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. Fee and Fee Arrangements The usual and customary fee for service is $225.00 per 50-minute session. Sessions longer than 50- minutes are charged for the additional time pro rata. Couples sessions are $250.00 for 60-minute session. 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 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. Patient (or responsible party) is expected to pay for services at the time services are rendered. Insurance Patient (or responsible party) is responsible for any and all fees. Therapist a considered an “Out of Network Provider.” Upon request client will receive a monthly statement for possible reimbursement by his/her insurance company, managed care organization, or any other third-party payer. Patient (or responsible party) is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments and deductibles. Cancellation Policy 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-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 privilege. Typically, doctor‐ 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 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. Fee and Fee Arrangements The usual and customary fee for service is $225.00 125.00 per 50-minute 50‐minute session. Sessions longer than 50- 50I minutes are charged for the additional time pro rata. Couples sessions are $250.00 for 60-minute sessionTherapist 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 what their insurance allows plus any copayments and deductibles. Therapist reserves the right to periodically adjust fee. Patient will be notified of any a fee adjustment in advance. From time-to-timetime‐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 five 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. Patient (or responsible party) is Patients are expected to pay for services at the time services are rendered. Insurance Patient (or responsible party) is responsible for any Therapist accepts cash and all fees. Therapist a considered an “Out of Network Providerchecks.” Upon request client will receive a monthly statement for possible reimbursement by his/her insurance company, managed care organization, or any other third-party payer. Patient (or responsible party) is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments and deductibles. Cancellation Policy 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 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. Fee and Fee Arrangements The usual and customary fee for service is $225.00 155 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 $215 for 85 minutes or $275 for 115 minutes. Special extended sessions beyond two hours are charged for billed at the additional time pro rata. Couples sessions are $250.00 for 60-minute session. Therapist reserves the right to periodically adjust 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. If Patient wishes to use insurance benefits, a separate insurance fee 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; no back-billing will be done. 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 can use for reimbursement. 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 five 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. Patient (or responsible party) is Patients are expected to pay for services at the time services are rendered. Insurance Patient Therapist accepts all major credit cards, checks, and cash (or responsible party) is responsible for any and all fees. Therapist a considered an “Out of Network Provider.” Upon request client will receive a monthly statement for possible reimbursement by his/her insurance company, managed care organization, or any other third-party payer. Patient (or responsible party) is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments and deductibles. Cancellation Policy Patient (or responsible party) is responsible for the full amount of the session fee for any missed session(sexact change only). Patient (or responsible party) There 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) 000-0000a $35 returned check fee.

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. Fee and Fee Arrangements The usual and customary fee for service is $225.00 125 per 50-minute session. Sessions longer than 50- minutes 50minutes are charged for the additional time pro rata. Couples sessions are $250.00 for 60Therapist reserves the right to periodically adjust this fee. Representative will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, HMOs, managed care organizations, or other third-minute sessionparty payors, or by agreement with Therapist. The agreed upon fee between Therapist and 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 Patient’s guardian(s) Representative 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 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 Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at the request of Patient or Representative and with the advance written authorization of Patient or Representative. Representative is responsible for payment of the agreed upon fee (or responsible partyon a pro rata basis) for any telephone calls longer than ten minutes. Representative is expected to pay for services at the time services are rendered. Therapist accepts cash or checks. Insurance Patient (or responsible party) Representative is responsible for any and all fees. Therapist a considered an “Out of Network Provider.” Upon request client will receive a monthly statement for possible reimbursement fees not reimbursed by his/her insurance company, managed care organization, or any other third-party payerpayor. Patient (or responsible party) Representative is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments and deductibles. Cancellation Policy Patient (or responsible party) Therapist is responsible for a contracted provider with the full amount following companies: Xxxxxx EAP, Xxxxxx Select and UBH and has agreed to a specified fee. If Representative intends to use benefits 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 his/her health insurance policy, Representative agrees to give inform Therapist at least 24 hour’s notice of cancellation. Cancellation notice should be left on Therapist’s voicemail at (000) 000-0000in 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. Fee and Fee Arrangements The usual and customary fee for service for individuals is $225.00 150 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. Couples sessions are 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. Should cancellation occur les than 24 hours