Office Policies & Consent to Treatment

 

Download, print & sign this form (click here) or fill out the form below to consent to treatment.

 

CONFIDENTIALITY: All information and your working relationship with me will be kept strictly confidential, except if:

  • You authorize the release of information.
  • I am ordered by court to release information.
  • You present the risk of physical harm to your self or others.
  • Child, dependent adult, or elder abuse is suspected.
  • In the latter two cases I am required by law to inform potential victims and/or legal authorities so that protective measures can be taken.

LITIGATION LIMITATIONS: In the case that you should be involved in a court case such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc. neither you nor your attorney, nor anyone else acting on your behalf will call on me to testify in court or at any other proceedings, nor will a disclosure of the psychotherapy records be requested.

FEES & PAYMENT METHODS: I accept electronic payment through my online billing platform, check or cash. Fees are billed on a weekly basis.

INSURANCE: Services may be covered by your health insurance or employee benefit plan. If you do have coverage, I am happy to give you an invoice to submit to your provider. If you have insurance, my contract remains with you and not with your insurance provider. Insurance companies do not reimburse all issues/conditions/problems, which are the focus of psychotherapy. It is your responsibility to verify the specifics of your coverage. I will provide a monthly statement that will contain all information required by your insurance provider should you choose to submit for reimbursement.

CANCELLATIONS: I will hold your therapy hour as yours each week. If you need to cancel or reschedule your regular session time, please let me know as soon as possible. I will do my best to find another time to the extent that I am available. You are responsible for paying your full session fee if you cancel within 48 hours of your scheduled session time for any reason.

  • Type your name to agree to the above terms.
  • Date Format: MM slash DD slash YYYY

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Clinical Member