Common use of ENDINGS Clause in Contracts

ENDINGS. If you are unhappy with any aspect of therapy, please don’t just leave. I ask that you let me know what’s not working for you so that we can either bridge the gap or create an opportunity for you to end on better terms. Of course, you may choose to discontinue therapy at any time for any reason, and I am happy to assist with referrals. On my part, it’s my professional responsibility to initiate termination and provide a referral to another counselor if I determine that you are not benefitting from the clinical services I provide. Additionally, I may end treatment due to repeated no-shows, late-cancellations, chronic treatment interruptions, or for lack of payment. REFERRALS/GROUP: A referral to another provider may become necessary if clinically determined that your mental health issues would be better treated by a professional with different expertise. It is unethical for me to practice beyond the level of my competence, education, training, or experience. I am not responsible for the care received from professionals to whom I refer you. Agreements made between you and me, as your private practitioner, do not extend to other professionals in the office suite, who each operate independently. PATIENT RIGHTS: A list of your client rights is posted in the waiting room. You have the right to ask any questions about your treatment or refuse to participate in treatment at any time. This office does not discriminate in the delivery of healthcare services based on race, ethnicity, national origin, citizenship or immigration status, religion, gender, gender identity, age, mental/physical disability, medical condition or history, sexual orientation, evidence of insurability, or payment source. INSURANCE OR EMPLOYEE ASSISTANCE PROGRAM: “I authorize the release of any information necessary (including notes, treatment summaries and diagnosis) to process insurance or Employee Assistance claims, to prove medical necessity for treatment, to request additional sessions, or to comply with mandated quality control or administrative chart reviews from the insurance plan." (Sign here) :X “I authorize payment of benefits to Xxxx X. Talbot, LICSW” (Sign here):X By signing below, you acknowledge you have read this Agreement, and you acknowledge receipt of my Notices of Privacy Practices. My Notice of Privacy Practices provides information about how I may use and disclose your private health information. I encourage you to read it in full. My Notice of Privacy Practices is subject to change. If I change my Notice, I will give you a revised Notice. If you have left treatment, you may obtain the revised notice from me at the above address and phone number. If you have any questions about the Notice, or any of the above, please feel free to ask. X X X Signature, Client Printed Name Date Signature, second client (if applicable) Printed Name, second client (if applicable) Date

ENDINGS. If you are or your child is unhappy with any aspect of therapy, please don’t just leave. leave – I ask that you let talk to me know what’s not working for you so that to see if we can either bridge the gap or create an opportunity for you to end on work it out. Even if we can’t, endings usually feel better termsthis way. Of course, you may choose to discontinue end therapy at any time for any reasontime, and I am happy to assist with referrals. On It is my part, it’s my professional responsibility ethical duty to initiate termination and provide a referral to another counselor if therapy only when I determine that feel you are not benefitting actively participating and benefiting from the clinical services I providesessions. Additionally, I may end treatment due to if there have been repeated no-shows, late-cancellations, chronic cancellations or other treatment interruptions. E-MAIL/SOCIAL MEDIA: In general, text is the quickest way to reach me. I often use text to arrange/change appointments. I use the Spruce app for Hippaa compliant text, voicemail, email, and fax. I also use Clinic Source with their client portal and email appointment reminders. I do not accept friend requests or contact requests from clients on social networking sites (Facebook, LinkedIn, etc.) out of concern for lack your confidentiality and my privacy. It may also blur the boundaries of paymentour working relationship. REFERRALS/GROUP: A referral to another provider may become necessary if clinically determined it becomes clear in my opinion that you or your mental health child's issues would be better treated by a professional with different expertise. It is unethical for me to practice beyond the level of my competence, education, training, or experience. I am not responsible for the care received from professionals to whom I refer you. Agreements made between you and me, as your private practitioner, I do not extend to involve other professionals in the office suite, who each operate independentlyindependent solo practices, and are not part of a group. PATIENT RIGHTS: A list of your client rights is posted in the waiting room. You have the right to ask any questions about your treatment or refuse to participate in treatment at any time. This office does not discriminate in the delivery of healthcare health care services based on race, ethnicity, national origin, citizenship or immigration status, religion, gender, gender