in advance, payment at the rate of _$250.00 for 60-minute session150__ 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 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 five 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. Patient (or responsible party) is Patients are expected to pay for services at the time services are rendered. Insurance Patient (Therapist accepts cash or responsible party) is responsible checks. There will be a $25 fee for any and all fees. Therapist a considered an “Out of Network Provider.” Upon request client will receive a monthly statement for possible reimbursement by his/her insurance company, managed care organization, or any other third-party payer. Patient (or responsible party) is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments and deductiblesreturned checks. Cancellation Policy 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 full fee of $150 for any missed session(s) or for any session(s) for which Patient failed to give Therapist at least 24 hour’s hours notice of cancellation. Cancellation notice should be left on Therapist’s voicemail voice mail at (000) 000-0000323.614.9422 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. Fee and Fee Arrangements The usual and customary fee for service is $225.00 140 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 rata. Couples sessions are $250.00 for 60-minute session110 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. 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 five 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. Patient (or responsible party) is Patients are expected to pay for services at the time services are rendered. Insurance Patient Therapist accepts cash, checks, and major credit cards (or responsible party) is responsible for any Visa and all fees. Therapist a considered an “Out of Network ProviderMasterCard).” Upon request client will receive a monthly statement for possible reimbursement by his/her insurance company, managed care organization, or any other third-party payer. Patient (or responsible party) is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments and deductibles. Cancellation Policy 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 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. Fee and Fee Arrangements The usual and customary fee for service is $225.00 per 50-minute session. Sessions longer than 50- 50-minutes are charged for the additional time pro rata. Couples sessions are $250.00 for 60-minute session. Therapist reserves the right to periodically adjust this 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 five 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. Patient (or responsible party) is Patients are expected to pay for services at the time services are rendered. Insurance Patient (or responsible party) is responsible for any Therapist accepts cash, most major credit cards and all checks. Payments received more than 30 days after services are rendered are subject to late fees. Therapist Returned checks will be subject to a considered an “Out of Network Provider$25 penalty. Delinquent bills may be turned over to a collection agency.” Upon request client will receive a monthly statement for possible reimbursement by his/her insurance company, managed care organization, or any other third-party payer. Patient (or responsible party) is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments and deductibles. Cancellation Policy 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. 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. Fee Billing and Fee Arrangements The usual and customary fee for service is $225.00 125.00 per 50-50- minute session. Sessions longer than 50- 50-minutes are charged for the additional time pro rata. Couples sessions are $250.00 for 60-minute session. Therapist reserves the right to periodically adjust this fee. Patient Representative will be notified of any fee adjustment in advance. From timeIn addition, this fee may be adjusted by contract with insurance companies, HMOs, managed care organizations, or other third-to-timeparty payors, or by agreement with Therapist. The agreed upon fee between Therapist and Representative is $125.00 or . Therapist may engage in telephone contact with Patient or Patient’s guardian(s) Representative for purposes other than scheduling sessions. Patient (or responsible party) Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than five 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. Patient (or responsible party) 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. Insurance Patient (or responsible party) Representative is responsible for any and all fees. Therapist a considered an “Out of Network Provider.” Upon request client will receive a monthly statement for possible reimbursement fees not reimbursed by his/her insurance company, managed care organization, or any other third-party payerpayor. Patient (or responsible party) Representative is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments payments, limitations, exclusions and deductibles. Cancellation Policy Patient (or responsible party) Therapist is responsible for a contracted provider with the full amount 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 session fee for any missed session(s). Patient (or responsible party) is also responsible for payment third-party of the agreed upon fee for any session(s) for which Patient failed your choice to give Therapist at least 24 hour’s notice seek reimbursement of cancellation. Cancellation notice should be left on Therapist’s voicemail at (000) 000-0000fees 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. Fee and Fee Arrangements The usual and customary fee for service is $225.00 per 50-minute 50-­‐minute session. Sessions longer than 50- minutes 50-­‐minutes are charged for the additional time pro rata. Couples sessions are $250.00 for 60-minute sessionTherapist 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 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. A Patient’s appointment is reserved exclusively for the Patient. Patient will be charged the full fee per session for any 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 a 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 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 five 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. Patient (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. Insurance Patient (or responsible party) is responsible for any and all fees. Therapist a considered an “Out of Network Provideraccepts cash