Common use of Client Privilege Clause in Contracts

Client Privilege. The information disclosed by Client, as well as any records created, is subject to the psychotherapist- client privilege. The psychotherapist-client privilege results from the special relationship between Therapist and Client in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the client is the holder of the psychotherapist-client privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-client privilege on Client's behalf. When a client is a minor child, the holder of the psychotherapist-client privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-client privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-client privilege with his/her attorney. Client, or Representative, should be aware that he/she might be waiving the psychotherapist-client privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Client, or Representative, should address any concerns he/she might have regarding the psychotherapist-client privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $120.00 per 50- minute session and $150.00 per 90- minute session. Therapist reserves the right to periodically adjust this fee. Representative will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. From time-to-time, Therapist may engage in telephone contact with Client or Representative for purposes other than scheduling sessions. Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at the request of Client or Representative and with the advance written authorization of Client or Representative. Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Representative is expected to pay for services at the time services are rendered. Therapist accepts cash, checks, and major credit cards.

Client Privilege. The information disclosed by Client, as well as any records created, is subject to the psychotherapist- client psychotherapist-Client privilege. The psychotherapist-client Client privilege results from the special relationship between Therapist and Client in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient Client privilege. Typically, the client Client is the holder of the psychotherapist-client psychotherapist- Client privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-client Client privilege on Client’s behalf until instructed, in writing, to do otherwise by a person with the authority to waive the privilege on Client's behalf. When a client Client is a minor child, the holder of the psychotherapist-client Client privilege is either the minor, a court appointed guardian, or a minor’s 's counsel. Parents typically do not have the authority to waive the psychotherapist-client Client privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-client Client privilege with his/her attorney. Client, or Representative, should be aware that he/she might be waiving the psychotherapist-client Client privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Client, or Representative, should address any concerns he/she might have regarding the psychotherapist-client psychotherapist- Client privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $120.00 130 per 50- 50-minute session of Individual Therapy and $150.00 per 90- minute sessionFamily Therapy. Sessions longer than 50-minutes are charged for the additional time pro rata. Most of the work Therapist does with a minor child is going to be in the Family Therapy format, and may be split with the Client and Representatives, and/or Client together with Representatives and other family members. These sessions will all be billed as Family Therapy. Therapist reserves the right to periodically adjust this fee. Representative will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. The agreed upon fee between Therapist and Representative is [insert usual and customary fee, or other agreed upon fee] . Therapist reserves the right to periodically adjust fee. Representative will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Client or Representative for purposes other than scheduling sessions. Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten fifteen minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at the request of Client or Representative and with the advance written authorization of Client or Representative. Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten fifteen minutes. Representative is expected to pay for services at the time services are rendered. Therapist accepts cash, checks, and major credit cards, including Visa, Mastercard, Discover, and American Express. There will be a $25 fee assessed on all returned or cancelled checks. If Representative has a returned or cancelled check, Therapist may request that Representative use a different method of payment for future services.

Client Privilege. The information disclosed by Client, as well as any records created, is subject to the psychotherapist- psychotherapist-client privilege. The psychotherapist-client privilege results from the special relationship between Therapist and Client in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient client privilege. Typically, the client is the holder of the psychotherapist-client privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-client privilege on Client's behalf’s behalf until instructed, in writing, to do otherwise by Client or Client’s representative. When a client is a minor child, the holder of the psychotherapist-client privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-client privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-client privilege with his/her attorney. Client, or Representative, Client should be aware that he/she might be waiving the psychotherapist-client privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Client, or Representative, Client should address any concerns he/she might have regarding the psychotherapist-client privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $120.00 120 per 50- minute session and $150.00 per 90- 45-minute session. Sessions longer than 45-minutes are charged for the additional time pro rata. Therapist reserves the right to periodically adjust this fee. Representative Client will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. The agreed upon fee between Therapist and Client is [insert usual and customary fee, or other agreed upon fee] ______________. Therapist reserves the right to periodically adjust fee. Client will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Client or Representative for purposes other than scheduling sessions. Representative Client is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at the Client’s request of Client or Representative and with the Client’s advance written authorization of authorization. Client or Representative. Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Representative is Clients are expected to pay for services at the time services are rendered. Therapist accepts cash, checks, debit cards and major credit cards. Insurance Client is responsible for any and all fees not reimbursed by his/her insurance company, managed care organization, or any other third-party payor. Client is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments and deductibles. Therapist is a contracted provider with the following companies: Anthem/Blue Cross, Magellan/Blue Shield, Value Options/Beacon, Military One Source, Humana, The Xxxxxx Group and some EAPs and has agreed by contract to a specified fee. Other insurance companies may have “out of network” clauses that will allow for reimbursement. If Client intends to use benefits of his/her health insurance policy, Client agrees to inform Therapist in advance.

