Common use of Counseling Services Clause in Contracts

Counseling Services. Psychotherapy calls for an active effort on your part. In order for counseling to be most successful you will have to work on the things we talk about during our session at home. In addition, your responsibilities are to provide relevant, accurate and complete information as to your history, symptoms, complaints, medication, and current status. Please make your best efforts to have relevant information (such as previous psychiatric evaluations, discharge summaries, school reports, etc.) ready at the time of your first session. As your therapist, I have the responsibility to ask you questions about you and your family’s history, as well as your feelings and actions. I also have the responsibility to provide you with direct information about treatment as well as my clinical recommendations. If you choose to terminate treatment, I can assist you in developing appropriate options, unless you choose otherwise. Individual and family sessions are 45 minutes in length. It is important for us to end on time, so I am able to document our session, review records and/or make collateral phone calls on your behalf. The frequency of sessions depends on clinical need and can be discussed at your first session and re-evaluated at subsequent sessions. My usual and customary fee for your first appointment, described as the “diagnostic assessment” or “intake” is $175.00. All other sessions (individual, family, collateral) are charged at $125.00 per session. Special evaluations/assessments (e.g. school/court related) are billed according to the breadth of the evaluation, duration of evaluation, and whether or not a formal report is required. Co-payments/session fees are due at the time of service. All payments for services are to be made by personal check, cash, or credit card. If your insurance company is being billed, I will make appropriate efforts to obtain payment; however, you as the client are responsible for any outstanding charges that are not covered. A service fee of $25.00 per month shall apply to any accounts for which there is an outstanding balance, including payments which are late, or if there has been no payment made by you or your insurance company on the balance within the past 30 days. If your account has not been paid for more than 60 days and arrangements for payments have not been agreed upon, I have the option of using legal means to secure payment. By signing this agreement, you understand that you are responsible for reasonable attorney and legal fees for accounts that go to collections. Any service requested by you the client (e.g., court testimony, written treatment summaries/recommendations, attendance at PPT meetings) is billable to you personally at the regular session rate of $125.00 per hour. If you have a brief, routine message please call and leave the message on my voice mail. If you are having a mental health emergency, or require urgent care, please call your local emergency services or proceed to your local emergency room. I check my voice mail twice per day and cannot guarantee that I will be readily available. I try to return messages within one business day. Phone calls are not to take place of a regular counseling session.

Counseling Services. Psychotherapy Your first appointment (or more, in some cases) will involve an evaluation of your needs. By the end of the evaluation your Clinician will be able to offer you some first impressions of what your work may include and recommendations for getting help. One of the recommendations may be individual counseling. It is your choice to start your therapeutic work with the Clinician who assessed you or with someone else. If you decide to work with someone else we are more than willing to help you find the most suitable match for you. Counseling is not easily described in general statements. It varies depending on the particular problems you are experiencing, the therapeutic methods used by your Clinician, and the personalities of the Clinician and client. There are many different methods Clinicians may use to deal with the problems that you hope to address. Counseling is not like a medical doctor visit. Instead, it calls for an a very active effort on your part. In order for the counseling to be most successful successful, you will have to work on the things we talk about that are discussed both during our session at homeyour sessions and on your own. In additionCounseling can have benefits and risks. Since counseling often involves discussing unpleasant aspects of your life, your responsibilities are to provide relevantyou may experience uncomfortable feelings like sadness, accurate and complete information as to your historyguilt, symptomsanger, complaintsshame, medicationfrustration, loneliness, and current statushelplessness. Please The changes you make in counseling may also affect your best efforts relationships in unexpected ways. Counseling has also been shown to have relevant information (such as previous psychiatric evaluationsmany benefits. Counseling often leads to better relationships, discharge summariessolutions to specific problems, school reportsand significant reductions in feelings of distress. But there are no guarantees of what you will experience. The initial evaluation will last from one to two sessions. During this time, etc.) ready at the time of your first session. As your therapist, I have the responsibility to ask you questions about you and your family’s history, as well as your feelings and actions. I also have Clinician can both decide if she/he is the responsibility best person to provide the services you with direct information about need in order to meet your treatment as well as my clinical recommendationsgoals. If counseling is begun, your Clinician will usually schedule one appointment per week at a time you each agree on. Once an appointment is scheduled, you will be expected to attend unless you provide advance notice of cancellation. If you choose need to terminate treatmentcancel an appointment, I can assist you in developing appropriate options, unless you choose otherwise. Individual and family sessions are 45 minutes in length. It it is important for your responsibility to contact us to end on time, so I am able cancel. ◊ Initial Intake Evaluation/ Diagnostic Assessment: $150 per 45 minute session ◊ Individual Counseling (Face to document our Face/Telehealth): $150 for 60 minute session, review records and/or make collateral $125 per 45 minute session, and $90 for 30 minute session ◊ Family/Couples Counseling: $150 per 45 minute session ◊ Group Counseling: $60 per person per 90 minute session ◊ SAP Evaluations: $475 ($675 for SAP Process) ◊ Summary Letters: $50 per letter ◊ Reports: $100 per report ◊ Missed Appointment/Late Cancellation (less than 24 hrs): $50 ◊ After two no-shows/late cancellations, client may be placed back on the waiting list ◊ Fees for reports, testing, letters, phone calls on your behalf. The frequency of sessions depends on clinical need over 5 minutes, generating reports, consulting with other agencies and can be discussed professionals at your first session request, paperwork and re-evaluated at subsequent sessionsdepositions resulting from a subpoena, and the time spent performing any other services you may request. My usual These services will be charged as they occur. DLS Clinicians do not testify in court cases unless under subpoena to do so. These services will not be billed to insurance or most third party payers and customary fee for are therefore your first appointment, described as the “diagnostic assessment” or “intake” financial responsibility. Payment is $175.00. All other sessions (individual, family, collateral) are charged at $125.00 per session. Special evaluations/assessments (e.g. school/court related) are billed according to the breadth due in advance of the evaluationservice being provided. ◊ Deductible, duration of evaluationco-insurance, and whether or and/or co-pay amounts, in addition those services not a formal report is required. Co-payments/session fees covered by another payer, are due at the time of serviceeach visit. All payments for services are to be made by personal check, cash, or credit card. If ◊ Although we may bill your insurance company and/or third party payer, you are ultimately responsible for payment of services rendered, and for contacting your insurance company and/or third party payer if payment is being billednot received in a timely manner. ◊ If your bill for services rendered is not paid within 30 days, I we may find it necessary to turn your account over to a collection agency. We will make appropriate efforts every effort to obtain payment; howeveravoid this by working with you to ensure timely payments on your account. However, if it does become necessary to turn your account over to a collection agency, we reserve the right to charge an additional collection fee. ◊ For your convenience, we accept Visa, MasterCard, Cash, Money Orders, Paypal (▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇.▇▇▇) and CashApp ($dlsdmv) payments. WE DO NOT ACCEPT CHECKS We answer our main office number (301-804-8279) Monday through Friday, 8am to 5pm. Your Clinician will provide you with their mobile number to contact them in between sessions as needed. Email is not a secure mediums in terms of privacy and confidentiality so our policy regarding, electronic communication, and cell phone use includes the client are responsible following: ◊ We do not provide counseling/counseling via email or text messaging. ◊ Email will be used for any outstanding charges administrative tasks only (as defined above). ◊ Clinicians may not acknowledge or return emails or text messages that are not coveredadministrative. A service fee This includes emergency texts and emails. ◊ Telehealth counseling is allowed if you are within the state of $25.00 per month shall apply to any accounts for which Maryland and/or the District of Columbia and there is an outstanding balance, including payments which are late, or if there has been no payment made completed intake paperwork on file. Insurance coverage of the service varies by you or your insurance company on the balance within the past 30 daysplan and often requires prior approval. ◊ If your account has not been paid Clinician leaves for more than 60 days and arrangements an extended period of time you will be given the information for payments another licensed Clinician with whom you may contact if you have not been agreed upon, I have the option of using legal means to secure paymenta crisis during your Clinician’s absence. By signing this agreement, you understand that you are responsible for reasonable attorney and legal fees for accounts that go to collections. Any service requested by you the client (e.g., court testimony, written treatment summaries/recommendations, attendance at PPT meetings) is billable to you personally at the regular session rate of $125.00 per hour. ◊ If you have an emergency DO NOT contact your Clinician’s cell phone, email, or the main number. Instead go to the nearest emergency department or call 911. Your Clinician should be contacted after the emergency is addressed. Clinicians’ may use Social media, including but not limited to Facebook and Twitter, in this practice as tools for marketing services and disseminating information. Social media of any kind are not secure in terms of privacy and confidentiality so our policy regarding the use of social media includes the following: ◊ We do not provide counseling via social media. ◊ Clinicians will not acknowledge or return private messages delivered via social media. ◊ Clinicians will not acknowledge or respond to client emergencies delivered via social media. ◊ If you have an emergency do not contact your Clinician via social media. Instead go to the emergency room nearest you or call 911. ◊ You may use social media to reveal your own identity as a briefclient of DLS but you may not reveal the identity of another client. Doing so would be a breach of confidentiality and DLS would take all available steps to protect the revealed client’s rights, routine message please call including blocking the offending client from accessing our social media and leave referring the message offending client to another practice. The law protects the privacy of all communications between a client and a Clinician. In most situations, DLS can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA (included with this intake packet). There are other situations that require only that you provide written, advance consent, which is provided by signing this document. Your signature on my voice mailthis Agreement provides consent for the following activities: ◊ Although you will probably meet with only one Clinician, you are receiving services from the office of DLS. Consequently, you will have a file in our office to which all Clinicians and staff will have necessary access. We utilize ▇▇▇▇▇▇▇▇▇.▇▇▇ an online data storage service to store client records. Amazon's servers infrastructure are certified, ensure the highest physical security and guarantee a 99.9% uptime. You can read more at ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇.▇▇▇/compliance. More information about TheraNest can be obtained at ▇▇▇▇▇://▇▇▇.▇▇▇▇▇▇▇▇▇.▇▇▇/home/faq. ◊ In most cases, we need to share protected information within DLS for both clinical and administrative purposes, such as scheduling, records management, and quality assurance. All of the mental health professionals and staff are bound by the same rules of confidentiality. ◊ In providing, coordinating, or managing your treatment and other services related to your counseling care, DLS sometimes interacts with other professionals concerning your well- being. An example of this would be when we consult with another health care provider, such as a physician. We will acquire a release of information to keep on file if such coordination is necessary. ◊ If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, DLS cannot provide any information without a) your (or your legal representative’s) written authorization, or b) a court order/subpoena. If you are having involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order DLS to disclose information. ◊ If a client files a complaint or lawsuit against DLS, we may disclose relevant information regarding that client in order to defend ourselves. ◊ If we have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or observe a child being subjected to conditions or circumstances that would reasonably result in abuse or neglect, the law requires that DLS file a report with the Maryland (MD) Department of Health and Human Services or with the District of Columbia’s (DC)Child & Family Services Agency. Once such a report is filed, we may be required to provide additional information. ◊ If we have reasonable cause to suspect that an elderly or disabled adult presents a likelihood of suffering serious physical harm and is in need of protective services, the law requires that DLS file a report with the MD Department of Health and Human Services or the DC Office of Aging. Once such a report is filed, we may be required to provide additional information. ◊ If we believe that it is necessary to disclose information to protect against a risk of serious harm being inflicted by you upon yourself, another person, or to the community, DLS may be required to take protective action. Depending on the situation, these actions may include initiating hospitalization and/or contacting the police. If such a situation arises, your Clinician will make every effort to fully discuss it with you before taking any action and we will limit our disclosure to what is necessary. ◊ If you disclose past sexual abuse by a mental health emergencyprovider we are obligated to report this to the proper authorities and licensing entities. ◊ While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and we are not attorneys. In situations where specific advice is required, formal legal advice may be needed. Different methods of providing counseling services are evolving all the time. At DLS we will utilize those means ethically and therapeutically. Technology- assisted distance counseling for individuals, couples, and groups involve the use of the telephone or the computer to enable Clinicians and clients to communicate at a distance when circumstances make this approach necessary or convenient. Telehealth counseling involves synchronous distance interaction among Clinicians and clients using one-to-one or conferencing features of the telephone to communicate or what is seen and heard via video to communicate. Telehealth via video is conducted within our secure HIPAA compliant electronic health record (EHR) system, Theranest. In order to utilize technology for counseling you will be asked to sign a teleheatlh counseling consent form. The laws and standards of our profession require that DLS keeps your Protected Health Information (PHI) about you in your clinical record. Your clinical record includes information about your reasons for seeking counseling, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, and any reports that have been sent to anyone. Except in the unusual circumstance where disclosure is reasonably likely to endanger you and/or others or when another individual (other than another health care provider) is referenced and we believe disclosing that information puts the other person at risk of substantial harm, you may examine and/or receive a copy of your clinical record, if you request it in writing. Because these are professional records, they can be misinterpreted by and/or be upsetting to untrained readers. For this reason, DLS recommends that you initially review them in your Clinician’s presence, or require urgent carehave them forwarded to another mental health professional so you can discuss the contents. In most circumstances, please call DLS is allowed to charge a copying fee of $25 (and for certain other expenses). If DLS refuses your local emergency services or proceed request for access to your local emergency roomclinical records, you have a right of review, which a Clinician will discuss with you upon request. I check my voice mail twice per day and cannot guarantee that I In the event of your Clinician’s death or incapacity, or the termination of the licensee’s counseling practice, all records will be readily availablesecured and archived with ▇▇▇▇▇▇▇▇▇.▇▇▇ records are password protected and will be secured by ▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇, Executive Director and ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇, Practice Manager. I try In the event of your Clinician’s termination, death, or incapacity, all records created as a contract Clinician with DLS will be secured and archived with ▇▇▇▇▇▇▇▇▇.▇▇▇ on an encrypted electronic server. In the event of the closure of ▇▇▇▇▇▇▇▇▇.▇▇▇ or the death or incapacitation of its owner, records created by contracted Clinicians will be secured and archived on an encrypted electronic server. Access will be granted to return messages within one business day▇▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇ or ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇. Phone calls We are in network for many insurance companies and we are willing to submit claims directly to your carrier for reimbursement. In the event, that we are not in-network with your insurance carrier and you elect to take place submit your claims for reimbursement we will provide you with paperwork that you need. You should be aware that in the process of filing for a regular third party payment, your contract with your health insurance carrier requires that your Clinician provide additional clinical information such as treatment plans or summaries, a diagnosis, or copies of your entire clinical record. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, Clinicians have no control over what the insurance companies do with it once it is in their hands. In such situations, your Clinician will make every effort to release only the minimum information about you that is necessary for the purpose requested. Clients under 18 years of age and their parents should be aware that the law may allow parents to examine their child’s treatment records. Because privacy in counseling sessionis often crucial to successful progress, particularly with teenagers, it is sometimes our policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, your Clinician would provide them (if requested) only with general information about the progress of your treatment, and your attendance at scheduled sessions. If requested, your Clinician could also provide parents with a summary of your treatment when it is complete. Any other communication to your parents will require your authorization, unless we feel that you are in danger or are a danger to someone else, in which case, we will notify the parents of our concern. Before giving parents any information, your Clinician will discuss the matter with you, if possible, and do her/his best to handle any objections you may have. In cases of divorce, a copy of the divorce decree indicating parental rights to view records and participate in treatment will be required.

