Common use of Litigation Limitation Clause in Contracts

Litigation Limitation. Due to the nature of psychotherapy with regard to the therapeutic process and confidential nature of the work, I/we agree that should there be legal proceedings (such as but not limited to divorce and custody disputes, injuries, lawsuits, etc.) that neither me (client), nor my attorney, nor anyone else acting on my behalf will call on the clinician to testify in court or in any other legal proceedings, nor will the disclosure of psychotherapy records be requested. Professional Records: The laws and standards of your clinician’s profession require that he/she prepare and maintain treatment records. You are entitled to receive a copy of your records, or a summary from your clinician, unless your clinician believes in his or her professional judgment that release of such information would adversely affect your health and well-being. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, we will be happy to review them with you so that we can discuss the contents. You will be charged an appropriate fee for any professional time we spend in reviewing records with you. In addition, we will charge for our costs in providing copies of the records. Emergency Procedures: If you need to contact our office between sessions, please call 000-000-0000 x000 and leave a message. I will do my best to return all phone calls as quickly as possible. In the event of an emergency, please call 911 or call the area Crisis Center at 000-000-0000. You can also go to your nearest Crisis Center or hospital Emergency Room. You may also consider calling the 24-hour “NJ Suicide Prevention Hopeline” at 000- 000-0000 for immediate information and resources. Mediation and Arbitration: All disputes arising out of our relationship to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a precondition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of the clinician and client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any resolved controversy related to this agreement should be submitted to and settled by binding arbitration in Gloucester County, NJ in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed. Notwithstanding the forgoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, the clinician can use legal means (court, collections agency, etc.) to obtain payment. See the Financial section of this agreement for details on payment and interest rates. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitration will determine that sum. Financial

Litigation Limitation. Due to the nature of psychotherapy with regard to the therapeutic process and the fact that it often involves making a full disclosure with regard to many matter which may be of a confidential nature of the worknature, I/we you agree that should there be legal proceedings (such as but not limited to divorce and custody disputes, injuries, lawsuits, etc.) that neither me (client), neither you (clients) nor my attorneyyour attorneys, nor anyone else acting on my behalf your behalf, will call on the clinician me to testify in court or in at any other legal proceedingsproceeding, nor will the a disclosure of the psychotherapy records be requested. Professional RecordsConsultation: The laws I consult regularly with other professionals regarding my clients; however, neither clients’ names, nor any other identifying information, are ever mentioned. My client’s identity remains completely anonymous and standards of your clinician’s profession require that he/she prepare and maintain treatment recordsconfidentiality is fully maintained. You are entitled to receive a copy of your records, or a summary from your clinician, unless your clinician believes in his or her professional judgment that release of such information would adversely affect your health and well-being. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, we will be happy to review them with you so that we can discuss the contents. You will be charged an appropriate fee for any professional time we spend in reviewing records with you. In addition, we will charge for our costs in providing copies of the records. Emergency ProceduresTELEPHONE & EMERGENCY PROCEDURES: If you need to contact our office me between sessions, please call leave a message on my answering machine (000-) 000-0000 x000 and leave a message. I your call will do my best to return all phone calls be returned as quickly soon as possible. In the event I check my messages a few times each day, unless I am out of town. If an emergencyemergency situation arises, please indicate it clearly in your message. If you need to talk to someone right away call 911 or call the area Crisis Xxxxxx Center for Psychiatry at (000-) 000-0000. You can also go to your nearest Crisis Center , or hospital Emergency Room. You may also consider calling the 24-hour “NJ Suicide Prevention Hopeline” at 000- 000-0000 for immediate information and resources. Mediation and Arbitration: All disputes arising out of our relationship to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a precondition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of the clinician and client(sPolice/Sheriff’s Department (911). The PAYMENTS & INSURANCE REIMBURSEMENT: For the Shared Parenting Support Program method of co-parenting counseling, a retainer of $1,900.00 will need to be paid seven days prior to the first session. There will also be an additional cost for materials totaling $75.00. Each 50 minute session will be deducted from the retainer at the rate of such mediation$190.00 per session. For any other co-parenting counseling, if anyclients agree to participate in a minimum of eight (8) sessions. If there is a need for co- parenting counseling to extend beyond eight sessions, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any resolved controversy related to this agreement should be submitted to and settled by binding arbitration in Gloucester County, NJ in accordance with the rules of the American Arbitration Association which are in effect clients will pay for each additional session at the time of the demand meeting. If your insurance will cover this type of counseling, I will supply you with an insurance billing form that you can submit to your insurance provider for arbitration is fileddirect reimbursement. Notwithstanding Yes, I will need an insurance xxxx for reimbursement THE PROCESS OF CO-PARENTING COUNSELING: Change happens because a person consciously decides to speak and behavior differently. Growth does not happen without purposeful choice and effort by that individual. Your co-parenting relationship will improve to the forgoing, degree both parents make the wise choice apply themselves and make the necessary changes. Only you can determine what you will say and do. Please know clearly that your children will thrive to the degree their parents provide a tension free environment and peaceful parental exchanges. Referrals: If in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, the clinician can use legal means (court, collections agency, etc.) to obtain payment. See the Financial section course of this agreement for details on payment and interest rates. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitration will our working together I determine that sumI can not assist you to the full degree you are in need of, I will refer you to another professional(s) who would likely be more able to assist you in your efforts to produce change and growth in your life. FinancialDuel Relationships: Therapy never involves sexual or business relationships or any other dual relationship that impairs the therapist’s objectivity, clinical judgment, and therapeutic effectiveness or can be exploitative in nature.

