The following information is given to provide a clear mutual understanding of the professional
and business aspects of our relationship. Please read this information carefully, and feel free
to ask questions or express any concerns you may have.
When you sign this document, it will also represent an agreement between us. We can discuss
any questions you have when you sign or at any time in the future.
I. GENERAL INFORMATION
A. Psychological Services
Psychotherapy varies depending on the personalities of therapist and client, particular issues
being addressed, length of treatment, and strategies used. Psychotherapy has both benefits and
risks. Risks may include experiencing uncomfortable feelings and/or working with unpleasant
life events. Psychotherapy often leads to significant reduction of distress, better relationships,
and resolution of specific problems. Success in therapy requires hard work on your part,
both during and between sessions.
B. Goals of Counseling
Counseling goals may be long-term (improving life quality, mindfulness, self-actualization)
or immediate (reducing anxiety, depression, improving relationships, changing behavior,
reducing substance use). You set your goals; I may offer suggestions on achieving them.
C. Intake and Assessment
During initial sessions we will:
- Discuss your presenting concerns.
- Get to know one another and determine treatment fit.
- Review special circumstances affecting care.
- Determine whether therapy together is appropriate.
- Set appointment schedules.
- Discuss additional evaluations if needed.
- Secure necessary releases of information.
D. Confidentiality
Confidentiality is protected by law except in specific situations such as:
1. Judicial Proceedings
- A judge may require testimony in certain legal cases.
- Litigation where emotional state is introduced may require documentation.
- Criminal cases may allow limited access to records.
- Court-ordered evaluations & malpractice cases may require disclosure.
2. Harm to Self or Others
- Mandatory reporting of abuse of children, elderly, or disabled persons.
- Duty to warn if client threatens harm to others.
- Required protective steps when client is suicidal.
3. Consultation and Supervision
Case consultation may occur; client identity is protected as much as possible.
4. Confidentiality and Technology
Online sessions (telehealth, email, text, phone) involve risks of unauthorized access.
Clients are encouraged to safeguard communication devices.
E. Professional Records
Records are maintained for continuity of care and preserved for at least 7 years.
F. Client Rights
You have rights including:
- Information about therapy.
- Consultation with another professional.
- Right to terminate therapy.
- Anti-discrimination protections.
G. Payment and Professional Fees
Fees are due at time of service. Payment may be made by cash, check, Venmo, or credit card.
Balances over 60 days incur finance charges. Collections may be used if needed.
H. Scheduling
Missed sessions without 48-hour notice will be billed. Insurance does not cover missed visits.
Efforts will be made to reschedule, but availability cannot be guaranteed.
I. Insurance and Fees
I am out-of-network for several plans. With permission, I can assist with understanding coverage.
Using insurance authorizes disclosure of clinical information when required by insurer.
Session fee: $175 per 50 minutes.
J. Contacting Me
Calls are returned same day when possible. In emergencies, call 911 or visit the nearest emergency room.
Your signature below indicates that you have read this entire Agreement, understand it,
and agree to its terms. It also confirms receipt of privacy practices and HIPAA information.