Informed Consent for Psychotherapy

General Information

The therapeutic relationship is unique in that it is highly personal and at the same time, a contractual

agreement. Given this, it is important for us to reach a clear understanding about how our relationship will

work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel

free to discuss any of this with me. Please read and indicate that you have reviewed this information and

agree to it by signing at the bottom of this page.

The Therapeutic Process

You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends

largely on your willingness to engage in this process, which may, at times, result in considerable discomfort.

Remembering unpleasant events and becoming aware of feelings attached to those events can bring on

strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your

behavior or circumstances will change. I can promise to support you and do my very best to understand you

and repeating patterns, as well as to help you clarify what it is that you want for yourself.

Confidentiality

The session content and all relevant materials to the client's treatment will be held confidential unless the

client requests in writing to have all or portions of such content released to a specifically named

person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:

• If a client threatens or attempts to commit suicide or otherwise conducts him/herself in a manner in

which there is a substantial risk of incurring serious bodily harm.

• If a client threatens grace bodily harm or death to another person.

• If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator,

observer of, or actual victim of physical, emotional, or sexual abuse or neglect of children under the age

of 18 years.

• Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.

• If your insurance company is involved, e.g. in filing a claim, insurance audits, case review or appeals, etc.

• If a court of law issues a legitimate court order by a judge for information states on the court order...as

required by law.

Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the

best treatment for you. Information about you may be shared in this context without using your name.

You may be asked to sign a Release of Information so that I may speak with other healthcare professionals or

to family members.

If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to

privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy.

However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it

appropriate not to engage in any lengthy discussions in public or outside of the therapy office.

Appointments and Cancellations

Please remember to cancel or reschedule your session 24 hours in advance. You will be responsible for the

entire fee ($125) if cancellation is less than 24 hours. Bearing in mind, I am aware that emergencies and

sickness happens. However, I ask that you respect my time, as I respect your time.

The standard meeting time for psychotherapy is 55 minutes. This means that we mutually respect each

other's time and we are SIGNING OFF of the session at the 55 minute mark. I ask that we adhere to this

timeline as closely as possible because going over time, not only means that I don't get any breaks between

sessions to eat, use the bathroom, let my dogs out, etc. But it also means that it is cutting into the next

individual's session time. If your session goes over the 55 minutes, you will be billed for an additional 30

minutes for "crisis" and the charge will be private pay (insurance does not cover this additional time) at the

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rate of $63.

You can request to have your session time (recognizing anything over 55 minutes will be charged private pay)

- however, this needs to be discussed with the therapist beforehand to allow for the therapist to schedule the

appropriate time.

Multiple sessions in one week may be covered by insurance on a "medical necessity" basis. This means that

while insurance may cover it for several weeks, they ultimately can determine that they will no longer cover it,

and at that point in time - we would need to explore a lower frequency of sessions, or you paying privately for

additional sessions that are not covered by insurance.

Private pay fees are as follows: $150 for the initial session, $125 for 55 minute sessions, $113 for 45 minute

sessions, and $63 for 30 minute sessions. As mentioned above, the no show/late cancelation rate is $125

(the full session fee). In addition to regular appointments, I charge $125 per hour for other professional

services you may need. These professional services, such as ESA letters, accommodations letters, court

letters, etc. (any professional service that requires me to commit time to) are billed based on my private pay

hourly rate as these are not services covered by insurance. Please be aware of this and refer to the Private

Pay sheet for more information.

I require a credit card/debit card/HSA card to be kept on file within the EHR systems (Alma and Sessions

Health). If at any point your payment method on file becomes no longer valid, services will be paused until an

updated method is placed on file. It is encouraged that individuals enroll in autopay for private pay and copay

charges. If you choose not to enroll in autopay, you are responsible for logging into your portal and providing

payment for your session immediately upon completion of the session. An outstanding balance of more then

14 days will result in a pause in services and a personal email reminder. An outstanding balance of 30 days or

more will result in further action including, but not limited to, the outstanding balance being sent to

collections. If you are having difficulty paying your balance, please reach out to me directly and we can work

out a mutually agreed upon payment plan.

Telephone Accessibility

If you need to contact me between sessions, please leave me a message on my voicemail or send me a

message via our HIPAA compliant EHR (Sessions Health) through your client portal. I am often not

immediately available; however, I will attempt to get back to you within 24 hours. If you are in need of

immediate contact, please call 911, or any local emergency room. Anything that needs to be discussed

between sessions requiring more than a 5 minute phone call, needs to be scheduled and is subject to being

charged.

Social Media and Telecommunication

Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not

accept friend or contact requests from current or former clients on any social networking site (Facebook,

Instagram, Snapchat, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can

compromise your confidentiality and our respective privacy. It may also blur the boundaries of our

therapeutic relationship. If you have questions about this, please bring them up when we meet and we can

talk more about it.

Electronic Communication

I cannot ensure the confidentiality of any form of communication through electronic media, including text

messages. If you prefer to communicate via email and text messaging for issues regarding scheduling or

cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee

immediate response and request that you do not use these methods of communication to discuss therapeutic

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content and/or request assistance for emergencies.

For cancellations or reschedules, the preferred method of working through that would be to utilize your

patient portal through the EHR (Sessions Health) to cancel and/or reschedule your own sessions in

compliance with my availability. If you do not see any availability, at that point, you are welcome to send me a

message via the EHR or email/text should you choose to utilize email/text message communication.

Minors

If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss

with you and your parents what information is appropriate for them to receive and which issues are more

appropriately kept confidential. If the minor is 12 years old, or younger, I REQUIRE at least once monthly

sessions with parents only to discuss progress. Please refer to the Minor Confidentiality Form.

Termination

Ending relationships can be difficult. Therefore, it is important to have a termination process in order to

achieve some closure. The appropriate length of the termination depends on the length and intensity of the

treatment. I may terminate treatment after appropriate discussion with you and a termination process if I

determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not

terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of

terminating. If therapy is terminated for any reason and you request another therapist, I will provide you with

a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another

referral source.

Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have

been made in advance, for legal and ethical reasons, I must consider the professional relationship

discontinued. In addition to that, if you late cancel or no show twice in a 30 days period, I must also consider

the professional relationship discontinued. In both cases, you will receive an email stating the nature of the

discontinuation, a list of local referrals and your patient portal will be moved to inactive.

2025 Updated Practice Policies

Private pay rates are subject to increase January 1, 2025 which would then change the no show/late

cancellation fee, as well as the fee for other professional services, and all other private pay services. This will

be communicated should the rates change.

Please sign below that you have read, understand, and agree to the Informed Consent for Psychotherapy

practices contained herein.