missed sessions present a special problem in therapy because the given hour is specifically blocked out for you and often can not be filled on short noticeare 60 minutes. If you must miss an appointment, please notify me as soon as possible at (▇▇▇) ▇▇▇-▇▇▇▇. I will try to find another time to reschedule the appointment. Unless you give 48 hours notice of your intention to miss the are late for a session, you will be billed for the that time is lost from your session. Insurance If I am late for a session, we will extend the session if you are willing to do so or we will make other arrangements by mutual consent. Please note my snow policy: I do not reimburse you for missed sessions. Sessions are 50 minutes long and are billed at the rate of $225 for individuals and $250 for couples and families. If this rate should change, you will be given at least 2 months notice. Longer or shorter sessions are pro-rated by prior mutual agreement. You will be expected to pay for each session at the time it is held unless we arrange for monthly follow ▇▇▇▇▇▇▇▇▇▇ County’s snow policy. Unless you hear from me in the morning, I will assume that we will be meeting. If you cannot make it to the appointment for any reason weather reasons, please call or email me by 8:00 a.m. (301-652-1582 or ▇▇▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇) and I will waive the 24-hour cancellation fee. If you do not reschedule an appointment within one month of our last session, I will assume that you have decided to discontinue treatment with me. Please be assured that you are always welcome to return regardless of how much time has lapsed since our last session. Fees are as specified on the signature page to be completed with me at our first session. You are responsible for payment for each therapy session at the time of the session by cash, check or credit card. During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. Please note, I do not participate in health insurance programs however I will provide you with an invoice with all the information needed should you wish to file a claim directly with the insurance company. It is your responsibility to contact your insurance company to determine if an authorization for treatment is required and to communicate that requirement to me. During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. If you become involved in legal action proceedings that requires your therapist or other counseling clinical staff to protect your privilege of confidentiality or testify on your behalf, you must agree to cover legal expenses and the therapist's time. I do not agree to take on any cases where there is an established legal case or where you would expect me to testify in any such case. Our contract is for treatment purposes only. In the rare case of your records being subpoenaed by the courtsrequire my participation, you will be expected to cover pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. [Because of the cost incurred difficulty of legal involvement, I charge $400 per hour for preparation and attendance at any legal proceeding.] Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the processing psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. It is very important to be aware that computers and email and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise the recordsprivacy and confidentiality of such communication. If you communicate confidential or private information via email or text, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via email or text. Please do not use email or text for emergencies. Due to computer or network problems, emails and texts may not be deliverable, and I may not check my emails or faxes frequently.

Sessions. The first few sessions will involve I normally conduct an evaluation of your needsthat will last from 2 to 4 sessions. During this that time, we can both decide if I am the best person to provide these the services you need in order to meet your treatment goals. By the end of this period of time, if I have not already done soIf psychotherapy is begun, I will be able to offer you some impressions of what the work will include if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working in this way. You always maintain the right to ask about other treatments for and about their risks and benefits. Once psychotherapy has begun, I usually schedule one 5045-minute session (one appointment hour of 50 45 minutes duration) per week at a time we agree upon. Based on your needson, although some sessions may be longer or more frequent. Missed sessions present a The following information pertains to my financial policy. I hope this will answer any questions that you may have, but if you do have any questions or special problem in therapy because concerns please do not hesitate to discuss them with me at the given hour is specifically blocked out for you and often can not be filled on short noticefirst session. Please acknowledge your understanding of this policy by signing at the end of this form. If you must miss would like a copy of this form for your records I will be happy to provide one for you. My fee is $175.00 for individual sessions and $185.00 for couples or family therapy sessions, paid at the end of each session. The usual therapy hour consists of 45 minutes. The fee for the initial diagnostic session is $195.00. Charges for services outside the usual therapy hour that you may request of me will be determined on an appointmentindividual basis. These services might include report writing, telephone conversations (lasting longer than 110 minutes), consulting with other professionals with your permission, and the preparation of records or treatment summaries. