Practice Policies
Welcome to my practice. In order to save time, I ask prospective patients to print out this form, read it over, sign it and bring it to your initial session. This document contains important information about my professional services and business policies. Please read it carefully and feel free to ask questions. Once you sign this document it will serve as an agreement between us. Should you choose, you may revoke your consent at any time.
 | If a patient states that they intend to harm themselves or another, the therapist has an obligation to report such information to the proper authorities. |
| If a patient is a minor fourteen years of age or older, the parent and the child will need to sign a release of information for the therapist to disclose information to insurance companies, schools etc... |
| Insurance companies require information for reimbursement and may forward this information to your primary physician that may include your treatment plan, diagnosis and progress in treatment. |
| Periodically the therapist may consult about a patient’s progress in treatment with another mental health professional. |
| My standard fee is $150.00 per therapeutic hour. The initial evaluation is $200.00. |
| Reports and letters are charged based on my hourly rate. So, for example, if a letter to a lawyer or school official takes a half an hour to prepare, the charge is $75.00 to be paid prior to mailing. |
| Sometimes patients do not pay their proper fees and the fee amount along with their name and address, after three notices, will be sent to a collection agency for collection. |
| If a patient cancels within 24 hours, they will be charged the therapist’s full fee of $150.00 per hour. This charge is not reimbursable by insurance companies. (For the first, and hopefully only missed appointment, I will charge a $35.00 cancellation fee; for sessions missed after that, I will charge my full fee.) |
| A treatment hour includes 45 minutes for therapy and 15 minutes for the therapist to prepare treatment notes and plans. |
| I have no waiting room: Please arrive on time. Patients dropped off are to be picked up when the 45 minute session has ended. |
| This is a home office with a gentle dog-- Patients/Guardian's need to inspect the premises and accept full legal and medical responsibility for any unforeseen incident that may occur before, after and during treatment. The therapist will not be held responsible for any incidents that may lead to injury. |
| Most appointments are made at a set time each week. If a last minute cancellation is due to an emergency, they will still be charged for that hour but, at the therapist's discretion, may be given an opportunity to re-schedule for another hour within a two week period. |
| The patient is fully responsible for the fee whether or not the insurance company pays or fails to pay for sessions. |
| The patient is fully responsible for the co-pay and must contact the insurance company about what the co-pay, deductible or other uncovered fees are. |
| The session fee is collected at the start of each session. |
| Please make arrangements to have extra potential baby sitters on call. Not having a sitter is not considered an emergency. |
| Please anticipate days that are difficult to leave from work or commuting delays. |
Please Print this out and bring it signed to initial session.
I have read, discussed all concerns, and agree to comply to the terms noted above:
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Patient/Guardian's Signature and Date.
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Witness and Date.