Client Privilege. The information disclosed by Client, as well as any records created, is subject to the psychotherapist- psychotherapist-client privilege. The psychotherapist-client privilege results from the special relationship between Therapist and Client in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient client privilege. Typically, the client is the holder of the psychotherapist-psychotherapist- client privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-client privilege on Client's behalf’s behalf until instructed, in writing, to do otherwise by Client or Client’s representative. When a client is a minor child, the holder of the psychotherapist-client privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-client privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-client privilege with his/her attorney. Client, or Representative, Client should be aware that he/she might be waiving the psychotherapist-client privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Client, or Representative, Client should address any concerns he/she might have regarding the psychotherapist-client privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $120.00 150 per 50- minute session and $150.00 per 90- 45-minute session. Sessions longer than 45- minutes are charged for the additional time pro rata. Therapist reserves the right to periodically adjust this fee. Representative Client will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-third- party payors, or by agreement with Therapist. The agreed upon fee between Therapist and Client will be . From time-to-time, Therapist may engage in telephone contact with Client or Representative for purposes other than scheduling sessions. Representative Client is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at the Client’s request of Client or Representative and with the Client’s advance written authorization of Client or Representativeauthorization. Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Representative is Clients are expected to pay for services at the time services are rendered. Therapist accepts cash, checks, debit cards and major credit cards.

Client Privilege. The information disclosed by Client, as well as any records created, is subject to the psychotherapist- client psychotherapist Client privilege. The psychotherapist-client Client privilege results from the special relationship between Therapist and Client in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient Client privilege. Typically, the client Client is the holder of the psychotherapist-client Client privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-client Client privilege on Client's behalf’s behalf until instructed, in writing, to do otherwise by Client or Client’s representative. When a client is a minor child, the holder of the psychotherapist-client privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-client privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-client privilege with his/her attorney. Client, or Representative, Client should be aware that he/she might be waiving the psychotherapist-client psychotherapist- Client privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Client, or Representative, Client should address any concerns he/she might have regarding the psychotherapist-client Client privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $120.00 175 per 50- minute session and $150.00 per 90- 45-minute session. Sessions longer than 45-minutes are charged for the additional time pro rata. Therapist reserves the right to periodically adjust this fee. Representative Client will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-third- party payors, or by agreement with Therapist. The agreed upon fee between Therapist and Client is . Therapist reserves the right to periodically adjust his fee. Client will be notified of any fee adjustment in advance. A Client’s appointment is reserved exclusively for the Client. Client will be charged the full fee per session for any missed or cancelled appointments. Client Initials: Unless you have made special arrangements with Therapist, if Client misses two or more appointments in a row Therapist may not be able to hold the appointment time and Client may lose their time slot. From time-to-time, Therapist may engage in telephone contact with Client or Representative for purposes other than scheduling sessions. Representative Client is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at the Client’s request of Client or Representative and with the Client’s advance written authorization of authorization. Client or Representative. Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Representative All past due accounts which have not had payment activity for 30 days or more will be reviewed and may be referred to a collection agency. Collection fees may be added to these accounts. The Client, or responsible party, agrees to pay Xxxxxx Xxxxxxxx, MA, LMFT, any reasonable costs of collection, plus attorney fees and court costs in the event that legal action is required for collection of fees. Like many other mental health providers, Therapist has formal relationships only with some managed health care providers. These are Aetna and MHN. Therapist does accept referrals only from these managed health care providers and will otherwise only be accepting private pay clients. The reasons for this include the overwhelming administrative time spent in dealing with insurance companies and financial concerns. This means private pay clients are expected to pay full fee at the time services are rendered while managed health care clients are expected to pay their co-pay. A private pay client may wish to submit statements to their insurance companies, since some will provide limited reimbursement for “off-plan providers.” If Client submits a bill for reimbursement, Client needs to make it clear that the Client/Member is to be reimbursed, not the provider. Clients are expected to pay for services at the time services are rendered. Therapist accepts cash, checks, and major select credit cards.