identity, age, mental/mental or physical disability, medical condition or historycondition, sexual orientation, medical history, evidence of insurability, or payment sourcesource of payment. INSURANCE OR EMPLOYEE ASSISTANCE PROGRAM: “I authorize the release of any information necessary (including notes, treatment summaries and diagnosis) to process insurance or Employee Assistance claims, to prove medical necessity for treatment, to request additional sessions, or to comply with mandated quality control or administrative chart reviews from the insurance plan." (Sign here) :X “I authorize payment of benefits to Xxxx X. Talbot, LICSW” (Sign here):X By signing below, you acknowledge you have read this Treatment Agreement, and you acknowledge receipt of my Notices of Privacy Practices. My Notice of Privacy Practices provides information about how I may use and disclose your private health information. I encourage you to read it in full. My Notice of Privacy Practices is subject to change. If I change my Notice, I will give you a revised Notice. If you have left treatment, you may obtain the revised notice from me at the above address and phone number. If you have any questions about the Notice, or any of the above, please feel free to ask. X X Client Signature, Date X Signature, Client Printed Name Date Signature, second client (if applicable) Printed Name, second client (if applicable) Parent or Guardian Date

ENDINGS. If you are or your child is unhappy with any aspect of therapy, please don’t just leave. leave – I ask that you let talk to me know what’s not working for you so that to see if we can either bridge the gap or create an opportunity for you to end on work it out. Even if we can’t, endings usually feel better termsthis way. Of course, you may choose to discontinue end therapy at any time for any reasontime, and I am happy to assist with referrals. On It is my part, it’s my professional responsibility ethical duty to initiate termination and provide a referral to another counselor if therapy only when I determine that feel you are not benefitting actively participating and benefiting from the clinical services I providesessions. Additionally, I may end treatment due to if there have been repeated no-shows, late-cancellations, chronic cancellations or other treatment interruptions. TREATMENT AGREEMENT FOR TEENS / CHILDREN (CONT’D) E-MAIL/SOCIAL MEDIA: In general, text, e-mail is the quickest way to reach me. I use text or e-mail to arrange/change appointments. I do not do therapy by e-mail. When cancelling, please leave BOTH a voicemail and e-mail. Please do not e-mail me information related to your therapy, as e-mail is not completely confidential, and important issues should be reserved for lack sessions. Be aware that e-mails between us become part of paymentyour legal record. I do not accept friend requests or contact requests from clients on social networking sites (Facebook, LinkedIn, etc.) out of concern for your confidentiality and my privacy. It may also blur the boundaries of our therapy relationship. REFERRALS/GROUP: A referral to another provider may become necessary if clinically determined it becomes clear in my opinion that your mental health child's issues would be better treated by a professional with different expertise. It is unethical for me to practice beyond the level of my competence, education, training, or experience. I am not responsible for the care received from professionals to whom I refer you. Agreements made between you and me, as your private practitioner, I do not extend to involve other professionals profession- als in the office suite, who each operate independently. PATIENT RIGHTS: A list of your client rights is posted in the waiting room. You have the right to ask any questions about your treatment or refuse to participate in treatment at any time. This office does not discriminate in the delivery of healthcare services based on race, ethnicity, national origin, citizenship or immigration status, religion, gender, gender identity, age, mental/physical disability, medical condition or history, sexual orientation, evidence of insurability, or payment source. INSURANCE OR EMPLOYEE ASSISTANCE PROGRAM: “I authorize the release of any information necessary (including notes, treatment summaries and diagnosis) to process insurance or Employee Assistance claims, to prove medical necessity for treatment, to request additional sessions, or to comply with mandated quality control or administrative chart reviews from the insurance plan." (Sign here) :X “I authorize payment of benefits to Xxxx X. Talbot, LICSW” (Sign here):X By signing below, you acknowledge you have read this Agreementindependent solo practices, and you acknowledge receipt are not part of my Notices of Privacy Practices. My Notice of Privacy Practices provides information about how I may use and disclose your private health information. I encourage you to read it in full. My Notice of Privacy Practices is subject to change. If I change my Notice, I will give you a revised Notice. If you have left treatment, you may obtain the revised notice from me at the above address and phone number. If you have any questions about the Notice, or any of the above, please feel free to ask. X X X Signature, Client Printed Name Date Signature, second client (if applicable) Printed Name, second client (if applicable) Dategroup.