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation, transportation, and waiting costs, even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $200.00 per hour for preparation and $350.00 per hour for attendance at any legal proceeding. Payment isexpected at the end of each session. Please discuss any exceptional circumstances with me at the first session. Visa and MasterCard are accepted for your convenience. An insurance receipt is available should you wish to submit your insurance claims personally. If you are a member of a managed care company in which I participate, I am required to file insurance for you. After our office manager verifies your insurance eligibility and level of benefits, I will gladly accept only the co-payment. Until that time, please plan on paying the full contracted amount. I will fill out forms and provide you with whatever assistance I c a n in helping you to receive the benefits to which you are entitled; however, you, NOT your insurance company, are responsible for the full payment of my fees. For that reason, it is very important that you find out personally what mental health services your insurance policy specifically covers. *** NOTE: The amount we are required to collect is based on information we receive from your insurance company. However, we do not always receive accurate and reliable information from the company. Therefore, please be aware that you may receive a later bill for services after a session if your insurance company declines to pay for the service. • Since your appointment time is reserved for you, please notify me as soon as possible if you find that you must cancel an appointment. Appointments not cancelled with at (▇▇▇) ▇▇▇-▇▇▇▇least 24 hours notice will be billed at the usual fee of $175.00 or $185.00. Missed appointments cannot be billed to the insurance company. You may leave a message on my confidential voicemail after hours and on weekends if you need to cancel an appointment. Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by my assistant or by my confidential voicemail. I will try make every effort to find another time return your call on the same day that you make it, with the exception of weekends and holidays. In the event of an emergency, a doctor is on call through Atlanta Psych Consultants 24 hours a day, 7 days a week. If you are difficult to reschedule the appointment. Unless you give 48 hours notice reach, please inform me of your intention to miss the session, some times when you will be billed available. You may contact the doctor on call through the answering service (770-928-5044). If I will be unavailable for an extended period of time, the sessionanswering service can provide you with the name of a colleague to contact, if necessary. Insurance Under Georgia law communications between patients and psychologists are confidential, and under ordinary circumstances only the patient can waive this privilege. However, there are three clear exceptions in which a psychologist is legally and ethically bound to break confidentiality: (1) the patient is imminently dangerous to him or her self, (2) the patient is imminently dangerous to others and/or has made specific threats to harm an identifiable third person, (3) there may exist actual or suspected incidents of child abuse or elder abuse. Although legally and ethically bound to break confidentiality under the aforementioned circumstances, I generally will not reimburse you for missed do so without attempting to discuss it with you. Patients under 18 years of age (who are not emancipated), and their parents, should be aware that the law allows parents to examine their child's treatment records, unless I believe that doing so would endanger the child, or the parents agree to suspend their right to examine the treatment record. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is my policy to request an agreement from parents that they consent to give up access to their child's records. If they agree, then during treatment I will provide them only with general information about the progress of their child's treatment, and his or her attendance at scheduled sessions. Sessions are 50 minutes long Any other communication will require the child's Authorization for Release of Information, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and are billed at the rate of $225 do my best to handle any objections he or she may have. I acknowledge responsibility for individuals and $250 for couples and familiesall fees incurred and, if it is necessary, I consent to have my account collected through an attorney or collection agency. If this rate should change, you I also agree that I will be given at least 2 months notice. Longer or shorter sessions are pro-rated by prior mutual agreement. You will be expected to pay responsible for each session at the time it is held unless we arrange for monthly ▇▇▇▇▇▇▇▇. If for any reason you should become involved in legal action that requires your therapist or other counseling clinical staff to protect your privilege all costs of confidentiality or testify on your behalflitigation, you must agree to cover legal expenses and the therapist's timeincluding attorney’s fees. I do not agree to take on any cases where there is an established legal case have read and understand the above policies. Patient Signature Date Parent (or where Guardian