Client Privilege. The information disclosed by Client, as well as any records created, is subject to the psychotherapist- client psychotherapist-Client privilege. The psychotherapist-client Client privilege results from the special relationship between Therapist and Client in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the client Client is the holder of the psychotherapist-client Client privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-client Client privilege on Client's behalf’s behalf until instructed, in writing, to do otherwise by Client or Client’s representative. When a client is a minor child, the holder of the psychotherapist-client privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-client privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-client privilege with his/her attorney. Client, or Representative, Client should be aware that he/she might be waiving the psychotherapist-client Client privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Client, or Representative, Client should address any concerns he/she might have regarding the psychotherapist-client Client privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $120.00 180 per 50- minute session and $150.00 per 90- 55-minute session. This fee is increased by $5 on the first of each year. At times, Therapist reserves may suggest sessions of other lengths, and if accepted by Client, these are billed at $250 for 85 minutes or $320 for 115 minutes. Special extended sessions beyond two hours are billed at the right to periodically adjust this hourly session fee. Representative Client will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. If Client wishes to use insurance benefits, a separate insurance fee consent will outline the fees specific to the individual’s plan. If Client does not wish to use insurance benefits, Client may choose to begin using benefits, if available, at any time in the future. Benefits utilization will begin at the time Therapist is provided policy information; no back-billing will be done. Therapist will bill primary insurance when the therapist is contracted with the insurance panel. For out of network and secondary insurance benefits, Therapist will provide a superbill that Client can use for reimbursement. From time-to-time, Therapist may engage in telephone contact with Client or Representative for purposes other than scheduling sessions. Representative Client is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at the Client’s request of Client or Representative and with the Client’s advance written authorization of authorization. Client or Representative. Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Representative is Clients are expected to pay for services at the time services are rendered. Therapist accepts cashall major credit cards, checks, and major credit cardscash (exact change only). There is a $35 returned check fee. Cancellation Policy Client is responsible for payment of the agreed upon fee for any missed session(s). Client is also responsible for payment of the agreed upon fee for any session(s) for which Client failed to give Therapist at least 24 hours notice of cancellation. Cancellation notice should be left on Therapist’s voice mail at 000-000-0000. Exceptions are made to the cancellation policy for illness or emergency, provided Therapist is notified as promptly as possible. Do not attend sessions if you are ill or if you have been exposed to individuals with coronavirus. If you are ill but still feeling well enough to attend a session, the session can be completed via telehealth. Termination of Therapy Therapist reserves the right to terminate therapy at his/her discretion. Reasons for termination include, but are not limited to, untimely payment of fees, failure to comply with treatment recommendations, conflicts of interest, failure to participate in therapy, Client needs are outside of Therapist’s scope of competence or practice, or Client is not making adequate progress in therapy. Client has the right to terminate therapy at his/her discretion. Upon either party’s decision to terminate therapy, Therapist will generally recommend that Client participate in at least one, or possibly more, termination sessions. These sessions are intended to facilitate a positive termination experience. Therapist will also attempt to ensure a smooth transition to another therapist by offering referrals to Client. If there has been no contact from Client for 30 days and no appointments are scheduled, the Client’s file will be closed. The file can be reopened at any time given adequate notice and Therapist availability. Therapist Availability Therapist has confidential voice mail that allows Client to leave a message at any time. Therapist will make every effort to return calls within 24 hours (or by the next business day), but cannot guarantee the calls will be returned immediately. Therapist is unable to provide 24-hour crisis service. In the event that Client is feeling unsafe or requires immediate medical or psychiatric assistance, he/she should call 911 or the county crisis line at 000-000-0000, or go to the nearest emergency room. Therapist Communications and Social Media Therapist may need to communicate with Client in between sessions. Email communication