Counseling Services. Psychotherapy calls for an active effort The purpose of treatment is to help clients resolve issues they have not felt successful in resolving on your parttheir own. In order for counseling to be Therapy is most likely successful you will have to work on the things we talk about during our session at home. In addition, your responsibilities are to provide relevant, accurate when clients diligently pursue and complete information as established goals. The length of treatment depends upon the clients individualized treatment plan. Clients need to your history, symptoms, complaints, medication, and current status. Please make your best efforts to have relevant information (such as previous psychiatric evaluations, discharge summaries, school reports, etc.) ready at the time of your first session. As your therapist, I have the responsibility to ask you questions about you and your family’s history, feel comfortable with their therapist as well as your feelings and actionstheir therapist’s treatment methods. Depending on a client’s needs, different methods of therapy may be used. I have a master’s degree in professional counseling and am licensed by the State of Arizona’s Board of Behavioral Health Examiners. I am also certified by the National Board of Certified Counselors. I am an integrative psychotherapist. Generally, this means that I utilize and have been trained in a number of treatment approaches including: Eye Movement Desensitization and Reprocessing (EMDR), Cognitive Behavioral Therapy (CBT), Emotionally Focused Therapy (EFT) Dialectical Behavioral Therapy (DBT), Mindfulness Based Stress Management, Internal Family Systems, and Reality Therapy/Choice Theory (RT/CT). This allows me to tailor your therapeutic experience to what will likely best suit your individual needs. I provide counseling and consultation to adults, adolescents, couples, families, and groups. Together we will develop a personal treatment plan that outlines the major issues you wish to address. With this plan, we will see what combinations of approaches will be most beneficial in helping you best reach your goals. Upon reaching your goals, I ask that you participate in a closing session to review your accomplishments and also allow time for me to assist you in identifying any support that might help you to maintain and enhance your growth in the future. You are expected to actively participate while working collaboratively with me to achieve your goals. You have the responsibility right to provide you with direct information about participate in important treatment decisions as well as my clinical recommendationsin the development of your treatment plan. Periodically, we will review and revise your plan to keep up to date with your current situation. Therapy is most successful when clients are willing to work diligently on their personal treatment plan in between counseling sessions. Thus, you may be asked to complete “homework assignments.” Therapy can have its benefits and its risks. It often involves discussing things that can be painful and you may also experience unpleasant feelings, such as: sadness, anger, guilt and loneliness. The benefits associated with working through unpleasant feelings includes promoting healing, growth and lasting positive change. Benefits may also include, but are not limited to: happier-healthier relationships, a more positive self- image, a sense of wellbeing and solutions to problems. However, there are no guarantees what your experience will be. The first session is a consultation and also the beginning of our journey together. The exploratory process may take a few sessions to complete. I will hear what you hope to gain from therapy and will also answer any questions you may have. I will share initial thoughts and a preliminary treatment plan. If I do not believe I am the appropriate person to be working with you, I may offer you the names of other counselors. If you choose do not believe that I am the right person for you, please do not hesitate to terminate treatmentsay so. Therapy often requires a significant amount of time, I can assist you in developing appropriate options, unless you choose otherwise. Individual money and family sessions are 45 minutes in lengthemotional energy. It is important for us you to end on time, so I am able feel comfortable with me. Please feel free to document our session, review records and/or make collateral phone calls on your behalfask any questions you may have. The frequency of sessions depends on clinical need and can be discussed at your first session and re-evaluated at subsequent sessions. My usual and customary fee for your first appointment, described as the “diagnostic assessment” or “intake” is $175.00. All other sessions (individual, family, collateral) are charged at $125.00 per session. Special evaluations/assessments (e.g. school/court related) are billed according to the breadth of the evaluation, duration of evaluation, and whether or not a formal report is required. Co-payments/session fees are due at the time of service. All payments for services are to be made by personal check, cash, or credit card. If your insurance company is being billed, I will make appropriate efforts to obtain payment; however, you as the client are responsible for any outstanding charges that are not covered. A service fee of $25.00 per month shall apply to any accounts for which there is an outstanding balance, including payments which are late, or if there has been no payment made by you or your insurance company on the balance within the past 30 days. If your account has not been paid for more than 60 days and arrangements for payments have not been agreed upon, I You have the option of using legal means right to secure payment. By signing this agreement, you understand that you are responsible for reasonable attorney and legal fees for accounts that go to collections. Any service requested by you refuse any recommended treatment at any time throughout the client (e.g., court testimony, written treatment summaries/recommendations, attendance at PPT meetings) is billable to you personally at the regular session rate of $125.00 per hour. If you have a brief, routine message please call and leave the message on my voice mailtherapeutic process. If you are having uncomfortable with any treatment recommendations, please let me know immediately. Should you choose to end your therapy prior to meeting our goals it is recommended that you schedule a closure session with me. With the exception of circumstances that involve danger to yourself and/or others, or if others have supplied information confidentially, you may examine and/or receive a copy of your clinical record (This does not include process notes taken during session). Your request will need to be in writing. Because these are professional records, they can be misinterpreted and/or upsetting to the untrained reader. For this reason, it is recommended that you initially review them in my presence, or have them forwarded to another mental health emergencycounselor so you can better discuss the contents. You may be charged a $ .20 per page copying fee. If the copying of the records lasts longer than 5 minutes, there will be an additional charge of $3.00 for every 5 minutes of time to copy the requested records. • Therapy Sessions: 45-50 Min – $165.00 • Therapy Sessions: 80-90 Min – $245.00 • Longer or shorter sessions will be billed in 15 minute increments. • In addition to weekly appointment, I charge a $165.00 per hour rate in 15 minute increments for other professional services you may need. These services may include, but are not limited to: Report writing, correspondence, telephone conversations lasting longer than 15 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and time I spend performing other professional services. • If you are involved in legal proceedings that require urgent caremy participation, please call your local emergency services or proceed you will be expected to your local emergency roompay for all of my professional time, including participation and transportation costs (even if another party requires my attendance). I check charge a minimum of $450.00 per hour for my voice mail twice per day and cannot guarantee that I will be readily available. I try to return messages within one business day. Phone calls are not to take place time in any matter associated with any type of a regular counseling sessionlegal proceedings.

Counseling Services. Your first appointment (or more, in some cases) will involve an assessment of your needs. By the end of the assessment ▇▇▇▇ ▇▇▇▇▇▇ will be able to offer you some first impressions of what your work may include and recommendations for getting help. One of the recommendations may be psychotherapy. If so, ▇▇▇▇ ▇▇▇▇▇▇ may or may not be able to provide you with psychotherapy, depending on your overall needs. If psychotherapy or any other recommendations suggested by your counselor include things that ▇▇▇▇ ▇▇▇▇▇▇ Counseling, Inc. cannot provide, you will be given suggestions of where you might receive those services. Wherever you choose to obtain treatment, you should evaluate the information from your initial assessment along with your own opinions of what sort of treatment you are willing to do and whether you feel comfortable working with ▇▇▇▇ ▇▇▇▇▇▇. Therapy involves a large commitment of time, energy, and often money, so you should be very careful about the therapist you select. If you have questions about the procedures used or conclusions made by ▇▇▇▇ ▇▇▇▇▇▇, please discuss them whenever they arise. If your doubts persist, your counselor will be happy to help you set up a meeting with another mental health professional for a second opinion. Psychotherapy is not easily described in general statements. It varies depending on the particular problems you are experiencing, the therapeutic methods used by your counselor, and the personalities of the counselor and client. There are many different methods counselors may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for an a very active effort on your part. In order for counseling the therapy to be most successful successful, you will have to work on things that are discussed both during your sessions and on your own. Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, shame, frustration, loneliness, and helplessness. The changes you make in therapy may also affect your relationships in unexpected ways. Psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience. The initial assessment will last from one to two sessions. During this time, you and ▇▇▇▇ ▇▇▇▇▇▇ can both decide if she is the things we talk about during our session at home. In addition, your responsibilities are best person to provide relevantthe services you need in order to meet your treatment goals. If psychotherapy is begun it is typical to schedule one meeting per week at a time you each agree on. Once an appointment is scheduled, accurate and complete information as you will be expected to your history, symptoms, complaints, medication, and current status. Please make your best efforts to have relevant information (such as previous psychiatric evaluations, discharge summaries, school reports, etc.) ready at the time attend unless you provide advance notice of your first session. As your therapist, I have the responsibility to ask you questions about you and your family’s history, as well as your feelings and actions. I also have the responsibility to provide you with direct information about treatment as well as my clinical recommendationscancellation. If you choose need to terminate treatmentcancel an appointment, I can assist you in developing appropriate optionsit is your responsibility to contact us to cancel. Fees will be collected when services are rendered. The fee per 50 minute counseling session is $135, unless you choose otherwiseand will be adjusted accordingly when 50 minutes is exceeded. Individual In addition to therapy services fees may include creating reports; creating copies of records on request; and family sessions consulting with other professionals at the client’s request. There will be an additional $25 fee assessed for any returned check. We understand that there are 45 minutes in lengthunforeseeable circumstances like sick children or bad weather. It Your appointment is important though, and ▇▇▇▇ ▇▇▇▇▇▇ is happy to contact you for us a phone session or a session via our HIPPA-compliant virtual therapy system so you don't need to end on timeleave your sick child or worry about traffic and weather. As long as you are in a confidential location, so I am able to document our session, review records and/or make collateral phone calls on we can help you keep your behalfregularly scheduled appointment. The frequency of sessions depends on clinical need and can be discussed at If you still must change or cancel your first session and re-evaluated at subsequent sessions. My usual and customary fee for your first counseling appointment, described as the “diagnostic assessment” or “intake” is $175.00. All other sessions (individual, family, collateral) are charged at $125.00 per session. Special evaluations/assessments (e.g. school/court related) are billed according to the breadth of the evaluation, duration of evaluation, and whether or not a formal report is required. Co-payments/session fees are due at the time of service. All payments for services are to please know: ● Cancellations must be made by personal check, cash, within 24 hours of session time. ● We cannot accommodate cancellations made via email as we do not monitor email on a regular basis. ● We cannot accommodate cancellations made after hours or credit card. If your insurance company is being billed, I will make appropriate efforts to obtain payment; however, you as the client are responsible for any outstanding charges that are not covered. A service fee of $25.00 per month shall apply to any accounts for which there is an outstanding balance, including payments which are late, or if there has been no payment made by you or your insurance company on the balance within the past 30 days. If your account has not been paid for more than 60 days and arrangements for payments have not been agreed upon, I have the option of using legal means to secure payment. By signing this agreement, you understand that you are responsible for reasonable attorney and legal fees for accounts that go to collections. Any service requested by you the client (e.g., court testimony, written treatment summaries/recommendations, attendance at PPT meetings) is billable to you personally at the regular session rate of $125.00 per hourholidays. If you have an appointment on a briefMonday or the first day following a holiday, routine message you must make your change or cancellation the last business day before your appointment. ● Cancellations with less than 24 hours’ notice will result in a $90 fee that will be collected at your next appointment, or, if payment information is on file, it will be debited from your credit card. ● After two no-shows/late cancellations, a pre-paid retainer will be required before scheduling any future appointments. ● Clients who have pre-paid agree to have the entire fee deducted from their pre-payment in cases of other no-shows and late changes/cancellations. ● Court testimony costs begin at $300 per hour with a minimum charge of three hours. A retainer of $1000 is due one week prior to the court date. Travel is billed at .55/mile. Failure to provide the specific fees as described constitutes a release from the requested court appearance. You (not your insurance company) are responsible for full payment of fees. It is very important that you find out exactly what mental health services your insurance policy covers. You must pay your ▇▇▇▇ first, then contact your insurance company regarding reimbursement. You can contact our main office number (281-350-1277) 24 hours a day/7 days a week. If an administrative assistant or ▇▇▇▇ ▇▇▇▇▇▇, does not answer, please call and leave the a message on my voice mailthe internal/secure voicemail system. If you Messages are having a mental health emergencytypically returned within 24 hours during the business week, or require urgent care48 hours for messages left on the weekend. You may have your counselor’s cell phone number in order to coordinate administrative tasks (defined as appointment arrival, please call your local emergency services appointment time, and directions). Email, and text messaging are not secure mediums in terms of privacy and confidentiality so our policy regarding, electronic communication, and cell phone use includes the following: ● We do not provide therapy/counseling via email or proceed to your local emergency roomtext messaging. I check my voice mail twice per day ● Text messaging and cannot guarantee that I email will be readily availableused for administrative tasks only (as defined above). I try to ● ▇▇▇▇ ▇▇▇▇▇▇ Counseling, Inc., may not acknowledge or return emails or text messages within one business day. Phone calls that are not to take place administrative. This includes emergency texts and emails. ● If ▇▇▇▇ ▇▇▇▇▇▇ leaves for an extended period of a regular counseling sessiontime you will be given the information for another licensed therapist with whom you may schedule if you need an appointment during your therapist’s absence.

Counseling Services. Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in mental health counseling, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Mental Health Counseling has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy calls for an requires a very active effort on your part. In order for counseling to be most successful successful, you will have to work on the things we talk about during our session at homediscuss in treatment outside of sessions, as a kind of homework. In addition, your responsibilities are to provide relevant, accurate and complete information as to your history, symptoms, complaints, medication, and current status. Please make your best efforts to have relevant information (such as previous psychiatric evaluations, discharge summaries, school reports, etc.) ready at the time The first 2 sessions will involve a comprehensive evaluation of your first sessionneeds. As your therapist, I have By the responsibility to ask you questions about you and your family’s history, as well as your feelings and actions. I also have the responsibility to provide you with direct information about treatment as well as my clinical recommendations. If you choose to terminate treatment, I can assist you in developing appropriate options, unless you choose otherwise. Individual and family sessions are 45 minutes in length. It is important for us to end on time, so I am able to document our session, review records and/or make collateral phone calls on your behalf. The frequency of sessions depends on clinical need and can be discussed at your first session and re-evaluated at subsequent sessions. My usual and customary fee for your first appointment, described as the “diagnostic assessment” or “intake” is $175.00. All other sessions (individual, family, collateral) are charged at $125.00 per session. Special evaluations/assessments (e.g. school/court related) are billed according to the breadth of the evaluation, duration of evaluation, and whether or not a formal report is required. Co-payments/session fees are due at the time of service. All payments for services are to be made by personal check, cash, or credit card. If your insurance company is being billed, I will be able to offer you some initial impressions of what our work might include. At that point, we will discuss your treatment goals and create an initial treatment plan. You should evaluate this information and make appropriate efforts to obtain payment; however, your own assessment about whether you as the client are responsible for any outstanding charges that are not covered. A service fee of $25.00 per month shall apply to any accounts for which there is an outstanding balance, including payments which are late, or if there has been no payment made by you or your insurance company on the balance within the past 30 days. If your account has not been paid for more than 60 days and arrangements for payments have not been agreed upon, I have the option of using legal means to secure payment. By signing this agreement, you understand that you are responsible for reasonable attorney and legal fees for accounts that go to collections. Any service requested by you the client (e.g., court testimony, written treatment summaries/recommendations, attendance at PPT meetings) is billable to you personally at the regular session rate of $125.00 per hourfeel comfortable working with me. If you have a briefquestions about my procedures, routine message please call and leave the message on my voice mailwe should discuss them whenever they arise. If you are having a mental health emergencyyour doubts persist, or require urgent care, please call your local emergency services or proceed to your local emergency room. I check my voice mail twice per day and cannot guarantee that I will be readily available. I try happy to return messages within one business day. Phone calls are not help you set up a meeting with another mental health professional for a second opinion or to take place of make a regular counseling sessionmove to another therapist that feels like a better fit.

Counseling Services. Your first appointment (or more, in some cases) will involve an assessment of your needs. By the end of the assessment I will be able to offer you some first impressions of what your work may include and recommendations for getting help. One of the recommendations may be psychotherapy. If so, ABO may or may not be able to provide you with psychotherapy, depending on your overall needs. If psychotherapy or any other recommendations suggested by me include things that ABO cannot provide, you will be given suggestions of where you might receive those services. Wherever you choose to obtain treatment, you should evaluate the information from your initial assessment along with your own opinions of what sort of treatment you are willing to do and whether you feel comfortable working with the treating clinician. Therapy involves a large commitment of time, energy, and often money, so you should be very careful about the counselor you select. If you have questions about the procedures used or conclusions made by me, please discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Psychotherapy is not easily described in general statements. It varies depending on the particular problems you are experiencing, the therapeutic methods used by your counselor, and the personalities of the counselor and client. There are many different methods counselors may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for an a very active effort on your part. In order for counseling the therapy to be most successful successful, you will have to work on things that are discussed both during your sessions and on your own. Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, shame, frustration, loneliness, and helplessness. The changes you make in therapy may also affect your relationships in unexpected ways. Psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience. The initial assessment will last from one to four sessions. During this time, you and I can both decide if I am is the things we talk about during our session at home. In addition, your responsibilities are best person to provide relevant, accurate and complete information as the services you need in order to meet your history, symptoms, complaints, medication, and current status. Please make your best efforts to have relevant information (such as previous psychiatric evaluations, discharge summaries, school reports, etc.) ready at the time of your first session. As your therapist, I have the responsibility to ask you questions about you and your family’s history, as well as your feelings and actions. I also have the responsibility to provide you with direct information about treatment as well as my clinical recommendationsgoals. If you choose to terminate treatmentbegin psychotherapy, I will usually schedule one meeting at a time agree upon. Once an appointment is scheduled, you will be expected to attend unless you provide advance notice of cancelation. If you need to cancel an appointment, it is your responsibility to contact me to cancel. Fees will be collected when services are rendered. In addition to therapy services fees may include assessment administration, scoring, and reporting; creating reports; creating copies of records on request; and consulting with other professionals at the client’s request. There will be an additional $25 fee assessed for any returned check. The fee for my services is $200 per hour. I understand that there are unforeseeable circumstances like sick children or bad weather. Your appointment is important though, and I am happy to contact you for a phone session or a session via a HIPAA-compliant virtual therapy system so you don't need to leave your sick child or worry about traffic and weather. As long as you are in a confidential location, I can assist help you in developing appropriate options, unless keep your regularly scheduled appointment. If you choose otherwise. Individual and family sessions are 45 minutes in length. It is important for us to end on time, so I am able to document our session, review records and/or make collateral phone calls on still must change or cancel your behalf. The frequency of sessions depends on clinical need and can be discussed at your first session and re-evaluated at subsequent sessions. My usual and customary fee for your first counseling appointment, described as the “diagnostic assessment” or “intake” is $175.00. All other sessions (individual, family, collateral) are charged at $125.00 per session. Special evaluations/assessments (e.g. school/court related) are billed according to the breadth of the evaluation, duration of evaluation, and whether or not a formal report is required. Co-payments/session fees are due at the time of service. All payments for services are to please know: • Cancelations must be made by personal checkwithin 48 hours of session time by: o Contacting us at ▇▇▇-▇▇▇-▇▇▇▇ and leaving a voice mail o Using our online scheduling program, cash, log in to your account and change or credit cardcancel your appointment. If your insurance company is being billed, I will make appropriate efforts • We do not take cancelations via email. Emails from our scheduling software are automated and clearly marked ‘no reply.’ Replies to obtain payment; however, you as the client are responsible for any outstanding charges that our email are not coveredmonitored. A service fee of $25.00 per month shall apply • I may not accommodate cancelations made after hours or on holidays to any accounts for which there is an outstanding balance, including payments which are late, or if there has been no payment made by you or your insurance company on the balance within the past 30 days. If your account has our main number as I cannot been paid for more than 60 days and arrangements for payments have not been agreed upon, I have the option of using legal means to secure payment. By signing this agreement, you understand that you are responsible for reasonable attorney and legal fees for accounts that go to collections. Any service requested by you the client (e.g., court testimony, written treatment summaries/recommendations, attendance at PPT meetings) is billable to you personally at the regular session rate of $125.00 per hourcheck voice mail regularly. If you have an appointment on a briefMonday or the first day following a holiday, routine you must make your change or cancelation the last business day before your appointment. • Cancelations with less than 24 hours’ notice will result in a fee equal to the total amount of the missed session that will be collected at your next appointment, or, if payment information is on file, it will be debited from your credit card. • *After two no-shows/late cancelations, you will pre-pay a retainer before scheduling any future appointments. • Clients who have pre-paid agree to have the entire fee deducted from their pre-payment in cases of other no-shows and late changes/cancelations. Any money left over from retainer after no-show fee is deducted will be refunded. • Court testimony costs begin at $250 per hour with a minimum charge of three hours. A retainer of $1000 is due one week prior to the court date. Travel is billed at .55/mile. Failure to provide the specific fees as described constitutes a release from the requested court appearance. • It is required that a minimum of 36 hours’ notice be given if the testimony is not required, otherwise the entire retainer may be forfeited. If proper notice is given, the retainer will be refunded. • Additional services related to court preparation including all correspondence with attorneys or other service providers via phone, email, or letter, documentation review and/or documentation preparation are also billed at $250 per hour, rounded to the nearest 15 minute increment. You (not your insurance company) are responsible for full payment of fees. It is very important that you find out exactly what mental health services your insurance policy covers. You must pay your ▇▇▇▇ first, then contact your insurance company regarding reimbursement. I answer the main office number 9:00 AM – 5:00 PM Monday through Friday (except holidays). Email, and text messaging are not secure mediums in terms of privacy and confidentiality so my policy is: • I do not provide therapy/counseling via email or text messaging. • I may not acknowledge or return emails or text messages. Our scheduling software uses ‘No reply’ email confirmations and text messaging so I will not see any emails or text message please call and replies to that service. • If I leave for an extended period of time you will be given the message on information for another licensed therapist with whom you may schedule if you need an appointment during my voice mailabsence. Keep in mind you will need to fill out other paperwork. • Social media is not a means of communication. If you are having a mental health emergencyfind me on social media, or require urgent care, please call your local emergency services or proceed to your local emergency room. I check my voice mail twice per day and cannot guarantee that I will be readily available. I try to return messages within one business day. Phone calls are not to take place of a regular counseling sessioncommunicate with you.