only.” Upon request client will receive a monthly statement for possible reimbursement by his/her insurance company, managed care organization, or any other third-party payer. Patient (or responsible party) is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments and deductibles. Cancellation Policy 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. Fee Billing and Fee Arrangements The usual and customary fee for service is $225.00 125.00 per 50-50- minute session. Sessions longer than 50- 50-minutes are charged for the additional time pro rata. Couples sessions are $250.00 for 60-minute session. Therapist reserves the right to periodically adjust this fee. Patient Representative will be notified of any fee adjustment in advance. From timeIn addition, this fee may be adjusted by contract with insurance companies, HMOs, managed care organizations, or other third-to-timeparty payors, or by agreement with Therapist. The agreed upon fee between Therapist and Representative is $125.00 or . Therapist may engage in telephone contact with Patient or Patient’s guardian(s) Representative for purposes other than scheduling sessions. Patient (or responsible party) Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than five 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. Patient (or responsible party) 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. Insurance Patient (or responsible party) Representative is responsible for any and all fees. Therapist a considered an “Out of Network Provider.” Upon request client will receive a monthly statement for possible reimbursement fees not reimbursed by his/her insurance company, managed care organization, or any other third-party payerpayor. Patient (or responsible party) Representative is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments payments, limitations, exclusions and deductibles. Cancellation Policy Patient (or responsible party) Therapist is responsible for a contracted provider with the full amount 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 session fee for any missed session(s). Patient (or responsible party) is also responsible for payment third-party of the agreed upon fee for any session(s) for which Patient failed your choice to give Therapist at least 24 hour’s notice seek reimbursement of cancellation. Cancellation notice should be left on Therapist’s voicemail at (000) 000-0000fees 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 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. Fee and Fee Arrangements The usual and customary fee for service is $225.00 150 per 50-minute session. Sessions longer than 50- minutes are charged for the additional time pro rata. Couples sessions are $250.00 for 60Therapist 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-minute sessionparty 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 five 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. Patient (or responsible party) is Patients are expected to pay for services at the time services are rendered. Insurance Patient Therapist accepts cash and major credit cards (or responsible partyvisa and mastercard) is responsible for any and all fees. Therapist a considered an “Out of Network Provideronly.” Upon request client will receive a monthly statement for possible reimbursement by his/her insurance company, managed care organization, or any other third-party payer. Patient (or responsible party) is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments and deductibles. Cancellation Policy 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 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. Fee and Fee Arrangements The usual and customary fee for service is $225.00 160 per 50-minute session. Sessions longer than 50- 50-minutes are charged for the additional time pro rata. Couples sessions are $250.00 for 60-minute session. Therapist reserves the right to periodically adjust this 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 five 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. Patient (or responsible party) is Patients are expected to pay for services at the time services are rendered. Insurance Patient Therapist accepts cash, checks, and paypal (or responsible party) is responsible for any Visa, MasterCharge, Discovery and all fees. Therapist a considered an “Out of Network ProviderAmerican Express).” Upon request client will receive a monthly statement for possible reimbursement by his/her insurance company, managed care organization, or any other third-party payer. Patient (or responsible party) is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments and deductibles. Cancellation Policy 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- 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. Fee and Fee Arrangements The usual and customary fee for service is $225.00 150 per 50-minute session. Sessions longer than 50- minutes are charged for the additional time pro rata. Couples sessions are $250.00 for 60Therapist 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-minute sessionparty 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 five 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. Patient (or responsible party) is Patients are expected to pay for services at the time services are rendered. Insurance Patient (or responsible party) is responsible for any Therapist accepts cash, checks, and all fees. Therapist a considered an “Out of Network Providermajor credit cards.” Upon request client will receive a monthly statement for possible reimbursement by his/her insurance company, managed care organization, or any other third-party payer. Patient (or responsible party) is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments and deductibles. Cancellation Policy 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-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. Fee and Fee Arrangements The usual and customary fee for service is $225.00 per 50-minute 50-­‐minute session. Sessions longer than 50- minutes 50-­‐minutes are charged for the additional time pro rata. Couples sessions are $250.00 for 60-minute sessionTherapist 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 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. A Patient’s appointment is reserved exclusively for the Patient. Patient will be charged the full fee per session for any 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 a 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 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 five 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. Patient (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. Insurance Patient (or responsible party) is responsible for any Therapist accepts cash, checks, and all fees. Therapist a considered an “Out of Network Providerselect credit cards.” Upon request client will receive a monthly statement for possible reimbursement by his/her insurance company, managed care organization, or any other third-party payer. Patient (or responsible party) is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments and deductibles. Cancellation Policy 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 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. Fee and Fee Arrangements The usual and customary fee for service is $225.00 170 per 50-minute session. Sessions longer than 50- 50-minutes are charged for the additional time pro rata. Couples sessions are $250.00 for 60-minute session. Therapist reserves the right to periodically adjust this 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 five 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. Patient (or responsible party) is Patients are expected to pay for services at the time services are rendered. Insurance Patient Therapist accepts cash, checks, and paypal (or responsible party) is responsible for any Visa, MasterCharge, Discovery and all fees. Therapist a considered an “Out of Network ProviderAmerican Express).” Upon request client will receive a monthly statement for possible reimbursement by his/her insurance company, managed care organization, or any other third-party payer. Patient (or responsible party) is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments and deductibles. Cancellation Policy 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 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. Fee and Fee Arrangements The usual and customary fee for service is $225.00 140 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 $200 for 85 minutes or $250 for 115 minutes. Special extended sessions beyond two hours are charged for billed at the additional time pro rata. Couples sessions are $250.00 for 60-minute session. Therapist reserves the right to periodically adjust 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. If Patient wishes to use insurance benefits, a separate insurance fee consent will outline the fees specific to the individual’s plan. 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 five 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. Patient (or responsible party) is Patients are expected to pay for services at the time services are rendered. Insurance Patient Therapist accepts all major credit cards, checks, and cash (or responsible party) exact change only). There is responsible for any and all fees. Therapist a considered an “Out of Network Provider.” Upon request client will receive a monthly statement for possible reimbursement by his/her insurance company, managed care organization, or any other third-party payer. Patient (or responsible party) is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments and deductibles$25 returned check fee. Cancellation Policy Patient (or responsible party) is responsible for the full amount payment of the session agreed upon 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 hours notice of cancellation. Cancellation notice should be left on Therapist’s voicemail voice mail at 858-731-6013. Termination of Therapy Therapist reserves the right to terminate therapy at his/her discretion. Reasons for termination include, but are not limited to, untimely payment of fees, failure to comply with treatment recommendations, conflicts of interest, failure to participate in therapy, Patient needs are outside of Therapist’s scope of competence or practice, or Patient is not making adequate progress in therapy. Patient has the right to terminate therapy at his/her discretion. Upon either party’s decision to terminate therapy, Therapist will generally recommend that Patient participate in at least one, or possibly more, termination sessions. These sessions are intended to facilitate a positive termination experience. Therapist will also attempt to ensure a smooth transition to another therapist by offering referrals to Patient. Therapist Availability Therapist has confidential voice mail that allows Patient to leave a message at any time. Therapist will make every effort to return calls within 24 hours (or by the next business day), but cannot guarantee the calls will be returned immediately. Therapist is unable to provide 24-hour crisis service. In the event that Patient is feeling unsafe or requires immediate medical or psychiatric assistance, he/she should call 911 or the county crisis line at 000) -000-0000., or go to the nearest emergency room. Therapist Communications and Social Media Therapist may need to communicate with Patient in between sessions. Please review the following considerations, and indicate contact preferences below. Email communication and text messaging is used only with Patient permission and only for administrative purposes. That means that email exchanges and text messages should be limited to things such as setting and changing appointments, billing matters and other related issues. If Patient chooses to communicate with Therapist by email, it should be with the understanding that all emails are retained in the logs of Patient’s and Therapist’s Internet service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider. If Patient chooses to use text messaging, it should be with the understanding that messages may be inadvertently seen by others, either by access to Patient’s phone or via the preview window. Emails or text messages Therapist receives from Patient and any responses may become a part of Patient’s therapy record. Therapist does not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). In addition, if it is discovered that an online relationship has inadvertently been established, that relationship will be cancelled. This is because these types of casual social contacts can jeopardize Patient confidentiality as well as the therapeutic relationship. Contact preferences: Phone: Do not Use OK to Use Preferred OK to leave voicemail Email: Do not Use OK to Use Preferred Text messaging: Do not Use OK to Use Preferred Acknowledgement By signing below, Patient acknowledges that he/she has reviewed and fully understands the terms and conditions of this Agreement. Patient has discussed such terms and conditions with Therapist, and has had any questions with regard to its terms and conditions answered to Patient’s satisfaction. Patient agrees to abide by the terms and conditions of this Agreement and consents to participate in psychotherapy with Therapist. Moreover, Patient agrees to hold Therapist free and harmless from any claims, demands, or suits for damages from any injury or complications whatsoever, save negligence, that may result from such treatment. Patient Name (please print) Signature of Patient (or authorized representative) Date