and text messaging is used only with Client permission and only for administrative purposes. That means that email exchanges and text messages should be limited to things such as setting and changing appointments, billing matters and other related issues. If Client chooses to communicate with Therapist by email, it should be with the understanding that all emails are retained in the logs of Client’s and Therapist’s Internet service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider. If Client chooses to use text messaging, it should be with the understanding that messages may be inadvertently seen by others, either by access to Client’s phone or via the preview window. Emails or text messages Therapist receives from Client and any responses may become a part of Client’s therapy record. Therapist does not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). In addition, if it is discovered that an online relationship has inadvertently been established, that relationship will be cancelled. This is because these types of casual social contacts can jeopardize Client confidentiality as well as the therapeutic relationship. Telehealth Sessions From time to time it may be appropriate to shift from in-person to telehealth sessions. There are potential risks and benefits unique to telehealth sessions. Potential benefits include easier access to therapy, continuity of care and a location that may be more convenient for Client. Potential risks include compromised confidentiality if Client participates in a telehealth session where there is the possibility of others overhearing the Client’s conversation. There are also potential risks related to the technology itself. There is a risk that there will be unauthorized access to the session, which will be mitigated by using a HIPAA-compliant platform whenever possible. If there is an interrupted transmission, the session will be completed via telephone. It is generally accepted that telehealth has similar efficacy as an in-person session, but there may be some limits to understanding of Client’s non-verbal communication. There are also challenges to addressing crises that arise during a session, which will be discussed on a case by case basis.

Client Privilege. The information disclosed by Clientyou, as well as any records created, is subject to the psychotherapist- psychotherapist-client privilege. The psychotherapist-client privilege results from the special relationship between Therapist and Client in the eyes of the lawClient. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the client is the holder of the psychotherapist-client privilege. If Therapist received I receive a subpoena for records, deposition testimony, or testimony in a court of law, Therapist I will assert the psychotherapist-client privilege on Client's behalfyour behalf until instructed, in writing, to do otherwise by you or your legal representative. When a client is a minor child, the holder of the psychotherapist-client privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-client privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-client privilege with his/her attorney. Client, or Representative, You should be aware that he/she you might be waiving the psychotherapist-client this privilege regarding your entire treatment if he/she makes his/her you make your mental or emotional state an issue in a legal proceeding. Client, or Representative, You should address any concerns he/she you might have regarding the psychotherapist-client privilege with his/her your attorney. Fee Client Litigation. I will not voluntarily participate in any litigation or custody dispute in which you and Fee Arrangements The another individual or entity are involved. While I generally have a policy of not communicating with clients’ attorneys and will generally not write or sign letters, reports, declarations, or affidavits to be used in any client’s legal matter, I will provide basic progress reports and other documentation to a probation or parole officer, judge, or lawyer IF it will serve the client favorably in a probation or parole situation. However, the time involved in the preparation of such reports or documentation will be billed to you. IN these instances, or should I be subpoenaed or ordered by a court of law to appear as a witness in an action involving you, you agree to reimburse me for any time spent for that preparation, travel time, or other time in which I have made myself available for such an appearance at my usual and customary fee for service is hourly rate of $120.00 100.00 per 50- minute session and $150.00 per 90- minute sessionhour. Therapist reserves the right to periodically adjust this fee. Representative will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. From time-to-time, Therapist may engage in telephone contact with Client or Representative for purposes other than scheduling sessions. Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at the request of Client or Representative and with the advance written authorization of Client or Representative. Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Representative is expected to pay for services at the time services are rendered. Therapist accepts cash, checks, and major credit cardsAvailability / Emergencies.