Counseling Services. Your first appointment (or more, in some cases) will involve an assessment of your needs. By the end of the assessment your counselor will be able to offer you some first impressions of what your work may include and recommendations for getting help. One of the recommendations may be psychotherapy. If so, ABO may or may not be able to provide you with psychotherapy, depending on your overall needs. If psychotherapy or any other recommendations suggested by your counselor include things that ABO cannot provide, you will be given suggestions of where you might receive those services. Wherever you choose to obtain treatment, you should evaluate the information from your initial assessment along with your own opinions of what sort of treatment you are willing to do and whether you feel comfortable working with the treating clinician. Therapy involves a large commitment of time, energy, and often money, so you should be very careful about the counselor you select. If you have questions about the procedures used or conclusions made by your counselor at ABO, please discuss them whenever they arise. If your doubts persist, your counselor will be happy to help you set up a meeting with another mental health professional for a second opinion. Psychotherapy is not easily described in general statements. It varies depending on the particular problems you are experiencing, the therapeutic methods used by your counselor, and the personalities of the counselor and client. There are many different methods counselors may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for an a very active effort on your part. In order for counseling the therapy to be most successful successful, you will have to work on the things we talk about that are discussed both during our session at homeyour sessions and on your own. In additionPsychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, your responsibilities are to provide relevantyou may experience uncomfortable feelings like sadness, accurate and complete information as to your historyguilt, symptomsanger, complaintsshame, medicationfrustration, loneliness, and current statushelplessness. Please The changes you make in therapy may also affect your best efforts relationships in unexpected ways. Psychotherapy has also been shown to have relevant information (such as previous psychiatric evaluationsmany benefits. Therapy often leads to better relationships, discharge summariessolutions to specific problems, school reportsand significant reductions in feelings of distress. But there are no guarantees of what you will experience. The initial assessment will last from one to four sessions. During this time, etc.) ready at the time of your first session. As your therapist, I have the responsibility to ask you questions about you and your family’s history, as well as your feelings and actions. I also have counselor can both decide if she/he is the responsibility best person to provide the services you with direct information about need in order to meet your treatment as well as my clinical recommendationsgoals. If you choose to terminate treatmentbegin psychotherapy, I can assist your counselor will usually schedule one meeting at a time you in developing appropriate optionseach agree on. Once an appointment is scheduled, you will be expected to attend unless you choose otherwiseprovide advance notice of cancellation. Individual If you need to cancel an appointment, it is your responsibility to contact us to cancel. Fees will be collected when services are rendered.*In addition to therapy services fees may include assessment administration, scoring, and family sessions reporting; creating reports; creating copies of records on request; and consulting with other professionals at the client’s request. There will be an additional $25 fee assessed for any returned check. We understand that there are 45 minutes in lengthunforeseeable circumstances like sick children or bad weather. It Your appointment is important though, and your therapist is happy to contact you for us a phone session or a session via our HIPPA-compliant virtual therapy system so you don't need to end on timeleave your sick child or worry about traffic and weather. As long as you are in a confidential location, so I am able to document our session, review records and/or make collateral phone calls on we can help you keep your behalfregularly scheduled appointment. The frequency of sessions depends on clinical need and can be discussed at If you still must change or cancel your first session and re-evaluated at subsequent sessions. My usual and customary fee for your first counseling appointment, described as the “diagnostic assessment” or “intake” is $175.00. All other sessions (individual, family, collateral) are charged at $125.00 per session. Special evaluations/assessments (e.g. school/court related) are billed according to the breadth of the evaluation, duration of evaluation, and whether or not a formal report is required. Co-payments/session fees are due at the time of service. All payments for services are to please know: • Cancellations must be made by personal check, cash, during business hours. • Cancellations must be made within 48 hours of session time if using our online scheduling program. • We cannot accommodate cancellations made via email as we do not monitor email on a regular basis. • We may not accommodate cancellations made after hours or credit card. If your insurance company is being billed, I will make appropriate efforts on holidays to obtain payment; however, you our main number as the client are responsible for any outstanding charges that are we cannot covered. A service fee of $25.00 per month shall apply to any accounts for which there is an outstanding balance, including payments which are late, or if there has been no payment made by you or your insurance company on the balance within the past 30 days. If your account has not been paid for more than 60 days and arrangements for payments have not been agreed upon, I have the option of using legal means to secure payment. By signing this agreement, you understand that you are responsible for reasonable attorney and legal fees for accounts that go to collections. Any service requested by you the client (e.g., court testimony, written treatment summaries/recommendations, attendance at PPT meetings) is billable to you personally at the regular session rate of $125.00 per hourcheck voice mail regularly. If you have an appointment on a briefMonday or the first day following a holiday, routine message please call you must make your change or cancellation the last business day before your appointment. • Cancellations with less than 24 hours’ notice will result in a fee equal to the total amount of the missed session that will be collected at your next appointment, or, if payment information is on file, it will be debited from your credit card. • *After two no-shows/late cancellations, you will pre-pay a retainer before scheduling any future appointments. • Clients who have pre-paid agree to have the entire fee deducted from their pre-payment in cases of other no-shows and leave late changes/cancellations. • Court testimony costs begin at $250 per hour with a minimum charge of three hours. A retainer of $1000 is due one week prior to the message on my voice mailcourt date. Travel is billed at .55/mile. Failure to provide the specific fees as described constitutes a release from the requested court appearance. • It is required that a minimum of 36 hours’ notice be given if the testimony is not required, otherwise the entire retainer may be forfeited. If proper notice is given, the retainer will be refunded. • Additional services related to court preparation including all correspondence with attorneys or other service providers via phone, email, or letter, documentation review and/or documentation preparation are also billed at $250 per hour, rounded to the nearest 15 minute increment. You (not your insurance company) are responsible for full payment of fees. It is very important that you are having a find out exactly what mental health emergencyservices your insurance policy covers. You must pay your ▇▇▇▇ first, then contact your insurance company regarding reimbursement. We answer our main office number 9:00 AM – 5:00 PM Monday through Friday (except holidays). You may have your counselor’s cell phone number in order to coordinate administrative tasks (defined as appointment arrival, appointment time, and directions). Email, and text messaging are not secure mediums in terms of privacy and confidentiality so our policy regarding, electronic communication, and cell phone use includes the following: • We do not provide therapy/counseling via email or require urgent care, please call your local emergency services or proceed to your local emergency roomtext messaging. I check my voice mail twice per day • Text messaging and cannot guarantee that I email will be readily availableused for administrative tasks only (as defined above). I try to • Therapists may not acknowledge or return emails or text messages within one business day. Phone calls that are not administrative. This includes emergency texts and emails. • If your therapist leaves for an extended period of time you will be given the information for another licensed therapist with whom you may schedule if you need an appointment during your therapist’s absence. You may need to take place of a regular counseling sessionfill out other paperwork if therapist is in another practice.

Counseling Services. Psychotherapy Counseling is not easily described in general statements. It varies depending on the per- sonalities of the counselor and client, and the particular problems you are experiencing. There are many different methods I may use to deal with problems you want to address. Counseling calls for an active effort on your part. In order for counseling to be It is most successful when you will have to work on the things we talk about during our session at homesessions and in between sessions. In additionCounseling can have benefits and risks. Since it often involves discussing unpleasant as- pects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustra- tion, loneliness, and helplessness. On the other hand, counseling has been shown to have many benefits. It often leads to better relationships, solutions to specific problems, and significant re- ductions in feelings of distress. Often, with counseling, people know themselves better and live happier, more fulfilling lives. There are no guarantees of what you will experience. Our first few sessions will involve an evaluation of your responsibilities are needs. During this time, we can both decide if I am the best person to provide relevantthe services you need in order to meet your treat- ment goals. I will offer my impressions of what our work will include and make suggestions for a treatment plan. Please evaluate this information and decide whether you feel comfortable work- ing with me. Counseling involves a large commitment of time, accurate and complete information as to your history, symptoms, complaints, medicationmoney, and current status. Please make your best efforts to have relevant information (such as previous psychiatric evaluations, discharge summaries, school reports, etc.) ready at the time of your first session. As your therapist, I have the responsibility to ask you questions about you and your family’s history, as well as your feelings and actions. I also have the responsibility to provide you with direct information about treatment as well as my clinical recommendations. If you choose to terminate treatment, I can assist you in developing appropriate options, unless you choose otherwise. Individual and family sessions are 45 minutes in length. It is important for us to end on timeenergy, so I am able to document our session, review records and/or make collateral phone calls on your behalf. The frequency of sessions depends on clinical need and can be discussed at your first session and re-evaluated at subsequent sessions. My usual and customary fee for your first appointment, described as mindful about the “diagnostic assessment” or “intake” is $175.00. All other sessions (individual, family, collateral) are charged at $125.00 per session. Special evaluations/assessments (e.g. school/court related) are billed according to the breadth of the evaluation, duration of evaluation, and whether or not a formal report is required. Co-payments/session fees are due at the time of service. All payments for services are to be made by personal check, cash, or credit card. If your insurance company is being billed, I will make appropriate efforts to obtain payment; however, therapist you as the client are responsible for any outstanding charges that are not covered. A service fee of $25.00 per month shall apply to any accounts for which there is an outstanding balance, including payments which are late, or if there has been no payment made by you or your insurance company on the balance within the past 30 days. If your account has not been paid for more than 60 days and arrangements for payments have not been agreed upon, I have the option of using legal means to secure payment. By signing this agreement, you understand that you are responsible for reasonable attorney and legal fees for accounts that go to collections. Any service requested by you the client (e.g., court testimony, written treatment summaries/recommendations, attendance at PPT meetings) is billable to you personally at the regular session rate of $125.00 per hourchoose. If you have a briefquestions about my procedures, routine message please call and leave the message on my voice mailwe can discuss them at any time. If your doubts persist, you are having a may consult with another mental health emergencyprofessional for a second opinion. If we work together, or require urgent care, please call your local emergency services or proceed to your local emergency room. I check my voice mail twice per day and cannot guarantee that I will usually schedule one 50-minute session per week at a time we agree on, although sessions may be readily availablelonger or more frequent. Once an appointment is sched- uled, you will be expected to pay for it unless you provide at least 24 hours advance notice of cancellation. Please note that insurance companies do not provide reimbursement for cancelled sessions. If possible, I try will find another time to return messages within one business day. Phone calls are not to take place of a regular counseling sessionreschedule your appointment.

Counseling Services. Psychotherapy calls The purpose of treatment is to help clients resolve issues they have not felt successful in resolving on their own. Therapy is successful when clients complete established goals. The length of treatment depends upon the clients individualized treatment plan. Clients need to feel comfortable with their therapist as well as their therapist’s treatment methods. Depending on a client’s needs, different methods of therapy may be used. ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇ is an integrative psychotherapist. This means that she utilizes a number of treatment approaches including: EMDR, Cognitive Behavioral Therapy, Dialectical Behavioral Therapy, Mindfulness Based Stress Management, Internal Family Systems, Ego State Therapy, Gestalt Therapy, and Hakomi. This allows ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇ to tailor make your therapeutic experience to what will best suit your individual needs. For detailed information regarding the therapeutic approaches, please go to ▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇, click on ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, and then click on the “Services offered.” Together we will develop a personal treatment plan that outlines the major issues you wish to address. With this plan, we will see what combinations of approaches will be most beneficial in helping you best reach your goals. Upon reaching your goals, I ask that you participate in a closing session to review your accomplishments and also allow time for an active effort on me to assist you in identifying any support that might help you to maintain and enhance your partgrowth in the future. In order for counseling You are expected to be active participants while working collaboratively with your therapist to achieve your goals. You have the right to participate in important treatment decisions as well as in the development of your treatment plan. Periodically, we will review and revise your plan to keep up to date with your current situation. Therapy is most successful you will have when clients are willing to work on things in between counseling sessions. You may be asked to complete “homework assignments.” Therapy can have its benefits and its risks. It often involves discussing things that can be painful and you may also experience unpleasant feelings, such as: sadness, anger, guilt and loneliness. The benefits associated with working through unpleasant feelings can be great. Benefits may include, but are not limited to: happier-healthier relationships, a positive self- image, a sense of wellbeing and solutions to problems. There are no guarantees what your experience will be. The first session is a consultation and also the things we talk about during beginning of our session at homejourney together. In additionThe exploratory process may take a few sessions to complete. At this time, your responsibilities are the therapist will hear what you hope to provide relevantgain from therapy and will also answer any questions you may have. The therapist will share initial thoughts and a preliminary treatment plan. If the therapist does not believe she is the appropriate person to be working with you, accurate and complete information as to your history, symptoms, complaints, medication, and current status. Please make your best efforts to have relevant information (such as previous psychiatric evaluations, discharge summaries, school reports, etc.) ready at she may offer you the time names of your first session. As your therapist, I have the responsibility to ask you questions about you and your family’s history, as well as your feelings and actions. I also have the responsibility to provide you with direct information about treatment as well as my clinical recommendationsother counselors. If you choose do not believe the therapist is the right person for you, please do not hesitate to terminate treatmentsay so. Therapy often requires a significant amount of time, I can assist you in developing appropriate options, unless you choose otherwise. Individual finances and family sessions are 45 minutes in lengthemotional energy. It is important for us you to end on time, so I am able feel comfortable with your therapist. Please feel free to document our session, review records and/or make collateral phone calls on your behalfask any questions you may have. The frequency of sessions depends on clinical need and can be discussed at your first session and re-evaluated at subsequent sessions. My usual and customary fee for your first appointment, described as the “diagnostic assessment” or “intake” is $175.00. All other sessions (individual, family, collateral) are charged at $125.00 per session. Special evaluations/assessments (e.g. school/court related) are billed according to the breadth of the evaluation, duration of evaluation, and whether or not a formal report is required. Co-payments/session fees are due at the time of service. All payments for services are to be made by personal check, cash, or credit card. If your insurance company is being billed, I will make appropriate efforts to obtain payment; however, you as the client are responsible for any outstanding charges that are not covered. A service fee of $25.00 per month shall apply to any accounts for which there is an outstanding balance, including payments which are late, or if there has been no payment made by you or your insurance company on the balance within the past 30 days. If your account has not been paid for more than 60 days and arrangements for payments have not been agreed upon, I You have the option of using legal means right to secure payment. By signing this agreement, you understand that you are responsible for reasonable attorney and legal fees for accounts that go to collections. Any service requested by you refuse any recommended treatment at any time throughout the client (e.g., court testimony, written treatment summaries/recommendations, attendance at PPT meetings) is billable to you personally at the regular session rate of $125.00 per hour. If you have a brief, routine message please call and leave the message on my voice mailtherapeutic process. If you are having uncomfortable with any treatment recommendations, please speak with your therapist. Should you choose to end your therapy prior to meeting your therapeutic goals it is recommended that you schedule a closure session with your therapist. With the exception of unusual circumstances that involve danger to yourself and/or others, or if others have supplied information confidentially, you may examine and/or receive a copy of your clinical record (This does not include process notes taken during session). Your request will need to be in writing. Because these are professional records, they can be misinterpreted and/or upsetting to the untrained reader. For this reason, it is recommended that you initially review them in the presence of your therapist, or have them forwarded to another mental health emergencycounselor so you can discuss the contents. You may be charged a $ .20 per page copying fee. If the copying of the records lasts longer than 5 minutes, or require urgent care, please call your local emergency services or proceed to your local emergency room. I check my voice mail twice per day and cannot guarantee that I there will be readily availablean additional $3.00 per every 5 minutes of time to copy the requested records. • Initial Intake Session: 120 mins $360.00 • Subsequent Psychotherapy Sessions: • Intensive Treatment Sessions: 3-5 days in a row in 2-3 hour blocks Full day – 3 hours in morning, 3 hours in afternoon (Price depends on needs of client intensive chosen) • In addition to weekly appointments, I try charge a $180.00-per hour in 15 minute increments for other professional services. These services may include: o Report writing o Correspondence o Telephone conversations lasting longer than 10 minutes o Attendance at meetings with other professionals you have authorized o Preparation of records or treatment summaries o Time spent performing any other services you may request of me • If you are involved in legal proceedings that require my participation, you will be expected to return messages within one business daypay for all of my professional time, including participation, transportation, participation costs (even if another party calls me to testify). Phone calls are not Due to take place of a regular counseling sessionthe difficulties related to legal involvement, I charge $300.00-per hour for my participation in legal proceedings.