Litigation Limitation. Due to the nature of psychotherapy with regard to the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters that may be of a confidential nature of the worknature, I/we agree it is agreed that should there be legal proceedings (such as as, but not limited to to, divorce and custody disputes, injuries, lawsuits, etc.) that neither me (client), neither you (the patient) nor my your attorney, nor anyone else acting on my your behalf will call on the clinician Xx. Xxxxxx to testify in court or in at any other legal proceedingsproceeding, nor will the a disclosure of the psychotherapy records be requested. Professional Records: The laws If, however, 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 standards transportation costs, even if I am called to testify by another party. Because of your clinician’s profession require that he/she prepare the difficulty of legal involvement, I charge $ 600.00 per hour for preparation, travel, and maintain treatment recordsattendance at any legal proceeding. You are entitled to receive a copy of your recordsContacting Me, Electronic Communications, & Communications Between Sessions. Even when I am in my office, I am often not immediately available by telephone, since I do not answer the phone when I am with patients. I do not check messages, answer, or return calls after 9 pm on weekdays, and I check for messages less frequently on weekends. When I am unavailable, my telephone is answered by confidential voicemail that I monitor frequently. I will make every effort to return your call on the same day. Unfortunately, I do not have a summary from your clinician, unless your clinician believes in his 24-hour answering service or her professional judgment that release of such information would adversely affect your health and wellthe staff to provide 24-being. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readershour emergency service. If you wish having a clinical emergency are unable to see reach me and feel that you cannot wait for me to return your recordscall, we call the police (911), your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be happy unavailable for an extended period of time I will provide you with the name of a colleague to review them with you so that we can discuss the contentscontact, if necessary. You will be charged an appropriate fee for any professional time we spend in reviewing records with you. In addition, we will charge for our costs in providing copies of the records. Emergency Procedures: If you need Please do not attempt to contact our office between sessions, please call 000-000-0000 x000 and leave a message. I will do my best to return all phone calls as quickly as possible. In me by fax or email in the event of an emergency, please call 911 or call the area Crisis Center at 000-000-0000. You can also go Under certain circumstances emergency phone consultation work may be subject to your nearest Crisis Center or hospital Emergency Roomcharge. We will decide together which kind of remote sessions service to use. You may also consider calling the 24-hour “NJ Suicide Prevention Hopeline” at 000- 000-0000 have to have certain computer or cell phone systems to use remote sessions services. We will only be using secured platforms (video or phone) to communicate and have our meetings. For communication between sessions, however, I only use email communication and text messaging with your permission and only for immediate information administrative purposes unless we have made another agreement. This means that email exchanges and resourcestext messages with my office should be limited to administrative matters. Mediation This includes things like setting and Arbitration: All disputes arising out of our relationship to this agreement to provide psychotherapy services shall first be referred to mediationchanging appointments, beforebilling matters, and as a precondition of, the initiation of arbitrationother related issues. The mediator shall be a neutral third party chosen by agreement of the clinician and client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any resolved controversy related to this agreement You should be submitted to aware that I cannot guarantee the confidentiality of any information communicated by email or text. Therefore, I will not discuss any clinical information by email or text and settled by binding arbitration in Gloucester Countyprefer that you do not either. Also, NJ in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed. Notwithstanding the forgoingI do not regularly check my email or texts, in the event that your account is overdue (unpaid) and nor do I respond immediately, so these methods should not be used if there is no agreement on a payment plan, the clinician can use legal means (court, collections agency, etcan emergency.) to obtain payment. See the Financial section of this agreement for details on payment and interest rates. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitration will determine that sum. Financial