ENDINGS. If you are unhappy with any aspect of therapy, please don’t just leave. I ask that you let talk to me know what’s not working for you so that to see if we can either bridge the gap or create an opportunity for you to end on work it out. Even if we can’t, endings usually feel better termsthis way. Of course, you may choose to discontinue end therapy at any time for any reasontime, and I am happy to assist with referrals. On It is my part, it’s my professional responsibility ethical duty to initiate termination and provide a referral to another counselor if therapy only when I determine that feel you are not benefitting actively participating and benefiting from the clinical services I providesessions. Additionally, I may end treatment due to if there have been repeated no-shows, late-cancellations, chronic repeated treatment interruptions, or for lack of payment. REFERRALS/GROUP: A referral to another provider may become necessary if clinically determined it becomes clear in my opinion that your mental health issues would be better treated by a professional with different expertise. It is unethical for me to practice beyond the level of my competence, education, training, or experience. I am not responsible for the care received from professionals to whom I refer you. Agreements made between you and me, as your private practitioner, I do not extend to involve other professionals in the office suite, who each operate independentlyindependent solo practices, and are not part of a group. PATIENT RIGHTS: A list of your client rights is posted in the waiting room. You have the right to ask any questions ques- tions about your treatment or refuse to participate in treatment at any time. This office does not discriminate in the delivery of healthcare health care services based on race, ethnicity, national origin, citizenship or immigration status, religion, gender, gender identity, age, mental/physical disability, medical condition or history, sexual orientation, evidence of insurability, or payment source. INSURANCE OR EMPLOYEE ASSISTANCE PROGRAMCOUPLES THERAPY: “WHO IS MY CLIENT? When I authorize work with couples, I consider you both to be my client. While I may have to designate one of you as the release main client on an insurance claim/invoice or treatment plan, I do not see either one of you as the source of any information necessary (including notesproblems. I know that each person has their part in relationship patterns. INDIVIDUAL SESSIONS: During the course of our work, treatment summaries and diagnosis) to process insurance I may see one or Employee Assistance claims, to prove medical necessity both of you individually for treatment, to request additional one or more sessions. In these sessions, I will not take on the role of individual therapist – these sessions are simply being done with the goal of furthering your couples work, unless otherwise indicated. If you feel the xxxxxxxxxxx.xxx need for additional individual support, I am happy to refer you to an individual therapist, if needed. NO-SE- CRETS POLICY: There may be times (ex. in an individual session or an email/text) where you might want to comply reveal something to me that you do not want shared with mandated quality control or administrative chart reviews from the insurance plan." (Sign here) :X “your partner. However, if I authorize payment of benefits am to Xxxx X. Talboteffectively serve you as a couple, LICSW” (Sign here):X By signing belowI cannot hold a secret in this way. Instead, I will urge you to discuss secrets you have shared with me with your partner. If you do not, and in my clinical judgment this secret could be negatively impacting therapy, I may feel it necessary to share it in a couples session. Thus, if you feel it necessary to talk about top- ics you are unwilling to have shared with your partner, you acknowledge you have read this Agreementmight want to consult an individual therapist. This “no secrets” policy is intended to help me be transparent with both partners at all times, and you acknowledge receipt of my Notices of Privacy Practicesto avoid being put in a situation where I would have to end couples treatment. My Notice of Privacy Practices provides information about how INFORMATION/RECORDS RELEASE: One medical record is kept for the couple, where I may use keep all session notes (whether for individual, couples, or family sessions) and disclose your private health information. I encourage you to read it in full. My Notice of Privacy Practices is subject to changesignificant emails, payment records, etc. If I change my Noticereceive a request for information about treatment or for records, I would be legally and ethically required to get a written release from both members of the couple before releasing information to anyone. This is true even for individual session notes. Exceptions to confidentiality are outlined above under “Confidentiality.” If records are subpoenaed, I will give you a revised Notice. If you have left treatment, you may obtain always assert the revised notice from me at the above address and phone number. If you have any questions about the Notice, or any psychotherapist-patient privilege on behalf of both members of the above, please feel free to ask. X X X Signature, Client Printed Name Date Signature, second client (if applicable) Printed Name, second client (if applicable) Datecouple.