Counseling Services. Psychotherapy calls for an active effort The purpose of treatment is to help clients resolve issues they have not felt successful in resolving on your parttheir own. In order for counseling to be Therapy is most likely successful you will have to work on the things we talk about during our session at home. In addition, your responsibilities are to provide relevant, accurate when clients diligently pursue and complete information as established goals. The length of treatment depends upon the clients individualized treatment plan. Clients need to your history, symptoms, complaints, medication, and current status. Please make your best efforts to have relevant information (such as previous psychiatric evaluations, discharge summaries, school reports, etc.) ready at the time of your first session. As your therapist, I have the responsibility to ask you questions about you and your family’s history, feel comfortable with their therapist as well as your feelings and actionstheir therapist’s treatment methods. Depending on a client’s needs, different methods of therapy may be used. I have a master’s degree in professional counseling and am licensed by the State of Arizona’s Board of Behavioral Health Examiners. I am also certified by the National Board of Certified Counselors. I am an integrative psychotherapist. Generally, this means that I utilize and have been trained in a number of treatment approaches including: Eye Movement Desensitization and Reprocessing (EMDR), Cognitive Behavioral Therapy (CBT), Emotionally Focused Therapy (EFT) Dialectical Behavioral Therapy (DBT), Mindfulness Based Stress Management, Internal Family Systems, and Reality Therapy/Choice Theory (RT/CT). This allows me to tailor your therapeutic experience to what will likely best suit your individual needs. I provide counseling and consultation to adults, adolescents, couples, families, and groups. Together we will develop a personal treatment plan that outlines the major issues you wish to address. With this plan, we will see what combinations of approaches will be most beneficial in helping you best reach your goals. Upon reaching your goals, I ask that you participate in a closing session to review your accomplishments and also allow time for me to assist you in identifying any support that might help you to maintain and enhance your growth in the future. You are expected to actively participate while working collaboratively with me to achieve your goals. You have the responsibility right to provide you with direct information about participate in important treatment decisions as well as my clinical recommendationsin the development of your treatment plan. Periodically, we will review and revise your plan to keep up to date with your current situation. Therapy is most successful when clients are willing to work diligently on their personal treatment plan in between counseling sessions. Thus, you may be asked to complete “homework assignments.” Therapy can have its benefits and its risks. It often involves discussing things that can be painful and you may also experience unpleasant feelings, such as: sadness, anger, guilt and loneliness. The benefits associated with working through unpleasant feelings includes promoting healing, growth and lasting positive change. Benefits may also include, but are not limited to: happier-healthier relationships, a more positive self- image, a sense of wellbeing and solutions to problems. However, there are no guarantees what your experience will be. The first session is a consultation and also the beginning of our journey together. The exploratory process may take a few sessions to complete. I will hear what you hope to gain from therapy and will also answer any questions you may have. I will share initial thoughts and a preliminary treatment plan. If I do not believe I am the appropriate person to be working with you, I may offer you the names of other counselors. If you choose do not believe that I am the right person for you, please do not hesitate to terminate treatmentsay so. Therapy often requires a significant amount of time, I can assist you in developing appropriate options, unless you choose otherwise. Individual money and family sessions are 45 minutes in lengthemotional energy. It is important for us you to end on time, so I am able feel comfortable with me. Please feel free to document our session, review records and/or make collateral phone calls on your behalfask any questions you may have. The frequency of sessions depends on clinical need and can be discussed at your first session and re-evaluated at subsequent sessions. My usual and customary fee for your first appointment, described as the “diagnostic assessment” or “intake” is $175.00. All other sessions (individual, family, collateral) are charged at $125.00 per session. Special evaluations/assessments (e.g. school/court related) are billed according to the breadth of the evaluation, duration of evaluation, and whether or not a formal report is required. Co-payments/session fees are due at the time of service. All payments for services are to be made by personal check, cash, or credit card. If your insurance company is being billed, I will make appropriate efforts to obtain payment; however, you as the client are responsible for any outstanding charges that are not covered. A service fee of $25.00 per month shall apply to any accounts for which there is an outstanding balance, including payments which are late, or if there has been no payment made by you or your insurance company on the balance within the past 30 days. If your account has not been paid for more than 60 days and arrangements for payments have not been agreed upon, I You have the option of using legal means right to secure payment. By signing this agreement, you understand that you are responsible for reasonable attorney and legal fees for accounts that go to collections. Any service requested by you refuse any recommended treatment at any time throughout the client (e.g., court testimony, written treatment summaries/recommendations, attendance at PPT meetings) is billable to you personally at the regular session rate of $125.00 per hour. If you have a brief, routine message please call and leave the message on my voice mailtherapeutic process. If you are having uncomfortable with any treatment recommendations, please let me know immediately. Should you choose to end your therapy prior to meeting our goals it is recommended that you schedule a closure session with me. With the exception of circumstances that involve danger to yourself and/or others, or if others have supplied information confidentially, you may examine and/or receive a copy of your clinical record (This does not include process notes taken during session). Your request will need to be in writing. Because these are professional records, they can be misinterpreted and/or upsetting to the untrained reader. For this reason, it is recommended that you initially review them in my presence, or have them forwarded to another mental health emergencycounselor so you can better discuss the contents. You may be charged a $ .20 per page copying fee. If the copying of the records lasts longer than 5 minutes, there will be an additional charge of $3.00 for every 5 minutes of time to copy the requested records. • Therapy Sessions: 45-50 Min- $130.00 • Therapy Sessions: 80-90 Min- $195.00 • Longer or shorter sessions will be billed in 15 Min. increments. • In addition to weekly appointments, I charge a $130.00-per hour rate in 15 minute increments for other professional services you may need. These services may include, but are not limited to: Report writing, correspondence, telephone conversations lasting longer than 15 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and time I spend performing other professional services. • If you are involved in legal proceedings that require urgent caremy participation, please call your local emergency services or proceed you will be expected to your local emergency roompay for all of my professional time, including participation and transportation costs (even if another party requires my attendance). I check charge a minimum of $450.00 per hour for my voice mail twice per day and cannot guarantee that I will be readily available. I try to return messages within one business day. Phone calls are not to take place time in any matter associated with any type of a regular counseling sessionlegal proceedings.

Counseling Services. Psychotherapy The Right Direction will provide counseling services for Individuals, Adults, Couples, Adolescents, and Families. Counseling is not easily described in general statements. It varies depending on the personalities of the counselor and the client and the particular problems you bring forward. There are many different methods I may use to deal with the problems that you hope to address. Counseling is not like a medical doctor's visit. Instead, it calls for an a very active effort on your part. In order for counseling For the therapy to be most successful successful, you will have to work on the things we talk about both during our session sessions and at home. In additionCounseling can have benefits and risks. Since counseling often involves discussing unpleasant aspects of your life, your responsibilities are to provide relevantyou may experience uncomfortable feelings like sadness, accurate and complete information as to your historyguilt, symptomsanger, complaintsfrustration, medicationloneliness, and current statushelplessness. Please make your best efforts On the other hand, counseling has also been shown to have relevant information (such as previous psychiatric evaluationsbenefits for people who go through it. Counseling often leads to better relationships, discharge summariessolutions to specific problems, school reports, etc.) ready at the time and significant reductions in feelings of distress. But there are no guarantees of what you will experience. Our first few sessions will involve a biopsychosocial evaluation of your first sessionneeds. As your therapist, I have By the responsibility to ask you questions about you and your family’s history, as well as your feelings and actions. I also have the responsibility to provide you with direct information about treatment as well as my clinical recommendations. If you choose to terminate treatment, I can assist you in developing appropriate options, unless you choose otherwise. Individual and family sessions are 45 minutes in length. It is important for us to end on time, so I am able to document our session, review records and/or make collateral phone calls on your behalf. The frequency of sessions depends on clinical need and can be discussed at your first session and re-evaluated at subsequent sessions. My usual and customary fee for your first appointment, described as the “diagnostic assessment” or “intake” is $175.00. All other sessions (individual, family, collateral) are charged at $125.00 per session. Special evaluations/assessments (e.g. school/court related) are billed according to the breadth of the evaluation, duration I will be able to offer you some first impressions of evaluationwhat our work will include and a treatment plan to follow if you decide to continue with counseling. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Counseling involves a large commitment of time, money, and whether or not a formal report is required. Co-payments/session fees are due at energy, so you should be very careful about the time of service. All payments for services are to be made by personal check, cash, or credit card. If your insurance company is being billed, I will make appropriate efforts to obtain payment; however, counselor you as the client are responsible for any outstanding charges that are not covered. A service fee of $25.00 per month shall apply to any accounts for which there is an outstanding balance, including payments which are late, or if there has been no payment made by you or your insurance company on the balance within the past 30 days. If your account has not been paid for more than 60 days and arrangements for payments have not been agreed upon, I have the option of using legal means to secure payment. By signing this agreement, you understand that you are responsible for reasonable attorney and legal fees for accounts that go to collections. Any service requested by you the client (e.g., court testimony, written treatment summaries/recommendations, attendance at PPT meetings) is billable to you personally at the regular session rate of $125.00 per hourselect. If you have a briefany questions about my procedures, routine message please call and leave the message on my voice mailyou should discuss them whenever they arise. If you are having a mental health emergencyyour doubts persist, or require urgent care, please call your local emergency services or proceed to your local emergency room. I check my voice mail twice per day and cannot guarantee that I will be readily available. I try happy to return messages within one business day. Phone calls are not to take place give you the contact information of another clinician or help you set up a regular counseling sessionmeeting with another health professional for a second opinion.

Counseling Services. Psychotherapy is not easily described in general statements. Therapy varies depending on the personalities of the psychotherapist and client, and the particular problems you are experiencing. There are many different methods I may use to deal with the problems that you hope to address. Psychotherapy calls for an a very active effort on your part. In order for counseling the therapy to be most successful successful, you will have to work be working on the things we talk about both during our session sessions and at home. In additionMy theoretical orientation is generally Cognitive-Behavioral (CBT). However, your responsibilities I also rely on attachment theory and object relations to work on long-standing patterns. For individuals dealing with interpersonal and emotional issues, my approach is influenced by research that indicates the importance of relationships upon the formation of one’s personality. Your task is to express what you are to provide relevant, accurate thinking and complete information feeling as to your history, symptoms, complaints, medicationopenly as possible, and current statusmine is to listen and help you to understand yourself better, in order to more effectively deal with the problems you are facing. Please make Cognitive-Behavioral work is based on the theory that our thoughts about events lead to our emotions and behaviors and that we can have some control over these thoughts to improve our feelings and behaviors. This theory has shown very good results in research. Psychotherapy can have both risks and benefits. Since therapy often involves discussing troubling and unpleasant aspects of your best efforts to have relevant information (life, you may experience some discomfort with feelings such as previous psychiatric evaluationssadness, discharge guilt, anger, frustration, loneliness, and helplessness. Some of the benefits of therapy are that it can lead to better relationships, solutions to specific problems, and significant reductions in feelings of distress. There are no specific predictions, certainties, or guarantees of what you will experience. Our first few sessions will involve an evaluation of your needs. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a commitment of time, money, and energy; I will do my best to help you make the best use of these resources. If you have questions about my procedures or any aspects of my work with you, we will discuss them whenever they arise. If you have persisting questions or doubts, I will be happy to help you set up a meeting with another mental health professional for a second opinion or a referral to a different therapist. You have the right to refuse treatment. It is your responsibility to choose the provider and treatment modality that may best suit your needs. I will usually schedule one 50-minute sessions (one appointment hour of 50 minutes duration) per week at a time we agree on. Once an appointment hour is scheduled, you are responsible to pay for that time and will be billed for that hour unless you notify me of your cancellation at least 24 hours prior to the scheduled appointment. (If a cancellation is unavoidable and my schedule allows, I will schedule you at a different time.) I charge a fee of $25 for no show or late cancelled appointments. My hourly fee is $140. In addition to in-office appointments, I charge this amount for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 15 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, school reportsvideo taping and assessment, etc.) ready and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. I charge a $1400 retainer before becoming involved in legal proceedings. You will be expected to pay for each session at the time it is held, unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. In some cases monthly payment arrangements may be made. In circumstances of your first session. As your therapistunusual financial hardship, I have the responsibility may be willing to ask you questions about you and your family’s history, as well as your feelings and actions. I also have the responsibility to provide you with direct information about treatment as well as my clinical recommendations. If you choose to terminate treatment, I can assist you in developing appropriate options, unless you choose otherwise. Individual and family sessions are 45 minutes in length. It is important for us to end on time, so I am able to document our session, review records and/or make collateral phone calls on your behalf. The frequency of sessions depends on clinical need and can be discussed at your first session and re-evaluated at subsequent sessions. My usual and customary negotiate a fee for your first appointment, described as the “diagnostic assessment” adjustment or “intake” is $175.00. All other sessions (individual, family, collateral) are charged at $125.00 per session. Special evaluations/assessments (e.g. school/court related) are billed according to the breadth of the evaluation, duration of evaluation, and whether or not a formal report is required. Co-payments/session fees are due at the time of service. All payments for services are to be made by personal check, cash, or credit card. If your insurance company is being billed, I will make appropriate efforts to obtain payment; however, you as the client are responsible for any outstanding charges that are not covered. A service fee of $25.00 per month shall apply to any accounts for which there is an outstanding balance, including payments which are late, or if there has been no payment made by you or your insurance company on the balance within the past 30 daysinstallment plan. If your account has not been paid for more than 60 days and arrangements for payments payment have not been agreed upon, I have the option of using legal means to secure the payment. By signing this agreementThis may involve hiring a collection agency or going though small claims court which will require me to disclose otherwise confidential information. In most collection situations, you understand that you are responsible for reasonable attorney the only information I release regarding a client’s treatment is his/her name, the nature of the services provided, and the amount due. When such legal fees for accounts that go to collections. Any service requested by you the client (e.g.action is necessary, court testimony, written treatment summaries/recommendations, attendance at PPT meetings) is billable to you personally at the regular session rate of $125.00 per hour. If you have a brief, routine message please call and leave the message on my voice mail. If you are having a mental health emergency, or require urgent care, please call your local emergency services or proceed to your local emergency room. I check my voice mail twice per day and cannot guarantee that I its costs will be readily available. I try to return messages within one business day. Phone calls are not to take place of a regular counseling sessionincluded in the claim.

Counseling Services. Psychotherapy calls SUD therapy/counseling is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in the SUD counseling process, you have certain rights and responsibilities that are important for an you to understand. There are also legal limitations to those rights that you should be aware of. I, as your SUD counselor, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. SUD therapy/counseling has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of therapy often requires discussing the unpleasant aspects of your life. However, therapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Therapy requires a very active effort on your part. In order for counseling to be most successful successful, you will have want to work on the put into practice things we talk about during discuss outside of sessions. The first 2-3 sessions will involve a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some initial impressions of what our session at homework might include. In additionAt that point, we will discuss your responsibilities are to provide relevant, accurate treatment goals and complete create an initial treatment plan. You should evaluate this information as to your history, symptoms, complaints, medication, and current status. Please make your best efforts own assessment about whether you feel comfortable working with me. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to have relevant information (such as previous psychiatric evaluations, discharge summaries, school reports, etc.) ready help you set up a meeting with another SUD professional for a second opinion. PROFESSIONAL FEES The standard fee for a 50-minute individual session is $125.00 and the standard fee for a 90 minute couples session is $175.00 You are responsible for paying the full amount at the time of your first session. As your therapist, I have the responsibility to ask you questions about you and your family’s history, as well as your feelings and actions. I also have the responsibility to provide you with direct information about treatment as well as my clinical recommendations. If you choose to terminate treatment, I can assist you in developing appropriate options, unless you choose otherwiseprior arrangements have been made. Individual and family sessions are 45 minutes in length. It is important for us to end on time, so I am able to document our session, review records and/or make collateral phone calls on your behalf. The frequency of sessions depends on clinical need and can be discussed at your first session and re-evaluated at subsequent sessions. My usual and customary fee for your first appointment, described as the “diagnostic assessment” or “intake” is $175.00. All other sessions (individual, family, collateral) are charged at $125.00 per session. Special evaluations/assessments (e.g. school/court related) are billed according to the breadth of the evaluation, duration of evaluation, and whether or not a formal report is required. Co-payments/session fees are due at the time of service. All payments for services are to Payment must be made by personal check, cash, or credit card. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment. APPOINTMENTS Appointments will ordinarily be 45-60 minutes in duration, once per week at a time we agree on, although some sessions may be more, or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24-hours notice. If you miss a session without canceling, or cancel with less than 24-hour notice, my policy is to collect the full session fee of $125.00/individual or $175.00/couples. It is important to note that insurance company companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for 100% of the full rate. If it is being billedpossible, I will make appropriate efforts try to obtain payment; howeverfind another time to reschedule the appointment. In addition, you as the client are responsible for any outstanding charges that are not covered. A service fee of $25.00 per month shall apply coming to any accounts for which there is an outstanding balance, including payments which your session on time; if you are late, or if there has been no payment made by you or your insurance company on appointment will still need to end at the balance within the past 30 daysscheduled time. If your account has not been paid for more than 60 days and arrangements for payments have not been agreed uponFinally, I have the option right to terminate treatment after 2 missed appointments or habitual tardiness. Thank you for understanding. To schedule, cancel or change and appointment you may call, text or email me. You can expect a response before the end of using legal means to secure paymentthe business day. By signing this agreement, you understand that you are responsible INSURANCE I am not a participating provider for reasonable attorney and legal fees for accounts that go to collections. Any service requested by you the client (e.g., court testimony, written treatment summaries/recommendations, attendance at PPT meetings) is billable to you personally at the regular session rate of $125.00 per hourany insurance plan. If you would like, I will supply you with a receipt of payment for services, which you can submit to your insurance company for reimbursement. Please note that not all insurance companies reimburse for out-of-network providers. PROFESSIONAL RECORDS I am required to keep appropriate records of the SUD therapy/counseling services that I provide. Your records are maintained in a secured, encrypted, HIPAA compliant web-based system. I keep brief records noting that you were here, your reasons for seeking SUD therapy/counseling, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records I receive from other providers, copies of records I send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a briefcopy of your file. Because these are professional records, routine message please call they may be misinterpreted and leave the message on my voice mail/ or upsetting to untrained readers. If For this reason, I recommend that you are having a initially review them with me, or have them forwarded to another mental health emergency, or require urgent care, please call professional to discuss the contents. You also have the right to request that a copy of your local emergency services or proceed file be made available to any other health care provider at your local emergency room. I check my voice mail twice per day and cannot guarantee that I will be readily available. I try to return messages within one business day. Phone calls are not to take place of a regular counseling sessionwritten request.