Litigation Limitation. Due to the nature of psychotherapy with regard to the therapeutic process and the fact that it often involves making a full disclosure with regard to many matter which may be of a confidential nature of the worknature, I/we you agree that should there be legal proceedings (such as but not limited to divorce and custody disputes, injuries, lawsuits, etc.) that neither me (client), neither you (clients) nor my attorneyyour attorneys, nor anyone else acting on my behalf your behalf, will call on the clinician me to testify in court or in at any other legal proceedingsproceeding, nor will the a disclosure of the psychotherapy records be requested. Professional RecordsConsultation: The laws I consult regularly with other professionals regarding my clients; however, neither clients’ names, nor any other identifying information, are ever mentioned. My client’s identity remains completely anonymous and standards of your clinician’s profession require that he/she prepare and maintain treatment recordsconfidentiality is fully maintained. You are entitled to receive a copy of your records, or a summary from your clinician, unless your clinician believes in his or her professional judgment that release of such information would adversely affect your health and well-being. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, we will be happy to review them with you so that we can discuss the contents. You will be charged an appropriate fee for any professional time we spend in reviewing records with you. In addition, we will charge for our costs in providing copies of the records. Emergency ProceduresTELEPHONE & EMERGENCY PROCEDURES: If you need to contact our office me between sessions, please call leave a message on my answering machine (000-) 000-0000 x000 and leave a message. I your call will do my best to return all phone calls be returned as quickly soon as possible. In the event I check my messages a few times each day, unless I am out of town. If an emergencyemergency situation arises, please indicate it clearly in your message. If you need to talk to someone right away call 911 or call the area Crisis Xxxxxx Center for Psychiatry at (000-) 000-0000. You can also go to your nearest Crisis Center , or hospital Emergency Room. You may also consider calling the 24-hour “NJ Suicide Prevention Hopeline” at 000- 000-0000 for immediate information and resources. Mediation and Arbitration: All disputes arising out of our relationship to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a precondition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of the clinician and client(sPolice/Sheriff’s Department (911). The PAYMENTS & INSURANCE REIMBURSEMENT: For the Shared Parenting Support Program method of co-parenting counseling, a retainer of $1,900.00 will need to be paid seven days prior to the first session. There will also be an additional cost for materials totaling $75.00. Each 50 minute session will be deducted from the retainer at the rate of such mediation$190.00 per session. For any other co-parenting counseling, if anyclients agree to participate in a minimum of eight (8) sessions. If there is a need for co- parenting counseling to extend beyond eight sessions, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any resolved controversy related to this agreement should be submitted to and settled by binding arbitration in Gloucester County, NJ in accordance with the rules of the American Arbitration Association which are in effect clients will pay for each additional session at the time of the demand meeting. If your insurance will cover this type of counseling, I will supply you with an insurance billing form that you can submit to your insurance provider for arbitration is fileddirect reimbursement. Notwithstanding Yes, I will need an insurance bill for reimbursement THE PROCESS OF CO-PARENTING COUNSELING: Change happens because a person consciously decides to speak and behavior differently. Growth does not happen without purposeful choice and effort by that individual. Your co-parenting relationship will improve to the forgoing, degree both parents make the wise choice apply themselves and make the necessary changes. Only you can determine what you will say and do. Please know clearly that your children will thrive to the degree their parents provide a tension free environment and peaceful parental exchanges. Referrals: If in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, the clinician can use legal means (court, collections agency, etc.) to obtain payment. See the Financial section course of this agreement for details on payment and interest rates. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitration will our working together I determine that sumI can not assist you to the full degree you are in need of, I will refer you to another professional(s) who would likely be more able to assist you in your efforts to produce change and growth in your life. FinancialDuel Relationships: Therapy never involves sexual or business relationships or any other dual relationship that impairs the therapist’s objectivity, clinical judgment, and therapeutic effectiveness or can be exploitative in nature.