ENDINGS. If you are unhappy with any aspect of therapy, please don’t just leave. ,I ask that you let talk to me know what’s not working for you so that to see if we can either bridge the gap or create an opportunity for you to end on work it out. Even if we can’t, endings usually feel better termsthis way. Of course, you may choose to discontinue end therapy at any time for any reasontime, and I am happy to assist with referrals. On It is my part, it’s my professional responsibility ethical duty to initiate termination and provide a referral to another counselor if therapy only when I determine that feel you are not benefitting actively participating and benefiting from the clinical services I providesessions. Additionally, I may end treatment due to if there have been repeated no-shows, late-cancellations, chronic repeated treatment interruptions, or for lack of payment. REFERRALS/GROUP: A referral to another provider may become necessary if clinically determined it becomes clear in my opinion that your mental health issues would be better treated by a professional with different expertise. It is unethical for me to practice beyond the level of my competence, education, training, or experience. I am not responsible for the care received from professionals to whom I refer you. Agreements made between you and me, as your private practitioner, I do not extend to involve other professionals in the office suite, who each operate independentlyindependent solo practices, and are not part of a group. PATIENT RIGHTS: A list of your client rights is posted in the waiting room. You have the right to ask any questions about your treatment or refuse to participate in treatment at any time. This office does not discriminate in the delivery of healthcare health care services based on race, ethnicity, national origin, citizenship or immigration status, religion, gender, gender identity, age, mental/physical disability, medical condition or history, sexual orientation, evidence of insurability, or payment source. INSURANCE OR EMPLOYEE ASSISTANCE PROGRAMCOUPLES THERAPY: “WHO IS MY CLIENT? When I authorize work with couples, I consider you both to be my client. While I may have to designate one of you as the release main client on an insurance claim/invoice or treatment plan, I do not see either one of you as the source of any information necessary (including notesproblems. I know that each person has their part in relationship patterns. INDIVIDUAL SESSIONS: During the course of our work, treatment summaries and diagnosis) to process insurance or Employee Assistance claims, to prove medical necessity for treatment, to request additional sessions, or to comply with mandated quality control or administrative chart reviews from the insurance plan." (Sign here) :X “I authorize payment of benefits to Xxxx X. Talbot, LICSW” (Sign here):X By signing below, you acknowledge you have read this Agreement, and you acknowledge receipt of my Notices of Privacy Practices. My Notice of Privacy Practices provides information about how I may use and disclose your private health informationsee one or both of you individually for one or more sessions. I encourage you to read it in full. My Notice of Privacy Practices is subject to change. If I change my NoticeIn these sessions, I will give you a revised Noticenot take on the role of individual therapist -- these sessions are simply being done with the goal of furthering your couples work, unless otherwise indicated. If you feel the need for additional individual support, I am happy to refer you to an individual therapist, if needed. NO- SECRETS POLICY: There may be times (ex. in an individual session or an email/text) where you might want to reveal something to me that you do not want shared with your partner. However, if I am to effectively serve you as a couple, I cannot hold a secret in this way. Instead, I will urge you to discuss secrets you have left treatment, you may obtain the revised notice from shared with me at the above address and phone numberwith your partner. If you do not, and in my clinical judgment this secret could be negatively impacting therapy, I may feel it necessary to share it in a couples session. Thus, if you feel it necessary to talk about topics you are unwilling to have any questions about shared with your partner, you might want to consult an individual therapist. This “no secrets” policy is intended to help me be transparent with both partners at all times, and to avoid being put a situation where I would have to end couples