of minor) Signature Date NAME: ADDRESS: PHONE Home: Cell: Work: Can a message be left at Home? Yes No Work? Yes No Cell? Yes No Email address: SOCIAL SECURITY#: SEX: Male Female MARITAL STATUS: DATE OF BIRTH: AGE: EMPLOYER: POSITION: REFERRED BY: May I contact this person? Yes No Have you been in therapy before? Yes No For your current issue? Yes No Phone #: Address: Name: Date of Birth: SS #: PHONE Home: Cell: Work: Name of Carrier: Name of Insured: Phone #: ID#: Group #: Insurance Patients: Please read and sign the following assignment of benefits if you would expect me like us to testify in any such case. Our contract is file your insurance for treatment purposes only. In the rare case of your records being subpoenaed by the courts, you will be expected to cover the cost incurred by me for the processing of the records.you

Sessions. The Our first few sessions will involve an evaluation of your (or your child’s) needs. During this time, we can both decide if I am the best person to provide these services in order to meet your treatment goals. By the end of this period of time, if I have not already done sothe evaluation, I will be able to offer you some first impressions of what the our work will include if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you (and your child when applicable) feel comfortable working in this waywith me. You always maintain Psychotherapy involves a large commitment of time, money, and energy, so you should be very careful about the right therapist you select. If you have any questions, please feel free to ask about other treatments for and about their risks and benefitsthem as they arise. Once psychotherapy has begun, I will usually schedule one 50-minute session (one appointment hour of 50 minutes durationduration – 40 minutes when doing play therapy) per week at a time we agree uponon although this may vary. Based on your needs, some sessions may be longer or more frequent. Missed sessions present a special problem in therapy because the given hour is specifically blocked out for you and often can not be filled on short notice. If you must miss To ensure that all clients have an equal opportunity to schedule an appointment, please all appointments require a 24 hour cancellation notice except for those rare occasions such as significant illness or unforeseeable emergencies. If a significant illness or emergency does arise, I ask that you notify me as soon as possible at so that I can plan accordingly. If an appointment is not cancelled 24 hours prior, or if you fail to arrive for your appointment, you will be charged a $125.00 cancellation fee. If you have booked your session within 24 hours of the appointment, but fail to arrive or cancel within a reasonable amount of time, but no less than 2 hours, you will be charged a $75.00 cancellation fee. Please understand that every “no show” appointment occupies a block of time that could have been dedicated to another client seeking care. Please also note that 3rd party payers do not provide reimbursement for unused sessions. This payment will be expected before you can schedule another appointment with me. My telephone number is (▇▇▇) ▇▇▇-▇▇▇▇. Due to the nature of my work, I am most often not immediately available by telephone. While I strive to be available during business hours, I will try not answer the phone when I am in an appointment or am otherwise unavailable. When I am unavailable, my telephone is answered by confidential voice mail that I monitor regularly. I will make every effort to find another time to reschedule return your call within 24 hours, with the appointmentexception of weekends, holidays, and vacations. Unless you give 48 hours notice of your intention to miss Nighttime and weekend calls will usually be returned the session, you will be billed for the session. Insurance will not reimburse you for missed sessions. Sessions are 50 minutes long and are billed at the rate of $225 for individuals and $250 for couples and familiesnext business day. If this rate should changeyou find yourself in an urgent situation, you make a judgment about the prudence of waiting for my call versus calling your primary care physician, 911, or the Anchorage Community Mental Health Center’s 24-hour crisis line (907-563-3200). If I am away for extended periods, my voice mail message will be given at least 2 months noticeindicate that and state when I will return. Longer or shorter sessions are pro-rated by prior mutual agreement. You will be expected to pay for each session at the time it My email address is held unless we arrange for monthly ▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇.▇▇▇. If Email is a convenient method of communication, though it is best used for any reason you should become involved in legal action administrative matters such as scheduling and payment issues. Please note that requires information transmitted by email is not entirely secure. Please use your therapist or other counseling clinical staff to protect judgment and your privilege own level of confidentiality or testify on your behalf, you must agree to cover legal expenses and the therapist's time. I do not agree to take on any cases where there is an established legal case or where you would expect me to testify in any such case. Our contract is for treatment purposes only. In the rare case of your records being subpoenaed by the courts, you will be expected to cover the cost incurred by me for the processing of the recordscomfort when transmitting personal information using this medium.