Litigation Limitation. Due to the nature of psychotherapy with regard to the therapeutic process and confidential nature of the worktherapeutic process, I/we you agree that should there be legal proceedings (such as but not limited to divorce and custody disputes, injuries, lawsuits, etc.) that neither me (client), nor my attorney, neither you nor anyone else acting on my your behalf will call on the clinician to request that I testify in court any legal proceeding or in disclose any other legal proceedings, nor will the disclosure of psychotherapy records be requested. Professional Records: The laws and standards of your clinician’s profession require that he/she prepare and maintain treatment therapy records. You Billing and Payments Fees are entitled to receive collected by my clinical supervisor, Xxx Xxxxxxx, via a copy of your records, or a summary from your clinician, unless your clinician believes in his or her professional judgment that release of such information would adversely affect your health and well-beingcredit card authorization form. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, we will be happy to review them with you so that we can discuss the contents. You Your credit card will be charged an appropriate fee shortly after each session. Prepayments for any professional time we spend in reviewing records with youmultiple sessions are also accepted. In additioncircumstances of unusual financial hardship, we I may be willing to negotiate a fee adjustment or a payment installment plan. I do not accept insurance, but can provide superbills periodically. If your insurance company accepts out-of-network providers, you can apply for reimbursements using the superbills. If full payment for services provided is not made within 60 days, I may use legal means to secure the payment, such as through a collection agency or small claims court. If such action is necessary, legal costs will charge for our costs be included in providing copies of the recordsclaim. Emergency Procedures: Contacting Me Email is the most reliable way to contact me. If you need to contact our office between sessionscall, please call 000-000-0000 x000 and do so during normal business hours. If I am not available, please leave a message. voicemail, and I will do my best to return all phone calls as quickly as possibleyour call. In the event of If you are an emergencyexisting client, please call 911 contact me at xxxxxxx@XxxxxxXxxxXXX.xxx or call the area Crisis Center at 000-000-0000. You can Please use email, text, or voicemail for scheduling and basic procedural purposes only. Avoid using them for clinical concerns. Email is also go acceptable to your nearest Crisis Center or hospital Emergency Roomtransfer documents. You may also consider calling the I do not provide 24-hour “NJ Suicide Prevention Hopeline” crisis services. If a life-threatening crisis should occur, please contact a crisis hotline, call 911, or go to a hospital emergency room. Discharge from Care You and I both have the right to end counseling at 000- 000-0000 for immediate information any time. Psychotherapy is best concluded with a formal termination process and resourcesscheduled final appointment. Mediation This allows us to review the therapeutic gains achieved, discuss how to maintain those gains, identify services or activities still needed, and Arbitration: All disputes arising out process any emotions regarding the ending of our relationship therapeutic relationship. If you stop scheduling appointments unexpectedly, I will make up to this agreement two attempts to provide psychotherapy services shall first contact you. If you do not reply, I will conclude that you no longer wish to be referred to mediation, before, my client and as a precondition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of the clinician and client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any resolved controversy related to this agreement should be submitted to and settled by binding arbitration in Gloucester County, NJ in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed. Notwithstanding the forgoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, the clinician can use legal means (court, collections agency, etcdischarge you from care.) to obtain payment. See the Financial section of this agreement for details on payment and interest rates. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitration will determine that sum. Financial

Litigation Limitation. Due to the nature of psychotherapy with regard to the therapeutic process and confidential nature of the work, I/we agree that should there be legal proceedings (such as but not limited to divorce and custody disputes, injuries, lawsuits, etc.) that neither me (client), nor my attorney, nor anyone else acting on my behalf will call on the clinician therapist to testify in court or in any other legal proceedings, nor will the disclosure of psychotherapy records be requested. Professional Records: The laws and standards of your cliniciantherapist’s profession require that he/she prepare and maintain treatment records. You are entitled to receive a copy of your records, or a summary from your cliniciantherapist, unless your clinician therapist believes in his or her professional judgment that release of such information would adversely affect your health and well-being. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, we will be happy to review them with you so that we can discuss the contents. You will be charged an appropriate fee for any professional time we spend in reviewing records with you. In addition, we will charge for our costs in providing copies of the records. Emergency Procedures: If you need to contact our office between sessions, please call 000-000-0000 x000 and leave a message for the appropriate party. If you need to speak with your therapist and you feel it is an emergency please state so on your message. I Your therapist will do my best to return all phone calls be notified of your message automatically via text message and call you back as quickly soon as possible. In the event of an emergencyIf you feel you cannot wait for your therapist to call you back, please call 911 or you can call the area Gloucester County Crisis Center at 000-000-0000. You can also , go to your nearest Crisis Center the closest emergency room, or hospital Emergency Room. You you may also consider calling call the 24-hour “NJ Suicide Prevention Hopeline” police at 000- 000-0000 for immediate information and resources911. Mediation and Arbitration: All disputes arising out of our relationship to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a precondition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of the clinician therapist and client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any resolved controversy related to this agreement should be submitted to and settled by binding arbitration in Gloucester County, NJ in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed. Notwithstanding the forgoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, the clinician therapist can use legal means (court, collections agency, etc.) to obtain payment. See the Financial section of this agreement for details on payment and interest rates. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitration will determine that sum. FinancialOffice Space, Staff, and Personal Health Information (PHI): Xxxxxx Xxxxxxx, MS, LPC contracts with South Jersey Psychological and Counseling Services, LLC (SJPCS) for professional office services. We maintain separate files and are not a group practice or professionally associated. By signing this agreement you acknowledge that the office staff of SJPCS will have access to your Personal Health Information (PHI) in order to file claims with insurance companies and for bookkeeping purposes. All office staff of SJPCS have agreed to strictly adhere to all HIPPA rules and regulations for confidentiality. Client Rights and Responsibilities Clients have the right to:

Litigation Limitation. Due to the nature of psychotherapy with regard to the therapeutic process and confidential nature of the work, I/we agree that should Should there be legal proceedings (such as but not limited to divorce and divorce, custody disputes, injuries, lawsuits, etc.) that neither me (client), nor my attorney, nor anyone else acting on my behalf I will call on the clinician to not testify in court or in at any other legal proceedings, nor will the proceeding and disclosure of clinical psychotherapy records should not be requestedrequested unless otherwise agreed upon. Professional RecordsCONSULTATION: The laws I may consult with other professional if I believe it will benefit the client. If I do so, the client’s identity remains completely anonymous to protect their privacy rights and standards maintain full confidentiality. E–MAILS, CELL PHONES, COMPUTERS, AND FAXES: It is important to be aware that computers and email communication cannot protect the privacy and confidentiality of such communication and that emails, faxes, and important texts are part of the medical records. CLIENT RECORDS: You have the right to review or receive a summary of your clinician’s profession require that he/she prepare records at any time, excepting certain circumstances, and maintain treatment records. You are entitled if assessed to receive be more appropriate the records would be provided to a copy mental health professional of your recordschoice. Upon your request and after obtaining your signed authorization, your clinical information may be released to agencies and persons specified by you. For clients’ whose therapy involves another person(s), as in couples or family therapy, or when family members and/or other adults have been involved in the treatment of an individual, a summary signed authorization must be obtained from your clinician, unless your clinician believes in his or her professional judgment that release of such information would adversely affect your health and well-beingall participating individuals who can legally authorize the release. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, we will be happy to review them with you so that we can discuss the contents. You will be charged an appropriate fee for any professional time we spend in reviewing records with you. In addition, we will charge for our costs in providing copies of the records. Emergency ProceduresTELEPHONE & EMERGENCY PROCEDURES: If you need to contact our office me between sessions, please call 000-000-0000 x000 send me an email @ xxxxxxx0000@xxxxx.xxx, and leave a message. I will do my best to return all phone calls get back with you as quickly soon as possible. In the event If your message is of an emergency, urgent nature please contact me on my cell phone @ (000) 000-0000. If you have an emergency situation and need to talk to someone right away please call 911 or call the area Crisis Center at 000-000-0000. You can also go to your nearest Crisis Center or hospital Emergency Roomemergency room. You may also consider calling the 24PAYMENTS & INSURANCE REIMBURSEMENT: My standard fee for psychotherapy is $150.00 for 60-hour “NJ Suicide Prevention Hopeline” at 000- 000-0000 for immediate information and resourcesminute sessions. Mediation and Arbitration: All disputes arising out of our relationship Professional services are either charged to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a precondition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of the clinician and client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any resolved controversy related to this agreement should be submitted to and settled by binding arbitration in Gloucester County, NJ in accordance with the rules of the American Arbitration Association which are in effect clients at the time of service, or billed to their insurance carrier. Co-pays are due at the demand time of