Client Privilege. The information disclosed by the Client, as well as any records created, is subject to the psychotherapist- psychotherapist-client privilege. The psychotherapist-client privilege results from the special relationship between the Therapist and the Client in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient client privilege. Typically, the client Client is the holder of the psychotherapist-client privilege. If the Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, the Therapist will assert the psychotherapist-client privilege on the Client's behalf’s behalf until instructed, in writing, to do otherwise by the Client or the Client’s representative. When a client is a minor child, the holder of the psychotherapist-client privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-client privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-client privilege with his/her attorney. Client, or Representative, The Client should be aware that he/she might be waiving the psychotherapist-client privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Client, or Representative, The Client should address any concerns he/she might have regarding the psychotherapist-client privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $120.00 per 50- minute session and $150.00 per 90- for a 50 minute session. Sessions longer than 50 minutes are charged for the additional time pro rata. The Therapist reserves the right to periodically adjust this fee. Representative The Client will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payorspayers, or by agreement with the Therapist. The agreed upon fee between the Therapist and the Client is . The Therapist reserves the right to periodically adjust fee. The Client will be notified of any fee adjustment in advance. From time-to-time to time, the Therapist may engage in telephone contact with the Client or Representative for purposes other than scheduling sessions. Representative The Client is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, the Therapist may engage in telephone contact with third parties at the Client’s request of Client or Representative and with the Client’s advance written authorization of authorization. The Client or Representative. Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Representative is Clients are expected to pay for services at the time services are rendered. The Therapist accepts cash, cash and checks, and major credit cards.

Client Privilege. The information disclosed by the Client, as well as any records created, is subject to the psychotherapist- psychotherapist-client privilege. The psychotherapist-client privilege results from the special relationship between the Therapist and the Client in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the client Client is the holder of the psychotherapist-client privilege. If the Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, the Therapist will assert the psychotherapist-client privilege on the Client's behalf’s behalf until instructed in writing to do otherwise by the Client or the Client’s representative. When a client is a minor child, the holder of the psychotherapist-client privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-client privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-client privilege with his/her attorney. Client, or Representative, The Client should be aware that he/she might be waiving the psychotherapist-psychotherapist- client privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Client, or Representative, The Client should address any concerns he/she might have regarding the psychotherapist-client privilege with his/her attorney. Fee and Fee Arrangements Arrangements: The usual and customary fee you are quoted is comparable to most of the Therapists in this area. The Client is expected to pay for services at the time services are rendered. It is asked that you pay your fee at the end of each session. Checks should be made payable to Xxxxxxxx Xxxxx. Please note: The Client is responsible for additional charges as the result of insufficient funds or other payment denial by the client’s bank or credit card institution (Typically $30.00). The fee for service services is $120.00 195.00 per 50- minute session and $150.00 per 90- 50-minute session. Sessions longer than 50 minutes are charged for the additional time pro rata (80 minutes @ $290.00). Assessments and Emergency Sessions may be subject to additional fees, which your therapist will advise you of prior to meeting with you. The Therapist reserves the right to periodically adjust this feefees. Representative The Client will be notified of any fee adjustment at least 30 days in advance. In addition, this Your fee may will be adjusted by contract with insurance companies, managed care organizations, or other thirdre-party payors, or by agreement with Therapistevaluated regularly and also at those times when your financial circumstances change. From time-to-time, the Therapist may engage in telephone contact with the Client or Representative for purposes other than scheduling sessions. Representative The Client is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten 10 minutes. In addition, from time-to-to- time, the Therapist may engage in telephone contact with third parties at the Client’s request of Client or Representative and with the Client’s advance written authorization of authorization. The Client or Representative. Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten 10 minutes. Representative is expected If the Client chooses to pay for services at by Mastercard or Visa the time services are rendered. Therapist accepts cash, checks, and major credit cardspayee on their statement will be Comprehensive Human Services Inc. This is the name of The Therapist’s Corporation.