treatment. INFORMATION/RECORDS RELEASE: One medical record is kept for the Noticecouple, where I keep all session notes (whether for individual, couples, or any family sessions) and significant emails, payment records, etc.. If I receive a request for information about treatment or for records, I would be legally and ethically required to get a written release from both members of the abovecouple before releasing information to anyone. This is true even for individual session notes. Exceptions to confidentiality are outlined above under "Confidentiality." If records are subpoenaed, please feel free to ask. X X X Signature, Client Printed Name Date Signature, second client (if applicable) Printed Name, second client (if applicable) DateI will always assert the psychotherapist-patient privilege on behalf of both members of the couple.

ENDINGS. If you are or your child is unhappy with any aspect of therapy, please don’t just leave. leave – I ask that you let talk to me know what’s not working for you so that to see if we can either bridge the gap or create an opportunity for you to end on work it out. Even if we can’t, endings usually feel better termsthis way. Of course, you may choose to discontinue end therapy at any time for any reasontime, and I am happy to assist with referrals. On It is my part, it’s my professional responsibility ethical duty to initiate termination and provide a referral to another counselor if therapy only when I determine that feel you are not benefitting actively participating and benefiting from the clinical services I providesessions. Additionally, I may end treatment due to if there have been repeated no-shows, late-cancellations, chronic cancellations or other treatment interruptions. TREATMENT AGREEMENT FOR CHILDREN (CONT’D) E-MAIL/SOCIAL MEDIA: In general, text, e-mail is the quickest way to reach me. I use text or e-mail to arrange/change appointments. I do not do therapy by e-mail. When cancelling, please leave BOTH a voicemail and e-mail. Please do not e-mail me information related to your therapy, as e-mail is not completely confidential, and important issues should be reserved for lack sessions. Be aware that e-mails between us become part of paymentyour legal record. I do not accept friend requests or contact requests from clients on social networking sites (Facebook, LinkedIn, etc.) out of concern for your confidentiality and my privacy. It may also blur the boundaries of our therapy relationship. REFERRALS/GROUP: A referral to another provider may become necessary if clinically determined it becomes clear in my opinion that your mental health child's issues would be better treated by a professional with different expertise. It is unethical for me to practice beyond the level of my competence, education, training, or experience. I am not responsible for the care received from professionals to whom I refer you. Agreements made between you and me, as your private practitioner, I do not extend to involve other professionals profession-als in the office suite, who each operate independentlyindependent solo practices, and are not part of a group. CHILD CUSODY/COURT CASES: I do not participate in court cases... If at any time your case takes on a legal standing I will evaluate it, if it is in the clients best interest to be referred to another clinician that will be available or willing to address and communicate with your various legal counsels. PATIENT RIGHTS: A list of your client rights is posted in the waiting roomoffice. You have the right to ask any questions about your treatment or refuse to participate in treatment at any time. This office does not discriminate in the delivery of healthcare health care services based on race, ethnicity, national origin, citizenship or immigration status, religion, gender, gender identity, age, mental/mental or physical disability, medical condition or historycondition, sexual orientation, medical history, evidence of insurability, or payment sourcesource of payment. INSURANCE OR EMPLOYEE ASSISTANCE PROGRAM: “I authorize the release of any information necessary (including notes, treatment summaries and diagnosis) to process insurance or Employee Assistance claims, to prove medical necessity for treatment, to request additional sessions, or to comply with mandated quality control or administrative chart reviews from the insurance plan." (Sign here) :X “I authorize payment of benefits to Xxxx X. Talbot, LICSW” (Sign here):X By signing below, you acknowledge you have read this Agreement, and you acknowledge