Counseling Services. Psychotherapy calls People choose to participate in counseling for a variety of reasons. For most, the purpose of counseling is to generally improve one’s overall quality of life by addressing issues of concern, such as anxiety, depression, marital difficulties, addiction, or grief. Individual experiences in counseling can be different, depending on factors such as the personalities of the client and therapist, the mode of counseling techniques that the therapist utilizes, the issue(s) being addressed, and the amount of effort that the client puts forth. Your initial sessions with Encourage Counseling Services will involve an active effort on evaluation of your partneeds. By the end of the evaluation, your therapist will be able to offer you some first impressions of what your work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with us. Therapy involves a commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about our procedures, you should discuss them with your therapist whenever they arise. If you wish, we will willingly provide you with referrals to other mental health professionals for a second opinion, as you always have the right to choose to continue to receive counseling services from us or to ask to be referred to someone else. Following the assessment period, which is typically one to two sessions, one 50-minute session will be scheduled per week. Sessions will occur at a time you and your therapist agree upon, although sessions may be scheduled more or less frequently according to your needs. It is important to note that if you are late to your appointment, your session will still end at the originally scheduled time. It should be noted that therapy can have benefits, as well as potential risks. Since therapy oftentimes involves discussing difficult aspects of your life, you may experience uncomfortable feelings such as sadness, guilt, anger, frustration, loneliness, and helplessness. Making changes in your beliefs or behaviors can be anxiety provoking, and can be disruptive to your current relationships. However, therapy has also been shown to have many benefits. For example, therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. Of course, every individual’s experience is different and there are no guarantees of what you will experience. It is important that you carefully consider whether these risks are worth the benefits to you of changing. Most people who take these risks find that therapy is helpful. Finally, the therapeutic relationship is ended after the last scheduled appointment, or when so stated by you or your therapist. As the client, you typically will be the one who decides when therapy will end, which usually occurs once you and your therapist agree that you have met your treatment goals. However, there are a few exceptions. One such exception is if your therapist does not believe that he/she is professionally able to meet your needs. This could possibly be because your therapist does not believe that he/she holds the proper training and skills to help you, due to the type of presenting problem that you have. In order such a situation your therapist will refer you to another therapist who may be able to meet your counseling needs. Professional Training and Approach to Therapy Your therapist through Encourage Counseling Services, ▇▇▇ ▇▇▇▇▇▇▇, holds a Master’s of Science Degree in Counseling Psychology, earned in 2003 at Northwest Missouri State University. She is a Licensed Professional Counselor in the state of Missouri. She is a professional member of the American Counseling Association, as well as the Missouri chapter of this organization. ▇▇▇ specializes in working with adult women, children, and families, and has a significant amount of experience in working with clients in the areas of trauma, anxiety, depression, grief, behavioral issues, and parenting. She utilizes a Cognitive Behavioral approach in her work, which is a philosophy of psychotherapy that evaluates the relationship between thoughts and emotions as behavior change. In her work with families she also utilizes a Family Systems approach, which entails addressing individual concerns to improve the overall functioning of a family. ▇▇▇ also uses a variety of techniques in therapy, depending on what will work best for counseling the client. Contacting Your Therapist If you need to speak with your therapist outside of your scheduled appointment time, you may leave a voicemail message with your contact information and your call will be returned within 48 hours. Your therapist will make every effort to return your call on the same day, with the exception of weekends and holidays. Encourage Counseling Services is not an emergency provider. Thus, in an emergency situation you are instructed to call 9-1-1 or the 24-hour Emergency Service Crisis Line (▇-▇▇▇-▇▇▇-▇▇▇▇). In addition, in the unlikely event that your therapist is unable to provide ongoing services, ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇, LPC (816-507-8896) will provide those services or will refer you to the appropriate resource. If you elect to communicate with your therapist by email, please be aware that email is not completely confidential. All emails are retained in the logs of your or your therapist’s internet service providers. While under normal circumstances these logs are not viewed, they are, in theory, available to be read by the system administrator(s) of the internet service provider. Any email that your therapist receives from you, and any responses that your therapist sends to you, will be printed out and kept in your treatment record. Confidentiality With the exception of the specific situations described below, you have the absolute right to the confidentiality of your therapy. This confidentiality is protected under the provisions of the federal Health Insurance Portability and Accountability Act (HIPAA). For detailed information regarding your rights regarding the protection of your Personal Health Information (PHI) please refer to the attached Notice of Privacy Practices, which reports when PHI may be used for treatment, payment, and health care options. By initialing you are indicating that you have also been provided with and read a copy of the Notice of Privacy Practices. In most successful situations, your therapist can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. This includes permission to inform your primary care physician and/or your psychiatrist that he/she is providing counseling services to you. It may be helpful for your therapist to confer with your medical professional with regard to your psychological treatment or to discuss any medical problems for which you are receiving treatment. If you agree to have your therapist inform your primary care physician and/or psychiatrist of the counseling services you are receiving, please indicate as such in the appropriate check box below, and provide his/her name and contact information. Physician Phone There are other situations that require only that you provide written, advance consent. Your signature on this agreement provides consent for those activities, as follows:  Your therapist may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, your therapist makes every effort to avoid revealing the identity of the client. The other professionals are also legally bound to keep the information confidential. All consultations will be noted in your clinical record.  If your insurance company is paying for a portion of or all of your counseling services, records containing your mental health diagnosis and dates of service must be provided to them.  If your therapist has reasonable cause to suspect that a child or an elderly or disabled adult has been or may be subjected to abuse or neglect, or observes such persons being subjected to such conditions or circumstances, the law requires that your therapist file a report with appropriate authorities.  If your therapist believes that you are in imminent danger of harming yourself, your therapist may legally break confidentiality and take protective action. These actions may include initiating hospitalization, contacting the police, and/or contacting your family.  If your therapist has reason to believe that you will harm another person, your therapist must attempt to inform that person and warn him/her of your intentions. Your therapist must also contact the police and ask them to protect your intended victim.  If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the above listed confidentiality laws. Your therapist cannot provide any information without your or your legal representative’s written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order your therapist to disclose information. Professional Records Your therapist will keep professional records of your therapy sessions and the therapeutic services that you receive, which will be maintained in a secure location that cannot be accessed by anyone else. These records will include information about your reasons for seeking therapy, your diagnosis, the goals that are set for treatment, your progress toward those goals, your medical, social, and treatment history, and any past treatment records that your therapist receives from other providers. Your clinical record will also include reports of any professional consultations, your billing records, and any reports that have been sent to work on the things we talk about during our session at homeanyone, including reports to your insurance carrier (if applicable). In addition, your responsibilities are to provide relevantclinical record will include information regarding the dates that therapy sessions occurred, accurate and complete information as to your history, symptoms, complaints, medicationinterventions that were utilized, and current statustopics that were discussed. Please You have the right to a copy of your file at any time, giving your therapist adequate time to make a copy for you. However, since psychological records are usually written in terminology that is difficult to understand, it is encouraged that you schedule an appointment with your best efforts therapist to review your records under his/her supervision and care. This service is provided free of charge. You also have relevant information the right to request that your therapist correct any errors in your file. In addition, you have the right to request that your therapist make a copy of your file available to any other health care provider or agency, upon your written request. Your records will be kept for seven years past the date of service; after that time they are destroyed and unavailable. In the event of your therapist’s death or incapacitation, your records will be stored by another practitioner for seven years, and will be available to you during that time. In such an event, ▇▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇, LPC (816-507-8896) has agreed to store such as previous psychiatric evaluations, discharge summaries, school reports, etc.) ready records. Professional Fees / Payments The fee for each counseling session is $100. You are responsible for full payment at the time of your first session. As your therapistservice, I have the responsibility to ask you questions about unless you and your family’s historytherapist have made other arrangements, as well as your feelings and actions. I also have the responsibility to provide you with direct information about treatment as well as my clinical recommendationsin writing, in advance. If your health insurance company is paying for the services you choose to terminate treatmentreceive, I can assist you in developing are responsible for paying appropriate options, unless you choose otherwise. Individual co-pays and family sessions are 45 minutes in length. It is important for us to end on time, so I am able to document our session, review records and/or make collateral phone calls on your behalf. The frequency of sessions depends on clinical need and can be discussed at your first session and re-evaluated at subsequent sessions. My usual and customary fee for your first appointment, described as the “diagnostic assessment” or “intake” is $175.00. All other sessions (individual, family, collateral) are charged at $125.00 per session. Special evaluations/assessments (e.g. school/court related) are billed according to the breadth of the evaluation, duration of evaluation, and whether or not a formal report is required. Co-payments/session fees are due deductibles at the time of service. All payments In addition to weekly appointments, your therapist will charge this amount for other professional services you may need, though the hourly cost will be broken down for work lasting for shorter periods of time than one hour. Other services include report writing, telephone conversations lasting longer than 15 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of your therapist. If you become involved in legal proceedings that require your therapist’s participation, you will be expected to pay for all of your therapist’s professional time, including preparation and transportation costs, even if he/she is called to testify by another party. Fees for legal proceedings are $100 per hour and will be requested in advance of any work performed. Once an appointment hour is scheduled, you will be expected to be made by personal check, cashpay the assigned fee unless you provide 24-hours advance notice of cancellation, or credit cardunless you were unable to attend due to circumstances beyond your control (e.g., illness or poor weather conditions). If your insurance company is being billed, I will make appropriate efforts to obtain payment; howeverOtherwise, you as will be responsible for paying for the client missed session at your next scheduled session. (It should be noted that insurance companies typically do not reimburse for cancelled sessions, so you are responsible for any outstanding charges that are payment.) Three sessions without payment will cancel future sessions until the account is paid in full. In addition, if your account should remain unpaid for more than 90 days, you will not covered. A service fee of $25.00 per month shall apply be able to any accounts receive services from Encourage Counseling Services until your account is paid for which there is an outstanding balance, including payments which are late, with the agreed upon terms or if there has been no payment made by you or your insurance company on the balance within the past 30 dayswill be referred to seek alternative mental health assistance. If your account has not been paid for more than 60 90 days and arrangements for payments payment have not been agreed upon, I have Encourage Counseling Services has the option of using legal means to secure the payment. By signing this agreementThis may involve hiring a collection agency, notification of the credit bureau, or going through small claims court which will require us to disclose otherwise confidential information. In most collection situations, the only information released regarding a client’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. Insurance Coverage If you understand plan to utilize your health insurance for your counseling services, it is important that you discover exactly what mental health services your insurance policy covers, and obtain preauthorization as necessary. Your therapist will assist you in receiving the benefits to which you are entitled; you are responsible for reasonable attorney providing appropriate information, such as your complete insurance identification information and legal any preauthorization codes, to your therapist in order for him/her to do so. It should also be noted that insurance companies typically do not accept bills from therapists unless they are on their preferred provider list. If your therapist is not a preferred provider for your particular health insurance company, you may still choose to submit claims to obtain reimbursement for your counseling services. However, in such cases you are responsible for full payment of fees and submitting claims for accounts that go to collections. Any service requested by you the client (e.g., court testimony, written treatment summaries/recommendations, attendance at PPT meetings) is billable to you personally at the regular session rate reimbursement of $125.00 per hourfees. If you choose to have your counseling services paid for in full or in part by your insurance company, there are typically additional limitations to your rights as a briefclient imposed by the contract of the managed care firm. These may include their decision to limit the number of sessions available to you, routine message please call and leave to decide the message time period within which you must complete your therapy, or to require you to use medication if their reviewing professional deems it appropriate. Your managed care firm may also decide that you must see another therapist in their network rather than your therapist through Encourage Counseling Services, if he/she is not on my voice mailtheir list of providers. If You should also be aware that your contract with your health insurance company requires that your therapist provide information relevant to the services that you are having provided. Your therapist is required to provide a clinical mental health emergencydiagnosis. Your therapist may be required to provide additional clinical information such as treatment plans or summaries, or require urgent carecopies of your entire clinical record. In such situations, please call your local emergency services or proceed therapist will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files. Though all insurance companies claim to keep such information confidential, your local emergency room. I check my voice mail twice per day and cannot guarantee that I will be readily available. I try to return messages within one business day. Phone calls are not to take place of a regular counseling session.therapist has no control over what

Counseling Services. Your first appointment (or more, in some cases) will involve an assessment of your needs. By the end of the assessment I will be able to offer you some first impressions of what your work may include and recommendation for getting help. One of the recommendations may be a psychotherapy. If so, I may or may not be able to provide you with psychotherapy, depending on your overall needs. If psychotherapy or any other recommendations suggested by me include things that I cannot provide, you will be given suggestions of where you might receive those services. Wherever you choose to obtain treatment or not, you should evaluate the information from your initial assessment along with your own opinions of what sort of treatment you are willing to do and whether you feel comfortable within with the treating clinician. Therapy involves a large commitment of time, energy, and often money, so you should be very careful about the therapist you select. If you have questions about the procedures used or conclusions made by me, ▇▇▇▇ ▇. ▇▇▇▇▇, LPC, please discuss them wherever they arise. If your doubts persist, I will be happy to offer referrals to you with another mental health professional for a 2nd opinion. Psychotherapy is not easily described in general statements. It varies depending on the particular problems you are experiencing, the therapeutic methods used by your counselor, and the personalities of the counselor and clients. There are many different methods counselors may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for an a very active effort on your part. In order for counseling the therapy to be most successful you will have to work on the things we talk about that are discussed both during our your session at home. In additionand on your own Psychotherapy can have benefits and risks since therapy is often involves discussing unpleasant aspects of your life, your responsibilities are to provide relevantyou may experience uncomfortable feelings like sadness, accurate and complete information as to your historyguilt, symptomsanger, complaintsshame, medicationfrustration, loneliness, and current statushelplessness. Please make The changes you ▇▇▇ in therapy may also affect your best efforts relationships in unexpected ways. Psychotherapy has also been shown to have relevant information (such as previous psychiatric evaluationsbenefits. Therapy often leads to better relationships, discharge summaries, school reports, etcsolutions to specific problems and significant reductions in feelings of distress. But there are no guarantees of what you will experience.) ready at the time of your first session. As your therapist, I have the responsibility to ask you questions about you and your family’s history, as well as your feelings and actions. I also have the responsibility to provide you with direct information about treatment as well as my clinical recommendations. If you choose to terminate treatment, I can assist you in developing appropriate options, unless you choose otherwise. Individual and family sessions are 45 minutes in length. It is important for us to end on time, so I am able to document our session, review records and/or make collateral phone calls on your behalf. The frequency of sessions depends on clinical need and can be discussed at your first session and re-evaluated at subsequent sessions. My usual and customary fee for your first appointment, described as the “diagnostic assessment” or “intake” is $175.00. All other sessions (individual, family, collateral) are charged at $125.00 per session. Special evaluations/assessments (e.g. school/court related) are billed according to the breadth of the evaluation, duration of evaluation, and whether or not a formal report is required. Co-payments/session fees are due at the time of service. All payments for services are to be made by personal check, cash, or credit card. If your insurance company is being billed, I will make appropriate efforts to obtain payment; however, you as the client are responsible for any outstanding charges that are not covered. A service fee of $25.00 per month shall apply to any accounts for which there is an outstanding balance, including payments which are late, or if there has been no payment made by you or your insurance company on the balance within the past 30 days. If your account has not been paid for more than 60 days and arrangements for payments have not been agreed upon, I have the option of using legal means to secure payment. By signing this agreement, you understand that you are responsible for reasonable attorney and legal fees for accounts that go to collections. Any service requested by you the client (e.g., court testimony, written treatment summaries/recommendations, attendance at PPT meetings) is billable to you personally at the regular session rate of $125.00 per hour. If you have a brief, routine message please call and leave the message on my voice mail. If you are having a mental health emergency, or require urgent care, please call your local emergency services or proceed to your local emergency room. I check my voice mail twice per day and cannot guarantee that I will be readily available. I try to return messages within one business day. Phone calls are not to take place of a regular counseling session.

Counseling Services. Psychotherapy calls for an Counseling is not easily described in general statements. It varies depending on the personality of the counselor and the client, as well as the problems and challenges you bring forward. There are many different methods I may use to deal with the problems you want to address. Counseling is not like a medical doctor visit. Instead, it requires a very active effort effort on your part. In order for the counseling to be most successful successful, you will have need to work on the things areas we talk about both during our session at homesessions and especially in between sessions. In addition, your responsibilities are to provide relevant, accurate Counseling can have both benefits and complete information as to your history, symptoms, complaints, medication, and current statusrisks. Please make your best efforts to have relevant information (such as previous psychiatric evaluations, discharge summaries, school reports, etc.) ready at the time Since counseling often involves discussing unpleasant aspects of your first sessionlife, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness and helplessness. As Counseling often leads to better relationships, solutions to specific problems and significant reductions in feelings of distress, however, there are no guarantees of what you will experience. By signing this document, you agree to not hold Cara Damier liable or responsible for any results or outcomes of counseling or coaching and to also not seek out legal action against ▇▇▇▇ ▇▇▇▇▇▇ for any reason. Our first few sessions will involve an evaluation of your therapist, I have needs. By the responsibility to ask you questions about you and your family’s history, as well as your feelings and actions. I also have the responsibility to provide you with direct information about treatment as well as my clinical recommendations. If you choose to terminate treatment, I can assist you in developing appropriate options, unless you choose otherwise. Individual and family sessions are 45 minutes in length. It is important for us to end on time, so I am able to document our session, review records and/or make collateral phone calls on your behalf. The frequency of sessions depends on clinical need and can be discussed at your first session and re-evaluated at subsequent sessions. My usual and customary fee for your first appointment, described as the “diagnostic assessment” or “intake” is $175.00. All other sessions (individual, family, collateral) are charged at $125.00 per session. Special evaluations/assessments (e.g. school/court related) are billed according to the breadth of the evaluation, duration I will be able to offer you some first impressions of evaluationwhat our work will entail and develop a treatment plan to follow should you decide to continue with counseling. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Counseling involves a significant commitment of time, money and energy, so you should be very careful about the counselor you select. If you have any questions about my approach or procedures, we should discuss them whenever they arise. This agreement is for Counseling or Coaching. While counseling and coaching can work with issues such as identifying and reaching life goals, and whether or changing the behaviors that aren’t working well for you, counseling/coaching is not a formal report is requiredintended to work through issues such as schizophrenia and suicidal behaviors. Co-payments/session fees are due at the time of service. All payments for services are to be made by personal check, cash, or credit card. If your insurance company is being billed, I will make appropriate efforts to obtain payment; howeverFor issues such as these, you as the client are responsible for any outstanding charges that are not covered. A service fee of $25.00 per month shall apply to any accounts for which there is an outstanding balance, including payments which are late, must see a Physician or if there has been no payment made by you or Licensed Mental Health Professional in your insurance company on the balance within the past 30 days. If your account has not been paid for more than 60 days and arrangements for payments have not been agreed upon, I have the option of using legal means to secure paymentlocation. By signing this agreement, you understand are agreeing that you are responsible understand the difference in these two functions and you will get appropriate professional help for reasonable attorney and legal fees for accounts that go to collections. Any service requested by you the client (e.g., court testimony, written treatment summaries/recommendations, attendance at PPT meetings) is billable to you personally at the regular session rate of $125.00 per hour. If you have a brief, routine message please call and leave the message on my voice mail. If you are having a mental health emergencyissues if necessary. Please feel free to ask questions at any time about your counselor’s/coach’s background, or require urgent care, please call your local emergency services or proceed to your local emergency room. I check my voice mail twice per day experience and cannot guarantee that I will be readily available. I try to return messages within one business day. Phone calls are not to take place of a regular counseling sessionprofessional orientation.