Client Privilege. The information disclosed by the Client, as well as any records created, is subject to the psychotherapist- psychotherapist-client privilege. The psychotherapist-client privilege results from the special relationship between the Therapist and the Client in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the client Client is the holder of the psychotherapist-client privilege. If the Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, the Therapist will assert the psychotherapist-client privilege on the Client's behalf’s behalf until instructed in writing to do otherwise by the Client or the Client’s representative. When a client is a minor child, the holder of the psychotherapist-client privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-client privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-client privilege with his/her attorney. Client, or Representative, The Client should be aware that he/she might be waiving the psychotherapist-psychotherapist- client privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Client, or Representative, The Client should address any concerns he/she might have regarding the psychotherapist-client privilege with his/her attorney. Fee and Fee Arrangements Arrangements: The usual and customary fee you are quoted is comparable to most of the Therapists in this area. The Client is expected to pay for services at the time services are rendered. It is asked that you pay your fee at the end of each session. Checks should be made payable to Xxxxxxxx Xxxxx. Please note: The Client is responsible for additional charges as the result of insufficient funds or other payment denial by the client’s bank or credit card institution (Typically $30.00). The fee for service services is $120.00 190.00 per 50- minute session and $150.00 per 90- 50-minute session. Couples Counseling is $190.00 per 50-minute session. Sessions longer than 50 minutes are charged for the additional time pro rata (80 minutes @ $285.00) Family sessions are 80 minutes @ $285.00 per session. Assessments and Emergency Sessions may be subject to additional fees, which your therapist will advise you of prior to meeting with you. The Therapist reserves the right to periodically adjust this feefees. Representative The Client will be notified of any fee adjustment at least 30 days in advance. In addition, this Your fee may will be adjusted by contract with insurance companies, managed care organizations, or other thirdre-party payors, or by agreement with Therapistevaluated regularly and also at those times when your financial circumstances change. From time-to-time, the Therapist may engage in telephone contact with the Client or Representative for purposes other than scheduling sessions. Representative The Client is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten 10 minutes. In addition, from time-to-to- time, the Therapist may engage in telephone contact with third parties at the Client’s request of Client or Representative and with the Client’s advance written authorization of authorization. The Client or Representative. Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten 10 minutes. Representative is expected If the Client chooses to pay for services at by Mastercard or Visa the time services are rendered. Therapist accepts cash, checks, and major credit cardspayee on their statement will be Comprehensive Human Services Inc. This is the name of The Therapist’s Corporation.

Client Privilege. The information disclosed by Clientclient, as well as any records created, is subject to the psychotherapist- psychotherapist-client privilege. The psychotherapist-client patient privilege results from the special relationship between Therapist and Client client in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the client is the holder of the psychotherapist-client privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-client privilege on Client's behalf. When a client’s behalf until instructed, in writing, to do otherwise by client is a minor child, the holder of the psychotherapist-client privilege is either the minor, a court appointed guardian, or minorclient’s counsel. Parents typically do not have the authority to waive the psychotherapist-client privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-client privilege with his/her attorney. Client, or Representative, should be aware that he/she might be waiving the psychotherapist-client privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Client, or Representative, should address any concerns he/she might have regarding the psychotherapist-client privilege with his/her attorneyrepresentative. Fee and Fee Arrangements The usual and customary fee for service is $120.00 per 50- minute session and $150.00 per 90- 50-minute session. Sessions longer than 50- minutes are charged for the additional time pro rata. Therapist reserves the right to periodically adjust this fee. Representative Client will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. From time-to-time, Therapist may engage in telephone contact with Client or Representative for purposes other than scheduling sessions. Representative Client is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at the Client’s request of Client or Representative and with the Client’s advance written authorization of authorization. Client or Representative. Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Representative is * Clients are expected to pay for services at the time services are rendered. Therapist accepts cash, checkschecks and money orders Insurance Patient is responsible for any and all fees not reimbursed by his/her insurance company, managed care organization, or any other third-party payor. Patient is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments and deductibles. Therapist is a contracted provider with the following companies: Beacon Health Strategies, Medi-Cal, Partnership HealthPlan of California, Optum Behavioral Health, Xxxxxx Health Plus, United Behavioral Health , and major credit cardshas agreed to a specified fee. If Patient intends to use benefits of his/her health insurance policy, Patient agrees to inform Therapist in advance.

