Common use of Patient Privilege Clause in Contracts

Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the patient is the holder of the psychotherapist- patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. The usual and customary fee for service is $150 per 50-minute session. Sessions longer than 50- minutes are charged for the additional time pro rata. Therapist reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is $ Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, checks, and major credit cards.

Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-psychotherapist patient privilege. The psychotherapist-patient psychotherapist-­‐patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client attorney-­‐client privilege or the doctor-patient doctor-­‐patient privilege. Typically, the patient is the holder of the psychotherapist- patient psychotherapist-­‐patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient psychotherapist-­‐patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-psychotherapist-­‐ patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient psychotherapist-­‐patient privilege with his/her attorney. The usual and customary fee for service is $150 per 50-minute 50-­‐minute session. Sessions longer than 50- minutes 50-­‐minutes are charged for the additional time pro rata. Therapist reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party third-­‐party payors, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is $ _. Therapist reserves the right to periodically adjust feeA Patient’s appointment is reserved exclusively for the Patient. Patient will be notified of charged the full fee per session for any fee adjustment missed or cancelled appointments unless Patient provides Xxxxxx Xxxxxxxx, MA, LMFT, with at least 24 hours notice. Unless you have made special arrangements with Therapist, if Patient misses two or more appointments in advancea row Therapist may not be able to hold the appointment time and Patient may lose their time slot. From time-to-timetime-­‐to-­‐time, Therapist may engage in telephone contact with Patient for purposes other than scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-timetime-­‐to-­‐time, Therapist may engage in telephone contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. All past due accounts which have not had payment activity for 30 days or more will be reviewed and may be referred to a collection agency. Collection fees may be added to these accounts. The Patient, or responsible party, agrees to pay Xxxxxx Xxxxxxxx, MA, LMFT, any reasonable costs of collection, plus attorney fees and court costs in the event that legal action is required for collection of fees. Like many other mental health providers, Therapist has formal relationships only with some managed health care providers. These are Blue Shield of California, Magellan, and Managed Health Network. Therapist does accept referrals only from these managed health care providers and will otherwise only be accepting private pay clients. The reasons for this include the overwhelming administrative time spent in dealing with insurance companies and financial concerns. This means private pay clients are expected to pay full fee at the time services are rendered while managed health care clients are expected to pay their co-­‐pay. A private pay client may wish to submit statements to their insurance companies, since some will provide limited reimbursement for “off-­‐plan providers.” If Patient submits a xxxx for reimbursement, Patient needs to make it clear that the Patient/Member is to be reimbursed, not the provider. Again, Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, checks, and major credit cardscash only.

Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the patient is the holder of the psychotherapist- psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. The usual and customary fee for service for individuals is $150 per 50-minute session. The usual and customary fee for service for couples is $200 per 50-minute session. Sessions longer than 50- 50-minutes are charged for the additional time pro rata. Therapist reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is $ Should cancellation occur les than 24 hours in advance, payment at the rate of _$150__ will be due. Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, cash or checks, and major credit cards. There will be a $25 fee for returned checks. Patient is responsible for payment of the full fee of $150 for any missed session(s) or for any session(s) for which Patient failed to give Therapist at least 24 hours notice of cancellation. Cancellation notice should be left on Therapist’s voice mail at 323.614.9422 or emailed to xxxxxxxxxxxx@xxxxx.xxx.

Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the patient is the holder of the psychotherapist- psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. The usual and customary fee for service is $150 130.00 per 50-50- minute session. Sessions longer than 50- 50-minutes are charged for the additional time pro rata. Therapist reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is $ Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, cash and checks, and major credit cards.

Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the patient is the holder of the psychotherapist- psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. The usual and customary fee for service is $150 140 per 50-minute session. Sessions longer than 50- At times, Therapist may suggest sessions of other lengths, and if accepted by Patient, these are billed at $200 for 80 minutes are charged or $250 for the additional time pro rata110 minutes. Therapist reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is $ Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, checks, and major credit cardscards (Visa and MasterCard).

Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the patient is the holder of the psychotherapist- psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. The usual and customary fee for service is $150 170 per 50-minute session. Sessions longer than 50- 50-minutes are charged for the additional time pro rata. Therapist reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is $ Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, checks, and major credit cardspaypal (Visa, MasterCharge, Discovery and American Express).

Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the patient is the holder of the psychotherapist- psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. The usual and customary fee for service is $150 per 50-minute session. Sessions longer than 50- 50-minutes are charged for the additional time pro rata. Therapist reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payorspayers, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is $ _ or the co-pay amount of is required at the time of each visit. If there is a deductible or if the insurance claim is denied, then the patient is responsible for the agreed upon fee as stated within. Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, checks, and major credit cards, including Visa, Master Card, American Express and Discover.

Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapistPsychotherapist-patient Patient privilege. The psychotherapistPsychotherapist-patient Patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client Patient privilege or the doctor-patient Patient privilege. Typically, the patient Patient is the holder of the psychotherapist- patient Psychotherapist-Patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapistPsychotherapist-patient Patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapistPsychotherapist-patient Patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapistPsychotherapist-patient Patient privilege with his/her attorney. The usual and customary fee for service is $150 per 50-minute session. Sessions longer than 50- 50-minutes are charged for the additional time pro rata. Therapist reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is $ Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, checks, and most major credit cardscards and checks. Payments received more than 30 days after services are rendered are subject to late fees. Returned checks will be subject to a $25 penalty. Delinquent bills may be turned over to a collection agency.

Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-psychotherapist- patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-doctor- patient privilege. Typically, the patient is the holder of the psychotherapist- psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. The usual and customary fee for service is $150 per 50-minute session. Sessions longer than 50- minutes are charged for the additional time pro rata. Therapist reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is $ . Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, checks, cash and major credit cardscards (visa and mastercard) only.

Patient Privilege. The information disclosed by PatientClient, as well as any records created, is subject to the psychotherapist-patient client privilege. The psychotherapist-patient client privilege results from the special relationship between Therapist and Patient Client in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient client privilege. Typically, the patient is the holder of the psychotherapist- patient privilege. If Kairos Counseling Inc or Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Kairos Counseling Inc. and Therapist will assert the psychotherapist-patient privilege on PatientClient’s behalf until instructed, in writing, to do otherwise by Patient Client or PatientClient’s representative. Patient Client should be aware that he/she might be waiving the psychotherapist-patient client privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient Client should address any concerns he/she might have regarding the psychotherapist-patient client privilege with his/her attorney. F ee and Fee Arrangements The usual and customary fee for service is $150 160 per 50-minute session. Sessions longer than 50- minutes are charged for the additional time pro rata. Therapist Kairos Counseling Inc. reserves the right to periodically adjust this fee. Patient Client will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. The agreed upon fee between Therapist Kairos Counseling Inc. and Patient Client is $ Therapist $160/hr. Kairos Counseling Inc. reserves the right to periodically adjust fee. Patient Client will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient Client for purposes other than scheduling sessions. Patient Client is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutesat the same rate as a regular therapy session. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at PatientClient’s request and with PatientClient’s advance written authorization. Patient Client is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutescalls. Patients Therapist may also engage in correspondence with third parties in the form of letters, emails, text messages, and voicemails. Client is also responsible for the therapist time spent on such communication on the same rate charged for therapy sessions. Clients are expected to pay for services at the time services are rendered. Kairos Counseling Inc. accepts cash and checks. I nsurance Should Client choose to use his/her insurance and Therapist accepts cashis considered out of network, checksKairos Counseling Inc. will provide Client with a statement, which Client can submit to the third-party of his/her choice to seek reimbursement of fees already paid. If you have a health insurance policy in which Therapist is considered in-network, it will usually provide some coverage for mental health treatment. Kairos Counseling Inc. will fill out forms and major credit cardsprovide Client with whatever assistance is necessary to receive the benefits to which client is entitled; however, Client (not insurance company) is responsible for full payment of fees. It is very important that Client find out exactly what mental health services Client’s insurance policy covers. Client should carefully read the section in insurance coverage booklet that describes mental health services. If Client has questions about the coverage, please call plan administrator. Of course, Kairos Counseling Inc. will provide assistance to help Client in understanding the insurance information.

Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the patient is the holder of the psychotherapist- psychotherapist-patient privilege. If Therapist received receives a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or a person with the authority to waive the privilege on Patient’s representativebehalf. Patient When a patient is a minor child, the holder of the psychotherapist-patient privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-patient privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-patient privilege with his/her attorney. Patient, or Representative, should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient Patient, or Representative, should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. The usual and customary fee for service is $150 125 per 50-minute session. Sessions longer than 50- minutes 50minutes are charged for the additional time pro rata. Therapist reserves the right to periodically adjust this fee. Patient Representative will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, HMOs, managed care organizations, or other third-party payors, or by agreement with Therapist. The agreed upon fee between Therapist and Patient Representative is $ . Therapist reserves the right to periodically adjust fee. Patient Representative will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient or Representative for purposes other than scheduling sessions. Patient Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient’s the request of Patient or Representative and with Patient’s the advance written authorizationauthorization of Patient or Representative. Patient Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are Representative is expected to pay for services at the time services are rendered. Therapist accepts cashcash or checks. Representative is responsible for any and all fees not reimbursed by his/her insurance company, checksmanaged care organization, or any other third-party payor. Representative is responsible for verifying and major credit cardsunderstanding the limits of his/her coverage, as well as his/her co-payments and deductibles. Therapist is a contracted provider with the following companies: Xxxxxx EAP, Xxxxxx Select and UBH and has agreed to a specified fee. If Representative intends to use benefits of his/her health insurance policy, Representative agrees to inform Therapist in advance.

Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the patient is the holder of the psychotherapist- psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. The usual and customary fee for service is $150 160 per 50-minute session. Sessions longer than 50- 50-minutes are charged for the additional time pro rata. Therapist reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is $ Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, checks, and major credit cardspaypal (Visa, MasterCharge, Discovery and American Express).

Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the patient is the holder of the psychotherapist- psychotherapist-patient privilege. If Therapist received receives a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or a person with the authority to waive the privilege on Patient’s representativebehalf. Patient When a patient is a minor child, the holder of the psychotherapist-patient privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-patient privilege for their minor children, unless given such authority by a court of law. Patient, or Representative, should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient Patient, or Representative, should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. The usual and customary fee for service is $150 125.00 per 50-50- minute session. Sessions longer than 50- 50-minutes are charged for the additional time pro rata. Therapist reserves the right to periodically adjust this fee. Patient Representative will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, HMOs, managed care organizations, or other third-party payors, or by agreement with Therapist. The agreed upon fee between Therapist and Patient Representative is $ Therapist reserves the right to periodically adjust fee$125.00 or . Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient or Representative for purposes other than scheduling sessions. Patient Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient’s the request of Patient or Representative and with Patient’s the advance written authorizationauthorization of Patient or Representative. Patient Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutescalls. Patients are Representative is expected to pay for services at the time services are rendered. Therapist accepts cash, checks, and major credit cards, including Visa and Mastercard, and American Express. Therapist will keep a copy of your credit card number on file. Please inform Therapist should you wish to use another form of payment. Representative is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments, limitations, exclusions and deductibles. Therapist is a contracted provider with the following insurance companies: and has agreed to a specified fee. If Representative intends to use benefits of his/her health insurance policy, Representative agrees to inform Therapist in advance. Additionally, should you choose to use your insurance, with out of network benefits, Therapist will provide you with a statement, which you can submit to the third-party of your choice to seek reimbursement of fees already paid.

Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-psychotherapist patient privilege. The psychotherapist-patient psychotherapist-­‐patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client attorney-­‐client privilege or the doctor-patient doctor-­‐patient privilege. Typically, the patient is the holder of the psychotherapist- patient psychotherapist-­‐patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient psychotherapist-­‐patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-psychotherapist-­‐ patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient psychotherapist-­‐patient privilege with his/her attorney. The usual and customary fee for service is $150 per 50-minute 50-­‐minute session. Sessions longer than 50- minutes 50-­‐minutes are charged for the additional time pro rata. Therapist reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party third-­‐party payors, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is $ _. Therapist reserves the right to periodically adjust feeA Patient’s appointment is reserved exclusively for the Patient. Patient will be notified of charged the full fee per session for any fee adjustment missed or cancelled appointments unless Patient provides Xxxxxx Xxxxxxxx, MA, LMFT, with at least 48 hours notice. Unless you have made special arrangements with Therapist, if Patient misses two or more appointments in advancea row Therapist may not be able to hold the appointment time and Patient may lose their time slot. From time-to-timetime-­‐to-­‐time, Therapist may engage in telephone contact with Patient for purposes other than scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-timetime-­‐to-­‐time, Therapist may engage in telephone contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. All past due accounts which have not had payment activity for 30 days or more will be reviewed and may be referred to a collection agency. Collection fees may be added to these accounts. The Patient, or responsible party, agrees to pay Xxxxxx Xxxxxxxx, MA, LMFT, any reasonable costs of collection, plus attorney fees and court costs in the event that legal action is required for collection of fees. Like many other mental health providers, Therapist has formal relationships only with some managed health care providers. These are Blue Shield of California, Cigna, Health Net, Magellan Behavioral Health, and Managed Health Network. Therapist does accept referrals only from these managed health care providers and will otherwise only be accepting private pay clients. The reasons for this include the overwhelming administrative time spent in dealing with insurance companies and financial concerns. This means private pay clients are expected to pay full fee at the time services are rendered while managed health care clients are expected to pay their co-­‐pay. A private pay client may wish to submit statements to their insurance companies, since some will provide limited reimbursement for “off-­‐plan providers.” If Patient submits a bill for reimbursement, Patient needs to make it clear that the Patient/Member is to be reimbursed, not the provider. Again, Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, checks, and major select credit cards.

Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the patient is the holder of the psychotherapist- psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. The usual and customary fee for service is $150 145 per 5055-minute session. Sessions longer than 50- This fee is increased by $5 on the first of each year. At times, Therapist may suggest sessions of other lengths, and if accepted by Patient, these are billed at $205 for 85 minutes or $255 for 115 minutes. Special extended sessions beyond two hours are charged for billed at the additional time pro rata. Therapist reserves the right to periodically adjust this hourly session fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. The agreed upon If Patient wishes to use insurance benefits, a separate insurance fee between consent will outline the fees specific to the individual’s plan. If Patient does not wish to use insurance benefits, Patient may choose to begin using benefits, if available, at any time in the future. Benefits utilization will begin at the time Therapist is provided policy information. Therapist will xxxx primary insurance when the therapist is contracted with the insurance panel. For out of network and secondary insurance benefits, Therapist will provide a superbill that Patient is $ Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advancecan use for reimbursement. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cashall major credit cards, checks, and major credit cardscash (exact change only). There is a $35 returned check fee.

Patient Privilege. The information disclosed by PatientClient, as well as any records created, is subject to the psychotherapist-patient psychotherapist- client privilege. The psychotherapist-patient client privilege results from the special relationship between Therapist and Patient Client in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient client privilege. Typically, the patient is the holder of the psychotherapist- psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on PatientClient’s behalf until instructed, in writing, to do otherwise by Patient Client or PatientClient’s representative. Patient Client should be aware that he/she might be waiving the psychotherapist-patient client privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient Client should address any concerns he/she might have regarding the psychotherapist-patient client privilege with his/her attorney. The usual and customary fee for service is $150 160 per 50-minute session. Sessions longer than 50- 50-minutes are charged for the additional time pro rata. Therapist reserves the right to periodically adjust this fee. Patient Client will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. The agreed upon fee between Therapist and Patient Client is $ $160/hr. Therapist reserves the right to periodically adjust fee. Patient Client will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient Client for purposes other than scheduling sessions. Patient Client is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutesat the same rate as a regular therapy session. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at PatientClient’s request and with PatientClient’s advance written authorization. Patient Client is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutescalls. Patients Therapist may also engage in correspondence with third parties in the form of letters, emails, text messages, and voicemails. Client is also responsible for the therapist time spent on such communication on the same rate charged for therapy sessions. Clients are expected to pay for services at the time services are rendered. Therapist accepts cash, cash and checks, and major credit cards.

Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the patient is the holder of the psychotherapist- patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. The usual and customary fee for service is $150 225.00 per 50-minute session. Sessions longer than 50- minutes are charged for the additional time pro rata. Therapist reserves the right to periodically adjust this feeCouples sessions are $250.00 for 60-minute session. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, managed care organizations, or other third-party payors, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is $ Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient or Patient’s guardian(s) for purposes other than scheduling sessions. Patient (or responsible party) is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten five minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are Patient (or responsible party) is expected to pay for services at the time services are rendered. Patient (or responsible party) is responsible for any and all fees. Therapist accepts casha considered an “Out of Network Provider.” Upon request client will receive a monthly statement for possible reimbursement by his/her insurance company, checksmanaged care organization, or any other third-party payer. Patient (or responsible party) is responsible for verifying and major credit cardsunderstanding the limits of his/her coverage, as well as his/her co-payments and deductibles. Patient (or responsible party) is responsible for the full amount of the session fee for any missed session(s). Patient (or responsible party) is also responsible for payment of the agreed upon fee for any session(s) for which Patient failed to give Therapist at least 24 hour’s notice of cancellation. Cancellation notice should be left on Therapist’s voicemail at (000) 000-0000.

Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the patient is the holder of the psychotherapist- psychotherapist-patient privilege. If Therapist received receives a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or a person with the authority to waive the privilege on Patient’s representativebehalf. Patient When a patient is a minor child, the holder of the psychotherapist-patient privilege is either the minor, a court appointed guardian, or minor’s counsel. Patient, or Representative, should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient Patient, or Representative, should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. The usual and customary fee for service is $150 125.00 per 50-50- minute session. Sessions longer than 50- 50-minutes are charged for the additional time pro rata. Therapist reserves the right to periodically adjust this fee. Patient Representative will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, HMOs, managed care organizations, or other third-party payors, or by agreement with Therapist. The agreed upon fee between Therapist and Patient Representative is $ Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, $125.00 or Therapist may engage in telephone contact with Patient or Representative for purposes other than scheduling sessions. Patient Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes, and will be billed $50.00. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient’s the request of Patient or Representative and with Patient’s the advance written authorizationauthorization of Patient or Representative. Patient Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutescalls. Patients are Representative is expected to pay for services at the time services are rendered. Therapist accepts cash, checks, and major credit cards, including Visa and Mastercard, and American Express. Therapist will keep a copy of your credit card number on file. Please inform Therapist should you wish to use another form of payment. Representative is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments, limitations, exclusions and deductibles. Therapist is a contracted provider with the following insurance companies: and has agreed to a specified fee. If Representative intends to use benefits of his/her health insurance policy, Representative agrees to inform Therapist in advance. Additionally, should you choose to use your insurance, with out of network benefits, Therapist will provide you with a statement, which you can submit to the third-party of your choice to seek reimbursement of fees already paid.

Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typically, the patient is the holder of the psychotherapist- psychotherapist-patient privilege. If Therapist received receives a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or a person with the authority to waive the privilege on Patient’s representativebehalf. Patient When a patient is a minor child, the holder of the psychotherapist-patient privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-patient privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-patient privilege with his/her attorney. Patient, or Representative, should be aware that he/she might be waiving the psychotherapist-/patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient Patient, or Representative, should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. The usual and customary fee for service is $150 $ 125.00 per 50-minute session. Sessions longer due before the start of each session. Longer than 50- minutes 50-minute sessions are charged for the additional time pro rata. Therapist reserves the right to periodically adjust this fee. Patient Representative will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, HMOs, managed care organizations, or other third-third party payors, or by agreement with Therapist. The agreed upon fee between Therapist and Patient Representative is $ . Therapist reserves the right to periodically adjust fee. Patient Representative will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient or Representative for purposes other than scheduling sessions. Patient Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient’s the request of Patient or Representative and with Patient’s the advance written authorizationauthorization of Patient or Representative. Patient Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are Representative is expected to pay for services at the time services are rendered. Therapist accepts cash, checks, and major credit cards, Representative is responsible for any and all fees not reimbursed by his/her insurance company, managed care organization, or any other third-party payor. Representative is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments and deductibles.