session and payable by cash or check made out to: Xxxxx Xxxx Therapy LLC. Sliding scale fees may apply for arbitration self pay clients, with an agreed upon fee to be determined before the first session. OFFICE POLICY for PRE AUTHORIZATIONS AND COPAYS: It is filedthe client’s responsibility to contact their insurance carrier(s) before the first therapy session to determine whether sessions will be covered by insurance payments. Notwithstanding If by the forgoingsecond therapy session, a client has not received pre authorization for insurance payments, payment for sessions will be on a self-pay basis due at time of service until the therapy sessions have been authorized for insurance payments. THE PROCESS OF THERAPY/EVALUATION AND SCOPE OF PRACTICE: Participation in therapy can result in a number of benefits; including improving interpersonal relationships and resolving the specific concerns that led you to seek therapy. Working toward these benefits requires your effort and active involvement in the event that therapeutic process both inside and out of the therapy session. During the evaluation or therapy session, remembering and talking about certain feelings and thoughts may result in experiencing some uncomfortable feelings such as anger, sadness, worry, or fear. Some of your account is overdue (unpaid) assumptions or perceptions may be challenged as you begin to consider and there is no agreement on a payment planexperiment with different ways of looking at, the clinician can use legal means (courtthinking about, collections agency, etc.) and responding in relationship and to obtain payment. See the Financial section of this agreement for details on payment and interest rates. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitration will determine that sum. Financiallife circumstances as with: intimate partners: family members: friends: co-

Litigation Limitation. Due to the nature of psychotherapy with regard to the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature of the worknature, I/we agree it is agreed that should there be legal proceedings (such as as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.) that ), neither me you (client), ) nor my your attorney, nor anyone else acting on my your behalf will call on the clinician Xxxxxxx X. Xxxxxx to testify in court or in at any other legal proceedingsproceeding, nor will the a disclosure of the psychotherapy records be requested. Professional RecordsConsultation: Xxxxxxx X Xxxxxx, LCSW, LPC consults regularly with other professionals regarding his clients; however, the client’s name or other identifying information is never mentioned. The laws client’s identity remains completely anonymous, and standards confidentiality is fully maintained. * Considering all of the above exclusions, if it is still appropriate, upon your clinician’s profession require request, Xxxxxxx X Xxxxxx, LCSW, LPC will release information to any agency/person you specify unless Xxxxxxx X Xxxxxx, LCSW, LPC concludes that he/she prepare and maintain treatment records. You are entitled to receive a copy of your records, or a summary from your clinician, unless your clinician believes in his or her professional judgment that release of releasing such information would adversely affect your health and well-beingmight be harmful in any way. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, we will be happy to review them with you so that we can discuss the contents. You will be charged an appropriate fee for any professional time we spend in reviewing records with you. In addition, we will charge for our costs in providing copies of the records. Emergency ProceduresTELEPHONE & EMERGENCY PROCEDURES: If you need to contact our office Xxxxxxx X Xxxxxx, LCSW, LPC between sessions, please call 000-000-0000 x000 and leave a message. I message on voice mail (503) 000- 0000 and your call will do my best to return all phone calls be returned as quickly soon as possible. In the event Xxxxxxx X Xxxxxx, LCSW, LPC checks his messages a few times a day, unless he is out of town. If an emergencyemergency situation arises, please indicate it clearly in your message. If you need to talk to someone right away, you can call 911 or call the area Crisis Center at 000-000-0000. You can also go to your nearest Crisis Center or hospital Emergency Room. You may also consider calling the 24-hour “NJ Suicide Prevention Hopeline” at 000- crisis line (000) 000-0000 for immediate information and resources. Mediation and Arbitration: All disputes arising out of our relationship to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a precondition of0000, the initiation Police (911), or go to your local hospital emergency room. PAYMENTS & INSURANCE REIMBURSEMENT: Clients are expected to pay my standard fee (on the Professional Disclosure Statement) at the end of arbitrationeach session unless other arrangements have been made. The mediator shall Telephone conversations, site visits, report writing and reading, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc. will be a neutral third party chosen by agreement of charged at the clinician and client(s). The cost of such mediation, if any, shall be split equallysame rate, unless otherwise agreedindicated and agreed otherwise. In Please notify Xxxxxxx Xxxxxx if any problem arises during the event course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that mediation is unsuccessfulprofessional services are rendered and charged to the clients and not to the insurance companies. Unless agreed upon differently, any resolved controversy related Xxxxxxx Xxxxxx will provide you with a copy of your receipt on a monthly basis, which you can then submit to this agreement should your insurance company for reimbursement if you so choose. As was indicated in the section, Health Insurance & Confidentiality of Records, you must be submitted to and settled by binding arbitration in Gloucester Countyaware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Insurance companies reimburse not all issues/conditions/problems, NJ in accordance with the rules of the American Arbitration Association which are in effect at the time focus of psychotherapy. It is your responsibility to verify the demand for arbitration is filed. Notwithstanding the forgoing, in the event that specifics of your account is overdue (unpaid) and there is no agreement on a payment plan, the clinician can use legal means (court, collections agency, etccoverage.) to obtain payment. See the Financial section of this agreement for details on payment and interest rates. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitration will determine that sum. Financial