Client Privilege. The information disclosed by Client, as well as any records created, is subject to the psychotherapist- client privilege. The psychotherapist-client privilege results from the special relationship between Therapist and Client in the eyes of the lawprivilege. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the client is the holder of the psychotherapisttherapist-client privilege. If Therapist therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapisttherapist asserts the therapist-client privilege on Client's behalf. When a client is a minor child, the holder behalf of the psychotherapist-client, until instructed, in writing, to do otherwise by client privilege is either the minor, a court appointed guardian, or minorclient’s counselrepresentative. Parents typically do not have the authority to waive the psychotherapist-client privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-client privilege with his/her attorney. Client, or Representative, Client should be aware that he/she might be waiving the psychotherapisttherapist-client privilege if he/she makes his/his or her mental or emotional state an issue in a legal proceeding. Client, or Representative, Client should address any concerns he/she might have regarding the psychotherapist-client privilege privilege. with his/her attorney. Fee Client Litigation Therapist will not voluntarily participate in any litigation, or custody dispute in which the client and Fee Arrangements The another individual, or entity, are parties. Therapist has a policy of not communicating with client’s attorney and will generally not write or sign letters, reports, declarations, or affidavits to be used in client’s legal matter. therapist will generally not provide records or testimony unless compelled to do so. Should therapist be subpoenaed, or ordered by a court of law, to appear as a witness in an action involving client, client agrees to reimburse therapist for any time spent in preparation, travel, or other time in which therapist has made herself available for such an appearance at therapists usual and customary fee for service is hourly rate of $120.00 per 50- minute session and $150.00 per 90- minute session250.00. Therapist reserves the right to periodically adjust this fee. Representative will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. From time-to-time, Therapist may engage in telephone contact with Cancellation Policy Client or Representative for purposes other than scheduling sessions. Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutesmissed session(s). In addition, from time-to-time, Therapist may engage in telephone contact with third parties at the request of Client or Representative and with the advance written authorization of Client or Representative. Representative is also responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone sessions for which the client failed to give the therapist at least 24 hours notice of cancellation. Cancellation notice should be left on the therapist’s voice mail or sent as a text message or e-mail. The therapist has a confidential voice mail system that allows Client to leave a message at any time. The therapist will make every effort to return calls longer than ten minuteswithin 24 hours (or the next business day) but can’t guarantee that the calls will be returned immediately. Representative The therapist is expected unable to pay provide 24 hour crisis service, but in the event that the client is feeling unsafe or requires immediate medical or psychiatric attention, he/she should dial 911 or go to the nearest emergency room. Termination of Therapy The therapist reserves the right to terminate therapy at her discretion. Reasons for services termination include, but are not limited to, untimely payment of fees, failure to comply with treatment recommendations, conflicts of interest, failure to participate in therapy, client’s needs are outside the scope of competence or practice, or client is not making adequate progress in therapy. Client has the right to terminate therapy at his/her discretion. Upon either party’s decision to terminate therapy, the time services are rendered. Therapist accepts cashtherapist will generally recommend to the client, checksat least one, and major credit cards.possibly more, termination sessions. These sessions are intended to facilitate a positive termination experience and give both parties an opportunity to reflect on the work that has been done. The therapist will also attempt to ensure a smooth transition to another therapist by offering referrals to the client. Acknowledgement By signing below, Client acknowledges that he/she has reviewed and fully understands the terms and conditions of this agreement. Client has discussed such terms and conditions with the therapist and has had any questions with regarding its terms answered to client satisfaction. Client agrees to abide by the terms of the agreement and consents to participate in psychotherapy with the therapist. Moreover, client agrees to hold therapist free and harmless from any claims, demands, or suits and damages from any injury or complications whatever, save negligence, that may result from such treatment. Name of client (please print) Signature of client date Client Address: street city/state email zip code cell phone Name of emergency contact Phone # of emergency contact Relationship to client Fill out below portion if client is under age 18 Name of parent or guardian Child’s date of birth Signature of parent or legal guardian date