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. Fee and Fee Arrangements The usual and customary fee for service is $225.00 per 50-minute 50-­‐minute session. Sessions longer than 50- minutes 50-­‐minutes are charged for the additional time pro rata. Couples sessions are $250.00 for 60-minute sessionTherapist 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 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. A Patient’s appointment is reserved exclusively for the Patient. Patient will be charged the full fee per session for any 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 a 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 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 five 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. Patient (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 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. Insurance Patient (or responsible party) is responsible for any Therapist accepts cash, checks, and all fees. Therapist a considered an “Out of Network Providerselect credit cards.” Upon request client will receive a monthly statement for possible reimbursement by his/her insurance company, managed care organization, or any other third-party payer. Patient (or responsible party) is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments and deductibles. Cancellation Policy 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 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. Fee and Fee Arrangements The usual and customary fee for service is $225.00 per 50-minute session. Sessions longer than 50- 50-minutes are charged for the additional time pro rata. Couples sessions are $250.00 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 payers, 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 60-minute sessionthe 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 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 five 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. Patient (or responsible party) is Patients are expected to pay for services at the time services are rendered. Insurance Patient (or responsible party) is responsible for any Therapist accepts cash, checks, and all fees. Therapist a considered an “Out of Network Providermajor credit cards, including Visa, Master Card, American Express and Discover.” Upon request client will receive a monthly statement for possible reimbursement by his/her insurance company, managed care organization, or any other third-party payer. Patient (or responsible party) is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments and deductibles. Cancellation Policy 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 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. Fee and Fee Arrangements The usual and customary fee for service is $225.00 130.00 per 50-50- minute session. Sessions longer than 50- 50-minutes are charged for the additional time pro rata. Couples sessions are $250.00 for 60Therapist 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-minute sessionparty payors, or by agreement with Therapist. 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 five 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. Patient (or responsible party) is Patients are expected to pay for services at the time services are rendered. Insurance Patient (or responsible party) is responsible for any Therapist accepts cash and all fees. Therapist a considered an “Out of Network Providerchecks.” Upon request client will receive a monthly statement for possible reimbursement by his/her insurance company, managed care organization, or any other third-party payer. Patient (or responsible party) is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments and deductibles. Cancellation Policy 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. 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. Fee and Fee Arrangements The usual and customary fee for service is $225.00 $ 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. Couples sessions are $250.00 for 60-minute sessionTherapist reserves the right to periodically adjust this fee. Representative will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with insurance companies, HMOs, managed care organizations, or other third party payors, or by agreement with Therapist. The agreed upon fee between Therapist and 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 Patient’s guardian(s) Representative 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 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 Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at the request of Patient or Representative and with the advance written authorization of Patient or Representative. Representative is responsible for payment of the agreed upon fee (or responsible partyon a pro rata basis) for any telephone calls longer than ten minutes. Representative is expected to pay for services at the time services are rendered. Therapist accepts cash, checks, and major credit cards, Insurance Patient (or responsible party) Representative is responsible for any and all fees. Therapist a considered an “Out of Network Provider.” Upon request client will receive a monthly statement for possible reimbursement fees not reimbursed by his/her insurance company, managed care organization, or any other third-party payerpayor. Patient (or responsible party) Representative is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments and deductibles. Cancellation Policy Patient (or responsible party) Therapist is responsible for a contracted provider with any insurance company, managed care organization. Should Representative choose to use his/her insurance, Therapist will provide Representative with a statement, which Representative can submit to the full amount third party of the session fee for any missed session(s). Patient (or responsible party) is also responsible for payment his/her choice to seek reimbursement of the agreed upon fee for any session(s) for which Patient failed fees already paid to give Therapist at least 24 hour’s notice of cancellation. Cancellation notice should be left on Therapist’s voicemail at (000) 000-0000.