Counseling Services. Psychotherapy Therapy varies depending on the personalities of the therapist and client, and the particular problems you are experiencing. There are many different methods we may use to deal with the problems that you hope to address. Therapy is not like a medical doctor visit. Instead, it calls for an a very active effort on your part. In order for counseling the therapy to be most successful successful, you will have to work on the things we talk about both during our session sessions and at home. In additionHomework will often be given when deemed necessary for therapy. Therapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, your responsibilities are you may experience uncomfortable feelings. On the other hand, therapy has also been shown to provide relevanthave many benefits. Therapy often leads to better relationships, accurate and complete information as solutions to your history, symptoms, complaints, medicationspecific problems, and current statussignificant reductions in feelings of distress. Please make your best efforts to have relevant information (such as previous psychiatric evaluations, discharge summaries, school reports, etc.) ready at the time But there are no guarantees of what you will experience. Our first few sessions will involve an evaluation of your first sessionneeds. As your therapist, I have By the responsibility to ask you questions about you and your family’s history, as well as your feelings and actions. I also have the responsibility to provide you with direct information about treatment as well as my clinical recommendations. If you choose to terminate treatment, I can assist you in developing appropriate options, unless you choose otherwise. Individual and family sessions are 45 minutes in length. It is important for us to end on time, so I am able to document our session, review records and/or make collateral phone calls on your behalf. The frequency of sessions depends on clinical need and can be discussed at your first session and re-evaluated at subsequent sessions. My usual and customary fee for your first appointment, described as the “diagnostic assessment” or “intake” is $175.00. All other sessions (individual, family, collateral) are charged at $125.00 per session. Special evaluations/assessments (e.g. school/court related) are billed according to the breadth of the evaluation, duration I will be able to offer you some first impressions of evaluationwhat our work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and whether or not a formal report is required. Co-payments/session fees are due at energy, so you should be very careful about the time of service. All payments for services are to be made by personal check, cash, or credit card. If your insurance company is being billed, I will make appropriate efforts to obtain payment; however, therapist you as the client are responsible for any outstanding charges that are not covered. A service fee of $25.00 per month shall apply to any accounts for which there is an outstanding balance, including payments which are late, or if there has been no payment made by you or your insurance company on the balance within the past 30 days. If your account has not been paid for more than 60 days and arrangements for payments have not been agreed upon, I have the option of using legal means to secure payment. By signing this agreement, you understand that you are responsible for reasonable attorney and legal fees for accounts that go to collections. Any service requested by you the client (e.g., court testimony, written treatment summaries/recommendations, attendance at PPT meetings) is billable to you personally at the regular session rate of $125.00 per hourselect. If you have a briefquestions about any procedures, routine message please call and leave the message on my voice mailwe should discuss them whenever they arise. If you are having a mental health emergencyyour doubts persist, or require urgent care, please call your local emergency services or proceed to your local emergency room. I check my voice mail twice per day and cannot guarantee that I will be readily availablehappy to help you set up a meeting with another mental health professional for a second opinion. My goal is for you to ultimately get the help you need, whether that is with me or with another therapist. If therapy is begun, we will usually schedule one 50-minute session (one appointment hour of 50 minutes duration) at a time we agree on, although some sessions may be longer or more frequent. Please be on time as I try to return messages within one business day. Phone calls are not to take place of a regular counseling sessionwill often have another session scheduled after you.

Counseling Services. Psychotherapy Counseling is not easily described in general statements. It varies depending on the personalities of the counselor and client, and the particular problems you bring forward. There are many different methods I may use to deal with the problems that you hope to address. Counseling is not like a visit to your family doctor. Instead, it calls for an a very active effort on your part. In order for the counseling to be most successful successful, you will have to work on the things we talk about both during our session sessions and at home. In additionCounseling can have benefits and risks. Since counseling often involves discussing unpleasant aspects of your life, your responsibilities you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, counseling has also been shown to have benefits for people who go through it. Counseling often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience. During the time of initial assessment, we can both decide if I am the best person to provide relevantthe services you need in order to meet your treatment goals. If counseling is begun, accurate I will schedule one appointment hour of not more than 50 minutes duration at a frequency and complete information as time we agree on, although some sessions may be longer or frequency may change. Once an appointment hour is scheduled, you will be expected to attend unless you provide 24 hours advance notice of cancellation, or unless we both agree that you were unable to attend due to circumstances beyond your historycontrol. You will be expected to pay $50 if you cancel less than 24 hours in advance and $70 if you provide no notice of cancellation since insurance providers do not pay for missed sessions. Mental Health/Substance Abuse Evaluation $185 for 45 - 50 minute session Individual / Couples Counseling Session $135 for 45 - 50 minute session Attendance At Any legal Proceeding (including preparation, symptoms, complaints, medicationtravel to and from court, and current statustime spent at the legal proceeding) $200 per hour Consultation (including report writing, phone conversation, text or email over 10 minutes) $60 per hour You will be expected to pay for each session at the time it is held unless you have insurance coverage. Please make your best efforts If you have insurance coverage, I will accept the insurance reimbursement for covered services and will only expect co-pay fees, if any, to have relevant information (such as previous psychiatric evaluations, discharge summaries, school reports, etc.) ready be paid at the time of your first sessionservice unless we agree otherwise. As your therapistIn circumstances of unusual financial hardship, I have the responsibility may be willing to ask you questions about you and your family’s history, as well as your feelings and actions. I also have the responsibility to provide you with direct information about treatment as well as my clinical recommendations. If you choose to terminate treatment, I can assist you in developing appropriate options, unless you choose otherwise. Individual and family sessions are 45 minutes in length. It is important for us to end on time, so I am able to document our session, review records and/or make collateral phone calls on your behalf. The frequency of sessions depends on clinical need and can be discussed at your first session and re-evaluated at subsequent sessions. My usual and customary fee for your first appointment, described as the “diagnostic assessment” or “intake” is $175.00. All other sessions (individual, family, collateral) are charged at $125.00 per session. Special evaluations/assessments (e.g. school/court related) are billed according to the breadth of the evaluation, duration of evaluation, and whether or not negotiate a formal report is required. Co-payments/session fees are due at the time of service. All payments for services are to be made by personal check, cash, or credit card. If your insurance company is being billed, I will make appropriate efforts to obtain payment; however, you as the client are responsible for any outstanding charges that are not covered. A service fee of $25.00 per month shall apply to any accounts for which there is an outstanding balance, including payments which are late, or if there has been no payment made by you or your insurance company on the balance within the past 30 daysinstallment plan. If your account has not been paid for more than 60 days and arrangements for payments payment have not been agreed upon, I have the option of using legal means to secure the payment. By signing this agreementThis may involve going through small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information I release regarding a client's treatment is his or her name, the nature of services provided, and the amount due. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you understand that you are responsible have available to pay for reasonable attorney and legal fees for accounts that go to collections. Any service requested by you the client (e.g., court testimony, written treatment summaries/recommendations, attendance at PPT meetings) is billable to you personally at the regular session rate of $125.00 per houryour treatment. If you have a briefhealth insurance policy, routine message please it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. For example, certain insurance providers may not allow some services and you will be expected to pay for all services not covered by your insurance plan. It is very important that you find out exactly what mental health services your insurance policy covers. You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. I am sometimes not immediately available by telephone. I probably will not answer the phone when I am with a client. When I am unavailable, my telephone is answered by voice mail that I continually monitor. I will return your call and leave on the message on my voice mailsame day. If you are having a mental health difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or call Rescue Mental Health Services at 419.255.2801. If it is an emergency, call 911 or require urgent care, please call your local go to the nearest emergency services or proceed to your local emergency roomroom and ask for the psychiatrist on call. I check my voice mail twice per day and cannot guarantee that If I will be readily available. unavailable for an extended time, I try to return messages within one business day. Phone calls are not to take place will provide you with the name of a regular counseling sessioncolleague to contact, if necessary.

Counseling Services. Your first appointment (or more, in some cases) will involve an assessment of your needs. By the end of the assessment your counselor will be able to offer you some first impressions of what your work may include and recommendations for getting help. One of the recommendations may be psychotherapy. If so, ABO may or may not be able to provide you with psychotherapy, depending on your overall needs. If psychotherapy or any other recommendations suggested by your counselor include things that ABO cannot provide, you will be given suggestions of where you might receive those services. Wherever you choose to obtain treatment, you should evaluate the information from your initial assessment along with your own opinions of what sort of treatment you are willing to do and whether you feel comfortable working with the treating clinician. Therapy involves a large commitment of time, energy, and often money, so you should be very careful about the therapist you select. If you have questions about the procedures used or conclusions made by your counselor at ABO, please discuss them whenever they arise. If your doubts persist, your counselor will be happy to help you set up a meeting with another mental health professional for a second opinion. Psychotherapy is not easily described in general statements. It varies depending on the particular problems you are experiencing, the therapeutic methods used by your counselor, and the personalities of the counselor and client. There are many different methods counselors may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for an a very active effort on your part. In order for counseling the therapy to be most successful successful, you will have to work on the things we talk about that are discussed both during our session at homeyour sessions and on your own. In additionPsychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, your responsibilities are to provide relevantyou may experience uncomfortable feelings like sadness, accurate and complete information as to your historyguilt, symptomsanger, complaintsshame, medicationfrustration, loneliness, and current statushelplessness. Please The changes you make in therapy may also affect your best efforts relationships in unexpected ways. Psychotherapy has also been shown to have relevant information (such as previous psychiatric evaluationsmany benefits. Therapy often leads to better relationships, discharge summariessolutions to specific problems, school reportsand significant reductions in feelings of distress. But there are no guarantees of what you will experience. The initial assessment will last from one to two sessions. During this time, etc.) ready at the time of your first session. As your therapist, I have the responsibility to ask you questions about you and your family’s history, as well as your feelings and actions. I also have counselor can both decide if she/he is the responsibility best person to provide the services you with direct information about need in order to meet your treatment as well as my clinical recommendationsgoals. If psychotherapy is begun, your counselor will usually schedule one meeting per week at a time you each agree on. Once an appointment is scheduled, you will be expected to attend unless you provide advance notice of cancellation. If you choose need to terminate treatmentcancel an appointment, I can assist you in developing appropriate optionsit is your responsibility to contact us to cancel. Fees will be collected when services are rendered. In addition to therapy services fees may include assessment administration, unless you choose otherwisescoring, and reporting; creating reports; creating copies of records on request; and consulting with other professionals at the client’s request. Individual and family sessions There will be an additional $25 fee assessed for any returned check. We understand that there are 45 minutes in lengthunforeseeable circumstances like sick children or bad weather. It Your appointment is important for us to end on time, so I am able to document our session, review records and/or make collateral phone calls on your behalf. The frequency of sessions depends on clinical need and can be discussed at your first session and re-evaluated at subsequent sessions. My usual and customary fee for your first appointment, described as the “diagnostic assessment” or “intake” is $175.00. All other sessions (individual, family, collateral) are charged at $125.00 per session. Special evaluations/assessments (e.g. school/court related) are billed according to the breadth of the evaluation, duration of evaluationthough, and whether your therapist is happy to contact you for a phone session or not a formal report is requiredsession via our HIPPA-compliant virtual therapy system so you don't need to leave your sick child or worry about traffic and weather. Co-payments/session fees are due at the time of service. All payments for services are to be made by personal check, cash, or credit card. If your insurance company is being billed, I will make appropriate efforts to obtain payment; however, you As long as the client are responsible for any outstanding charges that are not covered. A service fee of $25.00 per month shall apply to any accounts for which there is an outstanding balance, including payments which are late, or if there has been no payment made by you or your insurance company on the balance within the past 30 days. If your account has not been paid for more than 60 days and arrangements for payments have not been agreed upon, I have the option of using legal means to secure payment. By signing this agreement, you understand that you are responsible for reasonable attorney and legal fees for accounts that go to collections. Any service requested by in a confidential location, we can help you the client (e.g., court testimony, written treatment summaries/recommendations, attendance at PPT meetings) is billable to you personally at the regular session rate of $125.00 per hourkeep your regularly scheduled appointment. If you have still must change or cancel your counseling appointment please know: • Cancellations must be made during business hours. • Cancellations must be made within 48 hours of session time if using our online scheduling program. • We cannot accommodate cancellations made via email as we do not monitor email on a brief, routine message please call and leave the message regular basis. • We cannot accommodate cancellations made after hours or on my holidays to our main number as we do not accept voice mail. If you have an appointment on a Monday or the first day following a holiday, you must make your change or cancellation the last business day before your appointment. • Cancellations with less than 24 hours notice will result in a fee equal to the total amount of the missed session that will be collected at your next appointment, or, if payment information is on file, it will be debited from your credit card. • After two no-shows/late cancellations, you will pre-pay a retainer before scheduling any future appointments. • Clients who have pre-paid agree to have the entire fee deducted from their pre-payment in cases of other no-shows and late changes/cancellations. • Court testimony costs begin at $250 per hour with a minimum charge of three hours. A retainer of $1000 is due one week prior to the court date. Travel is billed at .55/mile. Failure to provide the specific fees as described constitutes a release from the requested court appearance. • It is required that a minimum of 36 hours’ notice be given if the testimony is not required, otherwise the entire retainer is forfeited. If proper notice is given, the retainer will be refunded. • Additional services related to court preparation including all correspondence with attorneys or other service providers via phone, email, or letter, documentation review and/or documentation preparation are having a also billed at $250 per hour, rounded to the nearest 15 minute increment. You (not your insurance company) are responsible for full payment of fees. It is very important that you find out exactly what mental health emergencyservices your insurance policy covers. You must pay your ▇▇▇▇ first, then contact your insurance company regarding reimbursement. We answer our main office number 8:00 AM – 5:00 PM Monday through Friday (except holidays). You may have your counselor’s cell phone number in order to coordinate administrative tasks (defined as appointment arrival, appointment time, and directions). Email, and text messaging are not secure mediums in terms of privacy and confidentiality so our policy regarding, electronic communication, and cell phone use includes the following: • We do not provide therapy/counseling via email or require urgent care, please call your local emergency services or proceed to your local emergency roomtext messaging. I check my voice mail twice per day • Text messaging and cannot guarantee that I email will be readily availableused for administrative tasks only (as defined above). I try to • Therapists may not acknowledge or return emails or text messages within one business day. Phone calls that are not to take place administrative. This includes emergency texts and emails. • If your therapist leaves for an extended period of a regular counseling sessiontime you will be given the information for another licensed therapist with whom you may schedule if you need an appointment during your therapist’s absence.

Counseling Services. Your first appointment (or more, in some cases) will involve an assessment of your needs. By the end of the assessment your counselor will be able to offer you some first impressions of what your work may include and recommendations for getting help. One of the recommendations may be psychotherapy. If so, APC may or may not be able to provide you with psychotherapy, depending on your overall needs. If psychotherapy or any other recommendations suggested by your counselor include things that APC cannot provide, you will be given suggestions of where you might receive those services. Wherever you choose to obtain treatment, you should evaluate the information from your initial assessment along with your own opinions of what sort of treatment you are willing to do and whether you feel comfortable working with the treating clinician. Therapy involves a large commitment of time, energy, and often money, so you should be very careful about the therapist you select. If you have questions about the procedures used or conclusions made by your counselor at APC, please discuss them whenever they arise. If your doubts persist, your counselor will be happy to help you set up a meeting with another mental health professional for a second opinion. Psychotherapy is not easily described in general statements. It varies depending on the particular problems you are experiencing, the therapeutic methods used by your counselor, and the personalities of the counselor and client. There are many different methods counselors may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for an a very active effort on your part. In order for counseling the therapy to be most successful successful, you will have to work on the things we talk about that are discussed both during our session at homeyour sessions and on your own. In additionPsychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, your responsibilities are to provide relevantyou may experience uncomfortable feelings like sadness, accurate and complete information as to your historyguilt, symptomsanger, complaintsshame, medicationfrustration, loneliness, and current statushelplessness. Please The changes you make in therapy may also affect your best efforts relationships in unexpected ways. Psychotherapy has also been shown to have relevant information (such as previous psychiatric evaluationsmany benefits. Therapy often leads to better relationships, discharge summaries, school reports, etc.) ready at the time of your first session. As your therapist, I have the responsibility solutions to ask you questions about you and your family’s history, as well as your feelings and actions. I also have the responsibility to provide you with direct information about treatment as well as my clinical recommendations. If you choose to terminate treatment, I can assist you in developing appropriate options, unless you choose otherwise. Individual and family sessions are 45 minutes in length. It is important for us to end on time, so I am able to document our session, review records and/or make collateral phone calls on your behalf. The frequency of sessions depends on clinical need and can be discussed at your first session and re-evaluated at subsequent sessions. My usual and customary fee for your first appointment, described as the “diagnostic assessment” or “intake” is $175.00. All other sessions (individual, family, collateral) are charged at $125.00 per session. Special evaluations/assessments (e.g. school/court related) are billed according to the breadth of the evaluation, duration of evaluationspecific problems, and whether or not a formal report is requiredsignificant reductions in feelings of distress. Co-payments/session fees But there are due at the time no guarantees of service. All payments for services are to be made by personal check, cash, or credit card. If your insurance company is being billed, I what you will make appropriate efforts to obtain payment; however, you as the client are responsible for any outstanding charges that are not covered. A service fee of $25.00 per month shall apply to any accounts for which there is an outstanding balance, including payments which are late, or if there has been no payment made by you or your insurance company on the balance within the past 30 days. If your account has not been paid for more than 60 days and arrangements for payments have not been agreed upon, I have the option of using legal means to secure payment. By signing this agreement, you understand that you are responsible for reasonable attorney and legal fees for accounts that go to collections. Any service requested by you the client (e.g., court testimony, written treatment summaries/recommendations, attendance at PPT meetings) is billable to you personally at the regular session rate of $125.00 per hour. If you have a brief, routine message please call and leave the message on my voice mail. If you are having a mental health emergency, or require urgent care, please call your local emergency services or proceed to your local emergency room. I check my voice mail twice per day and cannot guarantee that I will be readily available. I try to return messages within one business day. Phone calls are not to take place of a regular counseling sessionexperience.