Sessions. The first few Each individual session lasts 45 minutes and family sessions will involve an evaluation of are 60-80 minutes. If you are late for a session, that time is lost from your needssession. During this timeIf I am late for a session, we can both decide will extend the session if you are willing to do so or we will make other arrangements by mutual consent. Please note my snow policy: I am do not follow Montgomery County’s snow policy. Unless you hear from me in the best person to provide these services in order to meet your treatment goals. By the end of this period of time, if I have not already done somorning, I will assume that we will be able to offer you some impressions of what the work will include if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working in this way. You always maintain the right to ask about other treatments for and about their risks and benefits. Once psychotherapy has begun, I usually schedule one 50-minute session (one appointment hour of 50 minutes duration) per week at a time we agree upon. Based on your needs, some sessions may be longer or more frequent. Missed sessions present a special problem in therapy because the given hour is specifically blocked out for you and often can not be filled on short noticemeeting. If you must miss an appointmentcannot make it to the appointment for weather reasons, please notify call or email me as soon as possible at by 8:00 a.m. (▇▇▇) -▇▇▇-▇▇▇▇ or ▇▇▇▇@▇▇▇-▇▇▇▇▇▇▇▇▇-▇▇▇▇▇.▇▇▇) and I will waive the 24-hour cancellation fee. If you do not reschedule an appointment within one month of our last session, I will assume that you have decided to discontinue treatment with me. Please be assured that you are always welcome to return regardless of how much time has lapsed since our last session. Please confirm current fees with therapist: Additional time is billed at $ per quarter hour. These fees are also billed for services such as telephone calls not related to scheduling, special reports, and collateral consultation. You are responsible for payment for each therapy session at the time of the session by cash, check or credit card. I do not participate in health insurance programs however I will try provide you with an invoice with all the information needed should you wish to find another time file a claim directly with the insurance company. It is your responsibility to reschedule the appointmentcontact your insurance company to determine if an authorization for treatment is required and to communicate that requirement to me. Unless Please note, I am not a Medicare provider and therefore my services are not covered by Medicare. Should you give 48 hours notice want services from me and you are a Medicare recipient, this will serve as a separate private contract so that you may pay me out of your intention to miss the sessionpocket. Under this circumstance, you understand that you (or your beneficiaries or legal representatives) are waiving the right to submit claims or be reimbursed by Medicare for any services I provide that would otherwise be covered by Medicare if there was no private contract and a proper claim was submitted. You have every right to obtain similar services from a provider who has not opted out of Medicare. You understand that Medigap does not pay for services not covered by Medicare. The period of this agreement will be billed for 2 years from the sessiontime of signature. Insurance will not reimburse you for missed sessionsThis language is legalese required of me by Medicare guidelines! During the course of treatment, it may become necessary to increase fees. Sessions Fees are 50 minutes long reviewed in January and are billed at the rate June of $225 for individuals and $250 for couples and familieseach year. If this rate should changeyou become involved in legal proceedings that require my participation, you will be given at least 2 months notice. Longer or shorter sessions are pro-rated by prior mutual agreement. You will be expected to pay for each session all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. [Because of the difficulty of legal involvement, I charge $700 per hour for preparation and attendance at any legal proceeding.] Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call on the time it is held unless we arrange for monthly ▇▇▇▇▇▇▇▇same day you make it, with the exception of weekends and holidays. If you are unable to reach me and feel that you can’t wait for any reason me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you should become involved in legal action with the name of a colleague to contact, if necessary. It is very important to be aware that requires computers and email and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. If you communicate confidential or private information via email or text, I will assume that you have made an informed decision, will view it as your therapist agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via email or other counseling clinical staff to protect your privilege of confidentiality or testify on your behalf, you must agree to cover legal expenses and the therapist's timetext. I Please do not agree use email or text for emergencies. Due to take on any cases where there is an established legal case computer or where you would expect me to testify in any such case. Our contract is for treatment purposes only. In the rare case of your records being subpoenaed by the courtsnetwork problems, you will emails and texts may not be expected to cover the cost incurred by me for the processing of the recordsdeliverable, and I may not check my emails or faxes frequently.