Litigation Limitation. Due to the nature of psychotherapy with regard to the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature of the worknature, I/we agree it is agreed that should there be legal proceedings (such as as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.) that neither me (client), neither you nor my attorneyyour attorney(s), nor anyone else acting on my your behalf will call on the clinician me to testify in court or in at any other legal proceedingsproceeding, nor will the a disclosure of the psychotherapy records be requested. Professional Records: The laws and standards of your clinician’s profession require that he/she prepare and maintain treatment records. You are entitled to receive a copy of your records, or a summary from your clinician, unless your clinician believes in his or her professional judgment that release of such information would adversely affect your health and well-being. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, we will be happy to review them with you so that we can discuss the contents. You will be charged an appropriate fee for any professional time we spend in reviewing records with you. In addition, we will charge for our costs in providing copies of the records. Emergency Procedures: If you need to contact our office between sessions, please call 000-000-0000 x000 and leave a message. I will do my best to return all phone calls as quickly as possible. In the event of an emergency, please call 911 or call the area Crisis Center at 000-000-0000. You can also go to your nearest Crisis Center or hospital Emergency Room. You may also consider calling the 24-hour “NJ Suicide Prevention Hopeline” at 000- 000-0000 for immediate information and resources. Mediation and Arbitration: All disputes arising out of our relationship to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a precondition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of the clinician and client(s). The cost of such mediation, if any, shall be split equally, requested unless otherwise agreedagreed upon. In the event that mediation is unsuccessful, any resolved controversy related to this agreement should be submitted to and settled by binding arbitration in Gloucester County, NJ in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed. Notwithstanding the forgoingHowever, in the event that I am called to participate in any type of legal procedure because of my treatment of you, you agree to pay my then current standard forensic hourly rates for all time spent in preparing for, traveling to and from, and attending such legal proceeding(s), including depositions and court appearances, as well as any expenses I may incur, such as for legal consultations, in connection with the legal proceeding(s). CONSULTATION: I consult regularly with other professionals regarding clients; however, each client's identity remains completely anonymous, and confidentiality is fully maintained. You also agree that from time to time, I may have the need to consult with my practice attorney regarding legal issues involving your account care (this is overdue (unpaid) an infrequent occurrence but does happen from time to time). My practice attorney is bound by confidentiality rules also. In addition, I will reveal only the information that I need to reveal to receive appropriate legal advice in connection with those contacts. I may also use your information for health care operations, which are described in the Notice of Privacy Practices form. E–MAILS, CELL PHONES, COMPUTERS, & FAXES: It is very important to be aware that computers and there unencrypted e-mail, texts, and e-faxes communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. E-mails, texts, and e-faxes, in particular, are vulnerable to such unauthorized access due to the fact that servers or communication companies may have unlimited and direct access to all e-mails, texts and e-faxes that go through them. While data on my laptop is no agreement encrypted, e-mails and e-fax are not. It is always a possibility that e-faxes, texts, and email can be sent erroneously to the wrong address and computers. My laptop is equipped with a firewall, virus protection and a password, and I back up all confidential information from my computer on a payment planregular basis onto an encrypted hard drive. Also, be aware that some phone messages are transcribed and sent to me via unencrypted e-mails from sites such as Psychology Today and other marketing sites. Please notify me if you decide to avoid or limit, in any way, the clinician can use legal means (courtof e-mail, collections agencytexts, etccell phones calls, phone messages, or e-faxes. If you communicate confidential or private information via unencrypted e-mail, texts, or e-fax or via phone messages, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and I will honor your desire to communicate in such a way on such matters. Please do not use texts, e-mail, or faxes for emergencies, instead follow the procedures in the Telephone & Emergency Procedures section below.) to obtain payment. See the Financial section of this agreement for details on payment and interest rates. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitration will determine that sum. Financial