Counseling Services. Psychotherapy calls People choose to participate in counseling for a variety of reasons. For most, the purpose of counseling is to generally improve one’s overall quality of life by addressing issues of concern, such as anxiety, depression, marital difficulties, addiction, or grief. Individual experiences in counseling can be different, depending on factors such as the personalities of the client and therapist, the mode of counseling techniques that the therapist utilizes, the issue(s) being addressed, and the amount of effort that the client puts forth. Your initial sessions with Encourage Counseling Services will involve an active effort on evaluation of your partneeds. By the end of the evaluation, your therapist will be able to offer you some first impressions of what your work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with us. Therapy involves a commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about our procedures, you should discuss them with your therapist whenever they arise. If you wish, we will willingly provide you with referrals to other mental health professionals for a second opinion, as you always have the right to choose to continue to receive counseling services from us or to ask to be referred to someone else. Following the assessment period, which is typically one to two sessions, one 50-minute session will be scheduled per week. Sessions will occur at a time you and your therapist agree upon, although sessions may be scheduled more or less frequently according to your needs. It is important to note that if you are late to your appointment, your session will still end at the originally scheduled time. It should be noted that therapy can have benefits, as well as potential risks. Since therapy oftentimes involves discussing difficult aspects of your life, you may experience uncomfortable feelings such as sadness, guilt, anger, frustration, loneliness, and helplessness. Making changes in your beliefs or behaviors can be anxiety provoking, and can be disruptive to your current relationships. However, therapy has also been shown to have many benefits. For example, therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. Of course, every individual’s experience is different and there are no guarantees of what you will experience. It is important that you carefully consider whether these risks are worth the benefits to you of changing. Most people who take these risks find that therapy is helpful. Finally, the therapeutic relationship is ended after the last scheduled appointment, or when so stated by you or your therapist. As the client, you typically will be the one who decides when therapy will end, which usually occurs once you and your therapist agree that you have met your treatment goals. However, there are a few exceptions. One such exception is if your therapist does not believe that he/she is professionally able to meet your needs. This could possibly be because your therapist does not believe that he/she holds the proper training and skills to help you, due to the type of presenting problem that you have. In order such a situation your therapist will refer you to another therapist who may be able to meet your counseling needs. Professional Training and Approach to Therapy Your therapist through Encourage Counseling Services, ▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇, holds a Master’s of Arts Degree in Counseling, earned in 2010 at MidAmerica Nazarene University, in Olathe, Kansas. He is a Licensed Professional Counselor (LPC) in the state of Missouri and a Nationally Certified Counselor (NCC). ▇▇▇▇▇ has a significant amount of experience in working with clients in the areas of trauma, anxiety, depression, grief, behavioral issues, as well as extreme mental health cases. He utilizes a Cognitive Behavioral approach in his work, which is a philosophy of psychotherapy that evaluates the relationship between thoughts and emotions as behavior change. ▇▇▇▇▇ also uses a variety of techniques in therapy, depending on what will work best for counseling the client. ▇▇▇▇▇’s overall emphasis is the therapeutic relationship he builds with his clients. He believes it’s in this relationship that real, authentic, lasting change can occur. Contacting Your Therapist If you need to speak with your therapist outside of your scheduled appointment time, you may leave a voicemail message with your contact information and your call will be returned within 48 hours. Your therapist will make every effort to return your call on the same day, with the exception of weekends and holidays. Encourage Counseling Services is not an emergency provider. Thus, in an emergency situation you are instructed to call 9-1-1 or the 24-hour Emergency Service Crisis Line (▇-▇▇▇-▇▇▇-▇▇▇▇). In addition, in the unlikely event that your therapist is unable to provide ongoing services, ▇▇▇ ▇▇▇▇▇▇▇, MS, LPC (816-223-6376) will provide those services or will refer you to the appropriate resource. If you elect to communicate with your therapist by email, please be aware that email is not completely confidential. All emails are retained in the logs of your or your therapist’s internet service providers. While under normal circumstances these logs are not viewed, they are, in theory, available to be read by the system administrator(s) of the internet service provider. Any email that your therapist receives from you, and any responses that your therapist sends to you, will be printed out and kept in your treatment record. Confidentiality With the exception of the specific situations described below, you have the absolute right to the confidentiality of your therapy. This confidentiality is protected under the provisions of the federal Health Insurance Portability and Accountability Act (HIPAA). For detailed information regarding your rights regarding the protection of your Personal Health Information (PHI) please refer to the attached Notice of Privacy Practices, which reports when PHI may be used for treatment, payment, and health care options. By initialing you are indicating that you have also been provided with and read a copy of the Notice of Privacy Practices. In most successful situations, your therapist can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. This includes permission to inform your primary care physician and/or your psychiatrist that he/she is providing counseling services to you. It may be helpful for your therapist to confer with your medical professional with regard to your psychological treatment or to discuss any medical problems for which you are receiving treatment. If you agree to have your therapist inform your primary care physician and/or psychiatrist of the counseling services you are receiving, please indicate as such in the appropriate check box below, and provide his/her name and contact information. Physician Phone There are other situations that require only that you provide written, advance consent. Your signature on this agreement provides consent for those activities, as follows:  Your therapist may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, your therapist makes every effort to avoid revealing the identity of the client. The other professionals are also legally bound to keep the information confidential. All consultations will be noted in your clinical record.  If your insurance company is paying for a portion of or all of your counseling services, records containing your mental health diagnosis and dates of service must be provided to them.  If your therapist has reasonable cause to suspect that a child or an elderly or disabled adult has been or may be subjected to abuse or neglect, or observes such persons being subjected to such conditions or circumstances, the law requires that your therapist file a report with appropriate authorities.  If your therapist believes that you are in imminent danger of harming yourself, your therapist may legally break confidentiality and take protective action. These actions may include initiating hospitalization, contacting the police, and/or contacting your family.  If your therapist has reason to believe that you will harm another person, your therapist must attempt to inform that person and warn him/her of your intentions. Your therapist must also contact the police and ask them to protect your intended victim.  If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the above listed confidentiality laws. Your therapist cannot provide any information without your or your legal representative’s written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order your therapist to disclose information. Professional Records Your therapist will keep professional records of your therapy sessions and the therapeutic services that you receive, which will be maintained in a secure location that cannot be accessed by anyone else. These records will include information about your reasons for seeking therapy, your diagnosis, the goals that are set for treatment, your progress toward those goals, your medical, social, and treatment history, and any past treatment records that your therapist receives from other providers. Your clinical record will also include reports of any professional consultations, your billing records, and any reports that have been sent to work on the things we talk about during our session at homeanyone, including reports to your insurance carrier (if applicable). In addition, your responsibilities are to provide relevantclinical record will include information regarding the dates that therapy sessions occurred, accurate and complete information as to your history, symptoms, complaints, medicationinterventions that were utilized, and current statustopics that were discussed. Please make your best efforts You have the right to have relevant information (such as previous psychiatric evaluations, discharge summaries, school reports, etc.) ready at the time a copy of your first sessionfile at any time, giving your therapist adequate time to make a copy for you. As However, since psychological records are usually written in terminology that is difficult to understand, it is encouraged that you schedule an appointment with your therapist, I have the responsibility therapist to ask you questions about you review your records under his/her supervision and your family’s history, as well as your feelings and actionscare. I This service is provided free of charge. You also have the responsibility right to provide request that your therapist correct any errors in your file. In addition, you have the right to request that your therapist make a copy of your file available to any other health care provider or agency, upon your written request. Your records will be kept for seven years past the date of service; after that time they are destroyed and unavailable. In the event of your therapist’s death or incapacitation, your records will be stored by another practitioner for seven years, and will be available to you during that time. In such an event, ▇▇▇ ▇▇▇▇▇▇▇, LPC (816-781-4414) has agreed to store such records. Professional Fees / Payments In addition to weekly appointments, your therapist will charge this amount for other professional services you may need, though the hourly cost will be broken down for work lasting for shorter periods of time than one hour. Other services include report writing, telephone conversations lasting longer than 15 minutes, consulting with direct information about other professionals with your permission, preparation of records or treatment as well as my clinical recommendationssummaries, and the time spent performing any other service you may request of your therapist. If you choose become involved in legal proceedings that require your therapist’s participation, you will be expected to terminate treatmentpay for all of your therapist’s professional time, I can assist including preparation and transportation costs, even if he/she is called to testify by another party. Fees for legal proceedings are $80 per hour and will be requested in advance of any work performed. Once an appointment hour is scheduled, you in developing appropriate options, will be expected to pay the assigned fee unless you choose otherwiseprovide 24-hours advance notice of cancellation, or unless you were unable to attend due to circumstances beyond your control (e.g., illness or poor weather conditions). Individual and family sessions are 45 minutes in lengthOtherwise, you will be responsible for paying for the missed session at your next scheduled session. (It is important should be noted that insurance companies typically do not reimburse for us to end on timecancelled sessions, so I am able to document our session, review records and/or make collateral phone calls on your behalf. The frequency of sessions depends on clinical need and can be discussed at your first session and re-evaluated at subsequent sessions. My usual and customary fee for your first appointment, described as the “diagnostic assessment” or “intake” is $175.00. All other sessions (individual, family, collateral) are charged at $125.00 per session. Special evaluations/assessments (e.g. school/court related) are billed according to the breadth of the evaluation, duration of evaluation, and whether or not a formal report is required. Co-payments/session fees are due at the time of service. All payments for services are to be made by personal check, cash, or credit card. If your insurance company is being billed, I will make appropriate efforts to obtain payment; however, you as the client are responsible for any outstanding charges that are payment.) Three sessions without payment will cancel future sessions until the account is paid in full. In addition, if your account should remain unpaid for more than 90 days, you will not covered. A service fee of $25.00 per month shall apply be able to any accounts receive services from Encourage Counseling Services until your account is paid for which there is an outstanding balance, including payments which are late, with the agreed upon terms or if there has been no payment made by you or your insurance company on the balance within the past 30 dayswill be referred to seek alternative mental health assistance. If your account has not been paid for more than 60 90 days and arrangements for payments payment have not been agreed upon, I have Encourage Counseling Services has the option of using legal means to secure the payment. This may involve hiring a collection agency, notification of the credit bureau, or going through small claims court which will require us to disclose otherwise confidential information. In most collection situations, the only information released regarding a client’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. Insurance Coverage If you plan to utilize your health insurance for your counseling services, it is important that you discover exactly what mental health services your insurance policy covers, and obtain preauthorization as necessary. Your therapist will assist you in receiving the benefits to which you are entitled; you are responsible for providing appropriate information, such as your complete insurance identification information and any preauthorization codes, to your therapist in order for him/her to do so. It should also be noted that insurance companies typically do not accept bills from therapists unless they are on their preferred provider list. If your therapist is not a preferred provider for your particular health insurance company, you may still choose to submit claims to obtain reimbursement for your counseling services. However, in such cases you are responsible for full payment of fees and submitting claims for reimbursement of fees. If you choose to have your counseling services paid for in full or in part by your insurance company, there are typically additional limitations to your rights as a client imposed by the contract of the managed care firm. These may include their decision to limit the number of sessions available to you, to decide the time period within which you must complete your therapy, or to require you to use medication if their reviewing professional deems it appropriate. Your managed care firm may also decide that you must see another therapist in their network rather than your therapist through Encourage Counseling Services, if he/she is not on their list of providers. You should also be aware that your contract with your health insurance company requires that your therapist provide information relevant to the services that you are provided. Your therapist is required to provide a clinical mental health diagnosis. Your therapist may be required to provide additional clinical information such as treatment plans or summaries, or copies of your entire clinical record. In such situations, your therapist will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files. Though all insurance companies claim to keep such information confidential, your therapist has no control over what is done with the information once it is released. Your therapist will provide you with a copy of any report submitted, if you request it. By signing this agreement, you understand agree that you are responsible for reasonable attorney and legal fees for accounts that go your therapist can provide requested information to collections. Any service requested by you the client (e.g., court testimony, written treatment summaries/recommendations, attendance at PPT meetings) is billable to you personally at the regular session rate of $125.00 per houryour carrier. If prior to receiving services you choose not to use your insurance, you have a brief, routine message please call and leave the message on my voice mail. If you are having a mental health emergency, or require urgent care, please call right to pay for your local emergency counseling services or proceed yourself to your local emergency room. I check my voice mail twice per day and cannot guarantee that I will be readily available. I try to return messages within one business day. Phone calls are not to take place of a regular counseling sessionavoid the problems described above unless prohibited by contract.

Counseling Services. Psychotherapy calls for an active effort Counseling varies depending on the personalities of the counselor and client, and the particular problem you bring to counseling. Counseling will frequently involve discussing your partpersonal concerns, thoughts and feelings. In order for the counseling to be most successful successful, you will have to work on the things we talk about both during our session at homesessions and between sessions. In additionCounseling can have risks and benefits. Initially, your responsibilities are you may experience uncomfortable levels of sadness, guilt, anxiety, anger, frustration, loneliness, helplessness, or other negative feelings. While you consider these risks, you should always know that the benefits of psychotherapy have been shown by scientists in hundreds of well-designed research studies. Therapy often leads to provide relevantsignificant reductions in feelings of distress, accurate and complete information as improvements in relationships, acquisition of skills to your history, symptoms, complaints, medicationcope with stress, and current statusimprovement in overall well-being. Please make your best efforts to have relevant information (such as previous psychiatric evaluations, discharge summaries, school reports, etc.) ready at the time But there are no guarantees of what you will experience. Our first session together will include an evaluation of your first sessionneeds. As your therapistAt the end of that meeting, I have the responsibility to ask will offer you questions about you some first impressions of what our work will include and your family’s history, as well as your feelings and actions. I also have the responsibility to provide you with direct information about a treatment as well as my clinical recommendationsplan that we will follow. If you choose have questions about our process, we should discuss them whenever they arise. I will be glad to terminate treatmentprovide outside referrals if your concerns continue. As an expert and experienced geriatric social service and mental health professional, I can assist you in developing appropriate am available to offer consultation on specific situations or concerns you’d like suggestions or advice about. Consultation is not a psychotherapeutic service and we will not be discussing your feelings or personal needs, however I would be glad to begin psychotherapy services if we agree that they would be beneficial. Common concerns that clients might ask for professional advice on are decisions about retirement, housing options, unless decisions about moving to a higher level of care, or advice about managing difficult situations in caregiving, navigating the health care system or end-of-life decisions. I am careful not to offer advice about legal or medical situations or decision making. While my suggestions and recommendations are based upon professional expertise and experience, the outcome of the particular situation is not guaranteed. Consultation is generally conducted over a few meetings. Reports with impressions and recommendations can be provided. In addition to meeting together in my office, I offer counseling over the phone or on video chat. Telemental health is the use of telephone and video technology for delivery of counseling services. These services can be beneficial in the situation where clients are unable to meet in my office for some reason. Telemental health has been shown to be beneficial as a mode of providing psychotherapy but does come with some potential risks including: less control over confidentiality, decreased emotional connection between therapist and client and reducing the likelihood of insurance reimbursement. While we may agree that telemental health is effective in your situation, we will need to discuss how often you choose otherwisewill return for face-to-face visits. Individual We will regularly review whether telemental health is continuing to be beneficial. My license covers telemental health services to residents of California only. If telemental health is appropriate for you, then I will provide this services through a HIPAA compliant system. These services claim to be HIPAA compliant and family sessions reliable, however I cannot guarantee there will not be concerns of service reliability, potential interruptions of services, security, or confidentiality. A session may have to be moved to phone or discontinued if service interruptions or delays occur. Clients are 45 minutes in lengthencouraged to research and understand the benefits and limits of this form of technology before using it. To increase security, it is recommended that you use a computer or mobile device that has up to date antivirus software and a personal firewall installed. It is important recommended that videoconferencing be completed on an internet service at a bandwidth of 384 kbps or higher in each of the downlink and uplink directions. Such services should provide a minimum of 640 x 360 resolution at 30 frames per second. As a client of telemental health services, you are responsible for us maintaining privacy on your end of the communication (e.g., storing electronic documents securely, ensuring sessions are not overheard, verifying that you are sending information to the correct recipient, avoiding use of employer-owned computers if employers have access to materials on the computer or network). Signing this consent indicates that you understand the risks in using technology for counseling. On some occasions, I may be able to meet you in your home to conduct therapy. In these cases, I will arrive 10 minutes early so that we can get comfortable, start on time and end on timeat 50 minutes, so just like a traditional session. Please assure that we have privacy and are not interrupted. My practice is part-time and I may not be available when you need crisis counseling. If you need more frequent contact than I am able to document provide in our sessionregular sessions, review records and/or make collateral phone calls on your behalf. The frequency of sessions depends on clinical need and I can be discussed at your first session and re-evaluated at subsequent sessions. My usual and customary fee for your first appointment, described as the “diagnostic assessment” or “intake” is $175.00. All other sessions (individual, family, collateral) are charged at $125.00 per session. Special evaluations/assessments (e.g. school/court related) are billed according provide referrals to the breadth of the evaluation, duration of evaluation, and whether or not a formal report is required. Co-payments/session fees are due at the time of clinicians who can provide this service. All payments for services are to be made by personal check, cash, or credit card. If your insurance company is being billed, I will make appropriate efforts to obtain payment; however, you as In the client are responsible for any outstanding charges that are not covered. A service fee case of $25.00 per month shall apply to any accounts for which there is an outstanding balance, including payments which are late, or if there has been no payment made by you or your insurance company on the balance within the past 30 days. If your account has not been paid for more than 60 days and arrangements for payments have not been agreed upon, I have the option of using legal means to secure payment. By signing this agreement, you understand that you are responsible for reasonable attorney and legal fees for accounts that go to collections. Any service requested by you the client (e.g., court testimony, written treatment summaries/recommendations, attendance at PPT meetings) is billable to you personally at the regular session rate of $125.00 per hour. If you have a brief, routine message please call and leave the message on my voice mail. If you are having a mental health emergency, or require urgent care, please call your local emergency services the Santa Clara County Crisis Line (▇▇▇-▇▇▇-▇▇▇▇), dial 911 or proceed go to your local emergency room. A free 30-minute meeting is available prior to beginning counseling. You should evaluate our conversation along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money and energy, so you should be very careful about the therapist you select. I check my voice mail twice per day and cannot guarantee that I offer traditional 50-minute appointments. The fee for a 50-minute session is $170.00. Mileage will be readily availablecharged for home visits at the following rate: $50.00 within 2 miles of my office $75.00 within 5 miles of my office $100.00 within 8 miles of my office In addition to these fees, I charge for additional services you may need: Consultation reports are billed at the rate of $170/hour broken down into 10-minute increments. I try to return messages within one business day. Phone calls are not to take place of a regular counseling sessionLegal proceedings that require my participation will also be billed.