Sessions. The first few Each individual session lasts 45-60 minutes and family sessions will involve an evaluation of are 60-80 minutes. If you are late for a session, that time is lost from your needssession. During this timeIf I am late for a session, we can both decide will extend the session if I am the best person you are willing to provide these services in order to meet your treatment goalsdo so or we will make other arrangements by mutual consent. By the end If you do not reschedule an appointment within one month of this period of time, if I have not already done soour last session, I will assume that you have decided to discontinue treatment with me. Please be able assured that you are always welcome to offer you some impressions return regardless of what how much time has lapsed since our last session. Fees are as specified on the work will include if you decide signature page to continue be completed with therapyme at our first session. You are responsible for payment for each therapy session at the time of the session by cash, check or credit card. During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. I do not participate in health insurance programs however I will provide you with an invoice with all the information needed should evaluate this information along you wish to file a claim directly with the insurance company. It is your own opinions responsibility to contact your insurance company to determine if an authorization for treatment is required and to communicate that requirement to me. During the course of whether you feel comfortable working treatment, it may become necessary to increase fees. Fees are reviewed in this way. You always maintain the right to ask about other treatments for January and about their risks and benefits. Once psychotherapy has begun, I usually schedule one 50-minute session (one appointment hour June of 50 minutes duration) per week at a time we agree upon. Based on your needs, some sessions may be longer or more frequent. Missed sessions present a special problem in therapy because the given hour is specifically blocked out for you and often can not be filled on short noticeeach year. If you must miss an appointment, please notify me as soon as possible at (▇▇▇) ▇▇▇-▇▇▇▇. I will try to find another time to reschedule the appointment. Unless you give 48 hours notice of your intention to miss the sessionbecome involved in legal proceedings that require my participation, you will be billed for the session. Insurance will not reimburse you for missed sessions. Sessions are 50 minutes long and are billed at the rate of $225 for individuals and $250 for couples and families. If this rate should change, you will be given at least 2 months notice. Longer or shorter sessions are pro-rated by prior mutual agreement. You will be expected to pay for each session at all of my professional time and expenses, including preparation costs, transportation costs, and attorney’s fees, even if I am called to testify by another party. My professional time related to these activities is $350 per hour. Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call on the time it is held unless we arrange for monthly ▇▇▇▇▇▇▇▇same day you make it, with the exception of weekends and holidays. If you are unable to reach me and feel that you can’t wait for any reason me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you should become involved in legal action with the name of a colleague to contact, if necessary. It is very important to be aware that requires computers and email and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. If you communicate confidential or private information via email or text, I will assume that you have made an informed decision, will view it as your therapist agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via email or other counseling clinical staff to protect your privilege of confidentiality or testify on your behalf, you must agree to cover legal expenses and the therapist's timetext. I Please do not agree use email or text for emergencies. Due to take on any cases where there is an established legal case computer or where you would expect me to testify in any such case. Our contract is for treatment purposes only. In the rare case of your records being subpoenaed by the courtsnetwork problems, you will emails and texts may not be expected to cover the cost incurred by me for the processing of the recordsdeliverable, and I may not check my emails or faxes frequently.