receipt of my Notices of Privacy Practices. My Notice of Privacy Practices provides information about how I may use and disclose your private health information. I encourage you to read it in full. My Notice of Privacy Practices is subject to change. If I change my Notice, I will give you a revised Notice. If you have left treatment, you may obtain the revised notice from me at the above address and phone number. If you have any questions about the Notice, or any of the above, please feel free to ask. X X X Signature, Minor Client Printed Name Date Signature, second client (if applicable) Printed Name, second client (if applicable) DateClient Date X X X Signature, Parent or Guardian Printed Name, Parent or Guardian Date X X X

ENDINGS. If you are unhappy with any aspect of therapy, please don’t just leave. leave – I ask that you let talk to me know what’s not working for you so that to see if we can either bridge the gap or create an opportunity for you to end on work it out. Even if we can’t, endings usually feel better termsthis way. Of course, you may choose to discontinue end therapy at any time for any reasontime, and I am happy to assist with referrals. On It is my part, it’s my professional responsibility ethical duty to initiate termination and provide a referral to another counselor if therapy only when I determine that feel you are not benefitting actively participating and benefiting from the clinical services I providesessions. Additionally, I may end treatment due to if there have been repeated no-shows, late-cancellations, chronic or other treatment interruptions, or for lack of payment. REFERRALS/GROUP: A referral to another provider may become necessary if clinically determined that your mental health issues would be better treated by a professional with different expertise. It is unethical for me to practice beyond the level of my competence, education, training, or experience. I am not responsible for the care received from professionals to whom I refer you. Agreements made between you and me, as your private practitioner, do not extend to other professionals in the office suite, who each operate independently. PATIENT RIGHTS: A list of your client rights is posted in the waiting room. You have the right to ask any questions about your treatment or refuse to participate in treatment at any time. This office does not discriminate in the delivery of healthcare services based on race, ethnicity, national origin, citizenship or immigration status, religion, gender, /gender identity, age, mental/mental or physical disability, medical condition or historycondition, sexual orientation, medical history, evidence of insurability, or payment sourcesource of payment. INSURANCE OR EMPLOYEE ASSISTANCE PROGRAMCOMPLAINTS: “The Arizona Board of Behavioral Health Examiners (licensing board name) receives and responds to complaints regarding services provided within the scope of practice of AZ LPC-1777 (license). You may contact the board online at xxxxxx.xx, or by calling (000) 000-0000 Please sign the following if using your insurance or employee assistance program: "I authorize the release of any information necessary (including Including notes, treatment summaries and diagnosis) to process insurance or Employee Assistance claims, to prove medical necessity for treatment, to request additional sessions, or to comply with mandated quality control treatment reviews or administrative chart reviews from the insurance plan." (Sign here) :X “. If my therapist is a network provider, I authorize payment of benefits to Xxxx X. Talbot, LICSW” (be made to him/her." Sign here):X here: If second client participating - sign here: Client or Authorized Representative Signature: I authorize payment of benefits to my therapist - Sign here: By signing below, you I acknowledge you that I have read this Agreement, and you acknowledge receipt of my Notices of Privacy Practices. My Notice of Privacy Practices provides information about how I may use and disclose your private health information. I encourage you to read it in full. My Notice of Privacy Practices is subject to change. If I change my Notice, I will give you a revised Notice. If you have left treatment, you may obtain the revised notice from me at understand the above address rights and phone number. If you have any questions about the Notice, or any of the above, please feel free to ask. X X X Signature, Client policies: Signature Printed Name Date Signature, second client (if applicable) Printed Name, second client (if applicable) Date