Counseling Services. Your first appointment (or more, in some cases) will involve an assessment of your needs. By the end of the assessment ▇▇▇▇ ▇▇▇▇▇▇ will be able to offer you some first impressions of what your work may include and recommendations for getting help. One of the recommendations may be psychotherapy. If so, ▇▇▇▇ ▇▇▇▇▇▇ may or may not be able to provide you with psychotherapy, depending on your overall needs. If psychotherapy or any other recommendations suggested by your counselor include things that ▇▇▇▇ ▇▇▇▇▇▇ Counseling, Inc. cannot provide, you will be given suggestions of where you might receive those services. Wherever you choose to obtain treatment, you should evaluate the information from your initial assessment along with your own opinions of what sort of treatment you are willing to do and whether you feel comfortable working with ▇▇▇▇ ▇▇▇▇▇▇. Therapy involves a large commitment of time, energy, and often money, so you should be very careful about the therapist you select. If you have questions about the procedures used or conclusions made by ▇▇▇▇ ▇▇▇▇▇▇, please discuss them whenever they arise. If your doubts persist, your counselor will be happy to help you set up a meeting with another mental health professional for a second opinion. Psychotherapy is not easily described in general statements. It varies depending on the particular problems you are experiencing, the therapeutic methods used by your counselor, and the personalities of the counselor and client. There are many different methods counselors may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for an a very active effort on your part. In order for counseling the therapy to be most successful successful, you will have to work on things that are discussed both during your sessions and on your own. Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, shame, frustration, loneliness, and helplessness. The changes you make in therapy may also affect your relationships in unexpected ways. Psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience. The initial assessment will last from one to two sessions. During this time, you and ▇▇▇▇ ▇▇▇▇▇▇ can both decide if she is the things we talk about during our session at home. In addition, your responsibilities are best person to provide relevantthe services you need in order to meet your treatment goals. If psychotherapy is begun it is typical to schedule one meeting per week at a time you each agree on. Once an appointment is scheduled, accurate and complete information as you will be expected to your history, symptoms, complaints, medication, and current status. Please make your best efforts to have relevant information (such as previous psychiatric evaluations, discharge summaries, school reports, etc.) ready at the time attend unless you provide advance notice of your first session. As your therapist, I have the responsibility to ask you questions about you and your family’s history, as well as your feelings and actions. I also have the responsibility to provide you with direct information about treatment as well as my clinical recommendationscancellation. If you choose need to terminate treatmentcancel an appointment, I can assist you in developing appropriate optionsit is your responsibility to contact us to cancel. Fees will be collected when services are rendered. The fee per 50 minute counseling session is $110, unless you choose otherwiseand will be adjusted accordingly when 50 minutes is exceeded. Individual In addition to therapy services fees may include creating reports; creating copies of records on request; and family sessions consulting with other professionals at the client’s request. There will be an additional $25 fee assessed for any returned check. We understand that there are 45 minutes in lengthunforeseeable circumstances like sick children or bad weather. It Your appointment is important though, and ▇▇▇▇ ▇▇▇▇▇▇ is happy to contact you for us a phone session or a session via our HIPPA-compliant virtual therapy system so you don't need to end on timeleave your sick child or worry about traffic and weather. As long as you are in a confidential location, so I am able to document our session, review records and/or make collateral phone calls on we can help you keep your behalfregularly scheduled appointment. The frequency of sessions depends on clinical need and can be discussed at If you still must change or cancel your first session and re-evaluated at subsequent sessions. My usual and customary fee for your first counseling appointment, described as the “diagnostic assessment” or “intake” is $175.00. All other sessions (individual, family, collateral) are charged at $125.00 per session. Special evaluations/assessments (e.g. school/court related) are billed according to the breadth of the evaluation, duration of evaluation, and whether or not a formal report is required. Co-payments/session fees are due at the time of service. All payments for services are to please know: ● Cancellations must be made by personal check, cash, within 24 hours of session time. ● We cannot accommodate cancellations made via email as we do not monitor email on a regular basis. ● We cannot accommodate cancellations made after hours or credit card. If your insurance company is being billed, I will make appropriate efforts to obtain payment; however, you as the client are responsible for any outstanding charges that are not covered. A service fee of $25.00 per month shall apply to any accounts for which there is an outstanding balance, including payments which are late, or if there has been no payment made by you or your insurance company on the balance within the past 30 days. If your account has not been paid for more than 60 days and arrangements for payments have not been agreed upon, I have the option of using legal means to secure payment. By signing this agreement, you understand that you are responsible for reasonable attorney and legal fees for accounts that go to collections. Any service requested by you the client (e.g., court testimony, written treatment summaries/recommendations, attendance at PPT meetings) is billable to you personally at the regular session rate of $125.00 per hourholidays. If you have an appointment on a briefMonday or the first day following a holiday, routine message you must make your change or cancellation the last business day before your appointment. ● Cancellations with less than 24 hours’ notice will result in a $75 fee that will be collected at your next appointment, or, if payment information is on file, it will be debited from your credit card. ● After two no-shows/late cancellations, a pre-paid retainer will be required before scheduling any future appointments. ● Clients who have pre-paid agree to have the entire fee deducted from their pre-payment in cases of other no-shows and late changes/cancellations. ● Court testimony costs begin at $250 per hour with a minimum charge of three hours. A retainer of $1000 is due one week prior to the court date. Travel is billed at .55/mile. Failure to provide the specific fees as described constitutes a release from the requested court appearance. You (not your insurance company) are responsible for full payment of fees. It is very important that you find out exactly what mental health services your insurance policy covers. You must pay your ▇▇▇▇ first, then contact your insurance company regarding reimbursement. You can contact our main office number (281-350-1277) 24 hours a day/7 days a week. If an administrative assistant or ▇▇▇▇ ▇▇▇▇▇▇, does not answer, please call and leave the a message on my voice mailthe internal/secure voicemail system. If you Messages are having a mental health emergencytypically returned within 24 hours during the business week, or require urgent care48 hours for messages left on the weekend. You may have your counselor’s cell phone number in order to coordinate administrative tasks (defined as appointment arrival, please call your local emergency services appointment time, and directions). Email, and text messaging are not secure mediums in terms of privacy and confidentiality so our policy regarding, electronic communication, and cell phone use includes the following: ● We do not provide therapy/counseling via email or proceed to your local emergency roomtext messaging. I check my voice mail twice per day ● Text messaging and cannot guarantee that I email will be readily availableused for administrative tasks only (as defined above). I try to ● ▇▇▇▇ ▇▇▇▇▇▇ Counseling, Inc., may not acknowledge or return emails or text messages within one business day. Phone calls that are not to take place administrative. This includes emergency texts and emails. ● If ▇▇▇▇ ▇▇▇▇▇▇ leaves for an extended period of a regular counseling sessiontime you will be given the information for another licensed therapist with whom you may schedule if you need an appointment during your therapist’s absence.

Counseling Services. Psychotherapy calls The purpose of treatment is to help clients resolve issues they have not felt successful in resolving on their own. Therapy is successful when clients complete established goals. The length of treatment depends upon the clients individualized treatment plan. Clients need to feel comfortable with their therapist as well as their therapist’s treatment methods. Depending on a client’s needs, different methods of therapy may be used. ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇ is an integrative psychotherapist. This means that she utilizes a number of treatment approaches including: EMDR, Cognitive Behavioral Therapy, Dialectical Behavioral Therapy, Mindfulness Based Stress Management, Internal Family Systems, Ego State Therapy, Gestalt Therapy, and Hakomi. This allows ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇ ▇▇▇▇▇▇ to tailor make your therapeutic experience to what will best suit your individual needs. For detailed information regarding the therapeutic approaches, please go to ▇▇▇.▇▇▇▇▇▇▇▇▇▇.▇▇▇, click on ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇, and then click on the “Services offered.” Together we will develop a personal treatment plan that outlines the major issues you wish to address. With this plan, we will see what combinations of approaches will be most beneficial in helping you best reach your goals. Upon reaching your goals, I ask that you participate in a closing session to review your accomplishments and also allow time for an active effort on me to assist you in identifying any support that might help you to maintain and enhance your partgrowth in the future. In order for counseling You are expected to be active participants while working collaboratively with your therapist to achieve your goals. You have the right to participate in important treatment decisions as well as in the development of your treatment plan. Periodically, we will review and revise your plan to keep up to date with your current situation. Therapy is most successful you will have when clients are willing to work on things in between counseling sessions. You may be asked to complete “homework assignments.” Therapy can have its benefits and its risks. It often involves discussing things that can be painful and you may also experience unpleasant feelings, such as: sadness, anger, guilt and loneliness. The benefits associated with working through unpleasant feelings can be great. Benefits may include, but are not limited to: happier-healthier relationships, a positive self- image, a sense of wellbeing and solutions to problems. There are no guarantees what your experience will be. The first session is a consultation and also the things we talk about during beginning of our session at homejourney together. In additionThe exploratory process may take a few sessions to complete. At this time, your responsibilities are the therapist will hear what you hope to provide relevantgain from therapy and will also answer any questions you may have. The therapist will share initial thoughts and a preliminary treatment plan. If the therapist does not believe she is the appropriate person to be working with you, accurate and complete information as to your history, symptoms, complaints, medication, and current status. Please make your best efforts to have relevant information (such as previous psychiatric evaluations, discharge summaries, school reports, etc.) ready at she may offer you the time names of your first session. As your therapist, I have the responsibility to ask you questions about you and your family’s history, as well as your feelings and actions. I also have the responsibility to provide you with direct information about treatment as well as my clinical recommendationsother counselors. If you choose do not believe the therapist is the right person for you, please do not hesitate to terminate treatmentsay so. Therapy often requires a significant amount of time, I can assist you in developing appropriate options, unless you choose otherwise. Individual finances and family sessions are 45 minutes in lengthemotional energy. It is important for us you to end on time, so I am able feel comfortable with your therapist. Please feel free to document our session, review records and/or make collateral phone calls on your behalfask any questions you may have. The frequency of sessions depends on clinical need and can be discussed at your first session and re-evaluated at subsequent sessions. My usual and customary fee for your first appointment, described as the “diagnostic assessment” or “intake” is $175.00. All other sessions (individual, family, collateral) are charged at $125.00 per session. Special evaluations/assessments (e.g. school/court related) are billed according to the breadth of the evaluation, duration of evaluation, and whether or not a formal report is required. Co-payments/session fees are due at the time of service. All payments for services are to be made by personal check, cash, or credit card. If your insurance company is being billed, I will make appropriate efforts to obtain payment; however, you as the client are responsible for any outstanding charges that are not covered. A service fee of $25.00 per month shall apply to any accounts for which there is an outstanding balance, including payments which are late, or if there has been no payment made by you or your insurance company on the balance within the past 30 days. If your account has not been paid for more than 60 days and arrangements for payments have not been agreed upon, I You have the option of using legal means right to secure payment. By signing this agreement, you understand that you are responsible for reasonable attorney and legal fees for accounts that go to collections. Any service requested by you refuse any recommended treatment at any time throughout the client (e.g., court testimony, written treatment summaries/recommendations, attendance at PPT meetings) is billable to you personally at the regular session rate of $125.00 per hour. If you have a brief, routine message please call and leave the message on my voice mailtherapeutic process. If you are having uncomfortable with any treatment recommendations, please speak with your therapist. Should you choose to end your therapy prior to meeting your therapeutic goals it is recommended that you schedule a closure session with your therapist. With the exception of unusual circumstances that involve danger to yourself and/or others, or if others have supplied information confidentially, you may examine and/or receive a copy of your clinical record (This does not include process notes taken during session). Your request will need to be in writing. Because these are professional records, they can be misinterpreted and/or upsetting to the untrained reader. For this reason, it is recommended that you initially review them in the presence of your therapist, or have them forwarded to another mental health emergencycounselor so you can discuss the contents. You may be charged a $ .20 per page copying fee. If the copying of the records lasts longer than 5 minutes, or require urgent care, please call your local emergency services or proceed to your local emergency room. I check my voice mail twice per day and cannot guarantee that I there will be readily availablean additional $3.00 per every 5 minutes of time to copy the requested records.  Initial Intake Session: 120 Min- $320.00  Subsequent Sessions: 90 Min- $240.00  1 Hour Session: 60 min- $160.00  Additional ½ hour Sessions: 30 min- $80.00  Intensive Treatment Sessions: 3-5 days (back to back) in 2 -3 hour blocks Full day – 3 hours in the am, 3 hours in the pm (Price depends on needs of client intensive chosen)  In addition to weekly appointments, I try charge a $160.00-per hour rate in 15 minute increments for other professional services you may need. These services may include: o Report writing o Correspondence o Telephone conversations lasting longer than 10 minutes o Attendance at meetings with other professionals you have authorized o Preparation of records or treatment summaries o Time spent performing any other services you may request of me  If you are involved in legal proceedings that require my participation, you will be expected to return messages within one business daypay for all of my professional time, including participation, transportation, participation costs (even if another party calls me to testify). Phone calls are not Due to take place of a regular counseling sessionthe difficulties related to legal involvement, I charge $250.00-per hour for my participation in legal proceedings.

Counseling Services. Psychotherapy calls Counseling is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in counseling, you have certain rights and responsibilities that are important for an you to understand. There are also legal limitations to those rights that you should be aware of. As your counselor I have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Counseling has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of counseling often requires discussing the unpleasant aspects of your life. However, counseling has been shown to have benefits for individuals who undertake it. Counseling often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Counseling requires a very active effort on your part. In order for counseling to be most successful successful, you will have to work on the things we talk discuss outside of sessions. The first session will involve a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some initial impressions of what our work might include. At that point, we will discuss your treatment goals and create an initial treatment plan. You should evaluate this information and make your own assessment about during our whether you feel comfortable working with me. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. APPOINTMENTS Appointments will ordinarily be 45-50 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed.. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours notice. If you miss a session at homewithout canceling, or cancel with less than 24 hour notice, you will be responsible for a $30.00 no show fee. If it is possible, I will try to find another time to reschedule the appointment. In addition, your responsibilities you are to provide relevant, accurate and complete information as responsible for coming to your historysession on time; if you are late, symptoms, complaints, medication, your appointment will still need to end on time. PROFESSIONAL FEES The standard fee for the initial intake is $110.00 and current statuseach subsequent session is $90.00. Please make your best efforts to have relevant information (such as previous psychiatric evaluations, discharge summaries, school reports, etc.) ready You are responsible for paying at the time of your first sessionsession unless prior arrangements have been made. As your therapist, I have the responsibility to ask you questions about you and your family’s history, as well as your feelings and actions. I also have the responsibility to provide you with direct information about treatment as well as my clinical recommendations. If you choose to terminate treatment, I Payment can assist you in developing appropriate options, unless you choose otherwise. Individual and family sessions are 45 minutes in length. It is important for us to end on time, so I am able to document our session, review records and/or make collateral phone calls on your behalf. The frequency of sessions depends on clinical need and can be discussed at your first session and re-evaluated at subsequent sessions. My usual and customary fee for your first appointment, described as the “diagnostic assessment” or “intake” is $175.00. All other sessions (individual, family, collateral) are charged at $125.00 per session. Special evaluations/assessments (e.g. school/court related) are billed according to the breadth of the evaluation, duration of evaluation, and whether or not a formal report is required. Co-payments/session fees are due at the time of service. All payments for services are to be made by personal check, cash, debit or credit card. If you refuse to pay your insurance company is being billeddebt, I will make appropriate efforts reserve the right to obtain payment; however, you as the client are responsible for any outstanding charges that are not covered. A service fee of $25.00 per month shall apply to any accounts for which there is use an outstanding balance, including payments which are late, attorney or if there has been no payment made by you or your insurance company on the balance within the past 30 days. If your account has not been paid for more than 60 days and arrangements for payments have not been agreed upon, I have the option of using legal means collection agency to secure payment. By signing In addition to weekly appointments, it is my practice to charge this agreement, you understand amount on a prorated basis (I will break down the hourly cost) for other professional services that you are responsible for reasonable attorney and legal fees for accounts may require such as report writing, telephone conversations that go to collections. Any service requested by you the client (e.g., court testimony, written treatment summaries/recommendationslast longer than 15 minutes, attendance at PPT meetings) is billable meetings or consultations which you have requested, or the time required to perform any other service which you personally at the regular session rate may request of $125.00 per hourme. If you have anticipate becoming involved in a briefcourt case, routine message please call and leave the message on my voice mailI recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you are having a mental health emergency, or require urgent care, please call your local emergency services or proceed to your local emergency room. I check my voice mail twice per day and cannot guarantee that I will be readily available. I try expected to return messages within one business day. Phone calls are not pay for the professional time required even if another party compels me to take place of a regular counseling sessiontestify.