Sessions. The first few Each individual session lasts 45-60 minutes and family sessions will involve an evaluation of are 60-80 minutes. If you are late for a session, that time is lost from your needssession. During this timeIf I am late for a session, we can both decide will extend the session if I am the best person you are willing to provide these services in order to meet your treatment goalsdo so or we will make other arrangements by mutual consent. By the end If you do not reschedule an appointment within one month of this period of time, if I have not already done soour last session, I will assume that you have decided to discontinue treatment with me. Please be able assured that you are always welcome to offer you some impressions return regardless of what the work will include if you decide how much time has lapsed since our last session. Please confirm current fees with therapist: $170 for 45-minute sessions $200 for 60-minute sessions $230 for 75-minute sessions Additional time is billed at $50 per quarter hour. These fees are also billed for services such as telephone calls not related to continue with therapyscheduling, special reports, and collateral consultation. You are responsible for payment for each therapy session at the time of the session by cash, check or credit card. I do not participate in health insurance programs however I will provide you with an invoice with all the information needed should evaluate this information along you wish to file a claim directly with the insurance company. It is your own opinions responsibility to contact your insurance company to determine if an authorization for treatment is required and to communicate that requirement to me. During the course of whether you feel comfortable working treatment, it may become necessary to increase fees. Fees are reviewed in this way. You always maintain the right to ask about other treatments for January and about their risks and benefits. Once psychotherapy has begun, I usually schedule one 50-minute session (one appointment hour June of 50 minutes duration) per week at a time we agree upon. Based on your needs, some sessions may be longer or more frequent. Missed sessions present a special problem in therapy because the given hour is specifically blocked out for you and often can not be filled on short noticeeach year. If you must miss an appointment, please notify me as soon as possible at (▇▇▇) ▇▇▇-▇▇▇▇. I will try to find another time to reschedule the appointment. Unless you give 48 hours notice of your intention to miss the sessionbecome involved in legal proceedings that require my participation, you will be billed for the session. Insurance will not reimburse you for missed sessions. Sessions are 50 minutes long and are billed at the rate of $225 for individuals and $250 for couples and families. If this rate should change, you will be given at least 2 months notice. Longer or shorter sessions are pro-rated by prior mutual agreement. You will be expected to pay for each session at all of my professional time and expenses, including preparation costs, transportation costs, and attorney’s fees, even if I am called to testify by another party. My professional time related to these activities is $350 per hour. Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call on the time it is held unless we arrange for monthly ▇▇▇▇▇▇▇▇same day you make it, with the exception of weekends and holidays. If you are unable to reach me and feel that you can’t wait for any reason me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you should become involved in legal action with the name of a colleague to contact, if necessary. It is very important to be aware that requires computers and email and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. If you communicate confidential or private information via email or text, I will assume that you have made an informed decision, will view it as your therapist agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via email or other counseling clinical staff to protect your privilege of confidentiality or testify on your behalf, you must agree to cover legal expenses and the therapist's timetext. I Please do not agree use email or text for emergencies. Due to take on any cases where there is an established legal case computer or where you would expect me to testify in any such case. Our contract is for treatment purposes only. In the rare case of your records being subpoenaed by the courtsnetwork problems, you will emails and texts may not be expected to cover the cost incurred by me for the processing of the recordsdeliverable, and I may not check my emails or faxes frequently.

Sessions. The first few Each individual session lasts 45 or 60 minutes and family sessions will involve an evaluation of are 60 minutes. If you are late for a session, that time is lost from your needssession. During this timeIf I am late for a session, we can both decide will extend the session if you are willing to do so or we will make other arrangements by mutual consent. Please note my snow policy: I am do not follow ▇▇▇▇▇▇▇▇▇▇ County’s snow policy. Unless you hear from me in the best person to provide these services in order to meet your treatment goals. By the end of this period of time, if I have not already done somorning, I will assume that we will be able to offer you some impressions of what the work will include if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working in this way. You always maintain the right to ask about other treatments for and about their risks and benefits. Once psychotherapy has begun, I usually schedule one 50-minute session (one appointment hour of 50 minutes duration) per week at a time we agree upon. Based on your needs, some sessions may be longer or more frequent. Missed sessions present a special problem in therapy because the given hour is specifically blocked out for you and often can not be filled on short noticemeeting. If you must miss an appointmentcannot make it to the appointment for weather reasons, please notify call or email me as soon as possible at by 8:00 a.m. (301-652-1582 or ▇▇▇) ▇▇@▇▇▇-▇▇▇▇▇▇▇▇▇-▇▇▇▇▇.