If your counseling is being paid through an Employee Assistance Program, please list the authorization number and number of sessions authorized.
Other Information
Health Information
Drug & Alcohol Assessment
Other Substance Assessment
Children & Adolescents
Marital Information
If you need to reschedule an appointment, 48 hours notice is required. If you have an emergency or illness, you can reschedule with less than 24 hours notice. If you do not show up for a scheduled time, for any reason, and provide no notice (latest notice can be 15 minutes past scheduled session start time) your credit card will be charged $450.00 & we will not make up that time. A credit card is required and processed on the day of missed appointment or if it is agreed as a payment for services. If I need to reschedule, I will give you at least 48 hours notice as well, barring an emergency or illness.
When there is a reasonable suspicion of abuse to a child, dependent or elder adult. When the client or a credible third party communicates a serious threat of harm to others.
When the psychotherapist believes the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a reasonably foreseeable visit(s) When the therapist has a reasonable belief that the client may be a danger to themselves, others or property of others.
A weekly commitment to therapy is expected unless an emergency or sudden illness. If there are several cancellations you may be referred out unless we are making closure.
The Patriot Act of 2001 may require therapists in certain circumstances to provide FBI agents with records and prohibits the therapist from disclosing to the patient that the FBI sought or obtained patient records. When disclosure is otherwise required by law.
ADDRESS CHANGES
Please advise if you change your address, telephone number, place of employment or insurance coverage or companies.
LITIGATION CHARGES
If I am required to attend a deposition, hearing or other legal proceeding in the capacity of your current or past therapist, you will be billed at $495 per hour for me I speak at the legal proceeding.my time, including preparation, telephone, and travel time.
Consider someone you know who may benefit from a referral for Counseling or Coaching. It is a wonderful complement. I thank you in advance. I HAVE READ AND UNDERSTAND THESE OFFICE POLICIES.
TELEHEALTH VIA VIDEO CONFERENCING AGREEMENT
After intake and the establishment of a therapeutic relationship, it may be possible for treatment delivery to occur via interactive video-conferencing (i.e., virtual “face-to-face” sessions) in lieu of, or in addition to, “in-person” sessions. Video conferencing (VC) is a real-time interactive audio and visual technology that enables our clinicians to provide mental health services remotely. The VC system we use (zoom) meets HIPAA standards of encryption and privacy protection but we cannot guarantee privacy. You will not have to purchase a plan or provide your name when you “join” our online meeting. Treatment delivery via VC may be a preferred method due to convenience, distance, or other circumstances. Although VC may be used when the clinician and client are in different locations, licensure regulations only allow a session to be conducted in the state in which the clinician is licensed and the client is located. An occasional exception can be made if temporary permission is available from another state. Telehealth via video conferencing may be a particularly beneficial way to conduct therapy when the client and clinician are in different locations. Risks to VC in general may include (but are not limited to): lack of reimbursement by your insurance company, the technology dropping due to internet connections, delays due to connections or other technologies, or a breach of information that is beyond our control. Clinical risks will be discussed in more detail with your clinician, but may include discomfort with virtual face-to-face versus in-person treatment, difficulties interpreting nonverbal communication, and importantly, limited access to immediate resources if risk of self-harm or harm to others becomes apparent. Your clinician will weigh these advantages against any potential risks prior to proceeding with telehealth sessions and will discuss the specifics of telehealth with you before using the technology. By signing the document below (page 2), you are stating that you are aware that your provider may contact your emergency contact person or the necessary authorities in case of an emergency. You are also acknowledging that if you believe there is imminent harm to yourself or another person, you will seek care immediately through your own local health care provider or at the nearest hospital emergency department or by calling 911. Below, please include the names and telephone numbers of your local emergency contacts (including local physician; crisis hotline; trusted family, friend, or confidant).
