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Policies
I
look forward to working with you. 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 he/she intends
to harm himself or herself, or another individual, 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
therapy 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:
__________________________
Patient/Guardian's
Signature and Date.
__________________________
Witness
and Date.
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