▇▇▇) and I will waive the 24-hour cancellation fee. If you do not reschedule an appointment within one month of our last session, I will assume that you have decided to discontinue treatment with me. Please be assured that you are always welcome to return regardless of how much time has lapsed since our last session. Current fees are as follows: $ for 45-minute sessions Additional time is billed at $45 per quarter hour. These fees are also billed for services such as telephone calls not related to scheduling, special reports, and collateral consultation. You are responsible for payment for each therapy session at the time of the session by cash, check or credit card. I do not participate in health insurance programs however I will try provide you with an invoice with all the information needed should you wish to find another time file a claim directly with the insurance company. It is your responsibility to reschedule contact your insurance company to determine if an authorization for treatment is required and to communicate that requirement to me. During the appointmentcourse of treatment, it may become necessary to increase fees. Unless Fees are reviewed in January and June of each year. If you give 48 hours notice of your intention to miss the sessionbecome involved in legal proceedings that require my participation, you will be billed for the session. Insurance will not reimburse you for missed sessions. Sessions are 50 minutes long and are billed at the rate of $225 for individuals and $250 for couples and families. If this rate should change, you will be given at least 2 months notice. Longer or shorter sessions are pro-rated by prior mutual agreement. You will be expected to pay for each session all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. [Because of the difficulty of legal involvement, I charge $700 per hour for preparation and attendance at any legal proceeding.] Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call on the time it is held unless we arrange for monthly ▇▇▇▇▇▇▇▇same day you make it, with the exception of weekends and holidays. If you are unable to reach me and feel that you can’t wait for any reason me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you should become involved in legal action with the name of a colleague to contact, if necessary. It is very important to be aware that requires computers and email and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. If you communicate confidential or private information via email or text, I will assume that you have made an informed decision, will view it as your therapist agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via email or other counseling clinical staff to protect your privilege of confidentiality or testify on your behalf, you must agree to cover legal expenses and the therapist's timetext. I Please do not agree use email or text for emergencies. Due to take on any cases where there is an established legal case computer or where you would expect me to testify in any such case. Our contract is for treatment purposes only. In the rare case of your records being subpoenaed by the courtsnetwork problems, you will emails and texts may not be expected to cover the cost incurred by me for the processing of the recordsdeliverable, and I may not check my emails or faxes frequently.

Sessions. The first few sessions will involve I normally conduct an evaluation of your needsthat will last from 2 to 4 sessions. During this time, we can both decide if I am the best person to provide these the services you need in order to meet you or your child’s treatment goals. By the end of this period of time, if I have not already done soIf psychotherapy is begun, I will be able to offer you some impressions of what the work will include if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working in this way. You always maintain the right to ask about other treatments for and about their risks and benefits. Once psychotherapy has begun, I usually schedule one one, 50-minute session (one appointment hour of 50 minutes duration) per week or every other week at a time we agree upon. Based on your needson, although some sessions may be longer or more frequent. Missed sessions present a special problem in therapy because the given hour Once an appointment session is specifically blocked out scheduled, you will be expected to pay for it unless you and often can not be filled on short noticeprovide 24 hours advance notice of cancellation or unless we both agree that you were unable to attend due to circumstances beyond your control. If you must miss an appointment, please notify me as soon as possible at (The per session fee for ▇▇▇) ▇▇▇-. ▇▇▇▇▇▇▇▇▇▇ is $▇▇▇.▇▇.▇▇▇ will be expected to pay for each session at the time it is held by credit card, check, or cash. Clients are expected to pay the session fee at the end of each session unless other arrangements have been made. Each appointment lasts approximately 50 minutes. In addition to regular appointments, I charge this amount for other professional services you may need, though I will try to find another break down the hourly cost if I work for periods less than one hour. Other services include report-writing, assessment, telephone conversations lasting longer than 10 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time to reschedule spent performing any other service you may request of me. Please be aware that some of these services will not be covered by your insurance and you will be responsible for the appointmentfees. Unless If you give 48 hours notice of your intention to miss the sessionbecome involved in legal proceedings that require my participation, you will be billed expected to pay for all of my professional time, including preparation and transportation costs. Because of the difficulty of legal involvement, we will charge more per hour for preparation and attendance at any legal proceeding. Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail. I will make every effort to return your non-emergency call within 48 hours, with the exception of weekends and holidays. If you are unable to reach me and believe you cannot wait for me to return your call, contact your family physician or the nearest emergency room and ask for the sessionpsychologist or psychiatrist on call, or dial 911. Insurance If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. Please do not use email or faxes for emergencies. I do not always check my e-mail daily. It is very important to be aware that computers and unencrypted e-mail, texts, and e- faxes communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. E-mails, texts, and e- faxes, in particular, are vulnerable to such unauthorized access due to the fact that servers or communication companies may have unlimited and direct access to all e-mails, texts and e- faxes that go through them. While my computers are password protected, e-mails and e-fax are not encrypted. It is always a possibility that e-faxes, texts, and email can be sent erroneously to the wrong address and computers. Voicemail messages are kept confidential as well, and accessed only by myself or another licensed psychologist that covers my practice in my absence. Please notify me if you decide to avoid or limit, in any way, the use of e-mail, texts, cell phones calls, phone messages, or e-faxes. If you communicate confidential or private information via unencrypted e-mail, texts or e-fax or via phone messages, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted. Please do not use texts, e- mail, or faxes for emergencies. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can release only information 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. Your signature on this Agreement provides consent for those activities, as follows: ● I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you do not object, I will not reimburse tell you about these consultations unless I believe that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). ● If a patient seriously threatens to harm himself/herself, I may be obligated to seek hospitalization for missed him/her, or to contact family members or others who can help provide protection. There are some situations where I am 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 your diagnosis and treatment, such information is protected by the psychologist- patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. ● If a government agency is requesting the information for health oversight activities, I may be required to provide it for them. ● If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. ● If a patient files worker’s compensation claim, I must, upon appropriate request, provide records relating to treatment or hospitalization for which compensation is being sought. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice. ● If I have cause to believe that a child who I am evaluating may be abused or neglected (including physical injury, substantial threat of harm, mental or emotional injury, or any kind of sexual contact or conduct), the law requires that I make a report to the appropriate governmental agency, usually the Department of Public Welfare. Once such a report is filed, I may be required to provide additional information. ● If I have reason to believe that an elderly person or other adult is in need of protective services (regarding abuse, neglect, exploitation, or abandonment), the law allows me to report this to appropriate authorities, usually the Department of Aging, in the case of an elderly person. Once such a report is filed, I may be required to provide additional information. ● If I believe that one of my patients presents a specific and immediate threat of serious bodily injury regarding a specifically identified or a reasonably identifiable victim and he/she is likely to carry out the threat or intent, I may be requires to take protective actions, such as warning the potential victim, contacting the police, or initiating proceedings for hospitalization. If such a situation arises, I will make every effort to fully discus it with you before taking any action and I will limit my disclosure to what is necessary. 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, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. The law and standards of my profession require that I keep Protected Health Information about you in your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone. Except in unusual circumstances that involve danger to yourself and/or others, 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 I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon your request. In addition, I may or may not also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the content of our conversations, my analysis of those conversations, and how they impact you in therapy. These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including companies without your written, signed Authorization. HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of Protected Health Information. These rights include requesting that I amend your record, requesting restrictions on what information from your Clinical Record 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; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached notice form, or any of my privacy policies and procedures. I am happy to discuss any of these rights with you. Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is my policy to request an agreement from the patient and his/her parents that the parents consent to give up their access to their child’s records. If they agree, during treatment, I will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. Sessions are 50 minutes long I will also provide parents with a summary of their child’s treatment when it is complete. Any other communications will require the child’s authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and are billed at the rate of $225 for individuals and $250 for couples and families. If this rate should change, you will be given at least 2 months notice. Longer or shorter sessions are pro-rated by prior mutual agreementdo my best to handle any objections he/she may have. You will be expected to pay for each session at the time it is held held, unless we arrange agree otherwise. Payment schedules for monthly ▇▇▇▇▇▇▇▇. If for any reason you should become involved in legal action that requires your therapist or other counseling clinical staff professional services will be agreed to protect your privilege of confidentiality or testify on your behalf, you must agree to cover legal expenses and the therapist's time. I do not agree to take on any cases where there is an established legal case or where you would expect me to testify in any such case. Our contract is for treatment purposes onlywhen they are requested. In the rare case circumstances of your records being subpoenaed by the courtsunusual financial hardship, you will I may be expected willing to cover the cost incurred by me for the processing of the recordsnegotiate a fee adjustment.