Common use of PSYCHOLOGICAL SERVICES Clause in Contracts

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to address. There are many different methods I may use to deal with those problems. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:

PSYCHOLOGICAL SERVICES. Psychological Services include child, family, and adult psychotherapies. In addition, Psychological Services can also include Psychological Testing/Assessment and Consultation with other businesses and professionals. Psychotherapy is not easily described in general statementsa unique and sometimes complex process. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressare experiencing. There are many different methods I may use to deal with those problemsthe problems that you hope to address, and I am willing to discuss them with you as our work transpires. Always ask me questions about your treatment whenever you have them. Psychotherapy is not like different than a medical doctor visit. InsteadInstead of being told what to do to solve your problem, it calls for a very e.g., take prescription medications or undergo surgery, Psychotherapy involves more active effort participation on your part. In order for the therapy Psychotherapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can also have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. However, improved sleepgiven that it is impossible to predict all the issues involved in anyone’s problems at the outset, and less fatigue. But there are no can never be specific guarantees as to of what you will experienceexperience or the achievements you might accomplish. Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the psychologist or therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client/patient in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. Each of our therapists also has corresponding responsibilities to you. These rights and responsibilities are described herein. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, grief, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has scientifically been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen or what results will be gained. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. ! In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first few sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I we will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you selectus. If you have questions about my proceduresany of our procedures or recommendations, we should discuss them whenever they arise. Appointments will ordinarily be 45-50 minutes in duration, several times per month, at a time that we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, we ask that you provide us with at least 24 hours’ notice. If you miss a session without cancelling or cancel with less than 24 hours’ notice, you are agreeing to pay the full fee for that time (unless we both agree that you were unable to attend due to circumstances that were beyond of your doubts persistcontrol). It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, I you will be happy responsible for the standard fee as described above. If it is possible, we will try to help find another time to reschedule the appointment. In addition, you set up a meeting with another mental health professional are responsible for a second opinioncoming to your sessions on time. Please note that If you are late, your appointment will still need to end at the psychological services I provide are not predetermined scheduled time. The standard fee for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee initial intake is $395 for an initial evaluation lasting 90 minutes, 150.00 and $250 for each subsequent psychotherapy session (either in-person is $100.00. You are responsible for paying at the time of your session unless prior arrangements and billing agreements have been made. Payments may be made by credit, checks or over cash. Any checks returned are subject to an additional $25.00 fee to cover the telephone) lasting 45 minutesbank fees the will incur. I If you refuse to pay your debt, we reserve the right to use an attorney or collection agency in the future to secure payment. In addition, to weekly appointments, it is our practice to charge this same $250 per 45-minutes rate amount on a prorated basis (we will break down the hourly costs) for other professional services that you may needrequire or request such as report writing, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone or teleconferencing conversations or email responses lasting that last longer than 15 minutes, and attendance at meetings or consultations, or the time spent performing required to perform any other service which you may request of meus. If you become anticipate becoming involved in legal proceedings a court case, we recommend that require my we discuss this fully before you waive your right to confidentially. If your case requires our participation, you will be expected to pay for any the professional time I spend on your legal matter, required even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for party compels us to testify or participate in any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:proceedings.

PSYCHOLOGICAL SERVICES. Your appointment will involve an evaluation of your needs. By the end of the evaluation, your clinician will be able to offer you some first impressions of what your work may include and recommendations for getting help. One of the recommendations may be psychotherapy. If so, the Counseling Center may or may not be able to provide you with psychotherapy, depending on your overall needs. If psychotherapy or any other recommendations suggested by your clinician include services that the Counseling Center cannot provide, you will be given suggestions of where you might receive those services. Wherever you choose to obtain treatment, you should evaluate the information received from the clinician who met with you along with your own opinions of what sort of treatment you are willing to do and whether you feel comfortable working with the treating clinician. Therapy involves a large commitment of time, energy, and often money, so you should be very careful about the therapist you select. If you have questions about the procedures used or conclusions made by your clinician, please discuss them whenever they arise. If your doubts persist, your clinician will be happy to help you set up a meeting with another mental health professional for a second opinion. Psychotherapy is not easily described in general statements. It varies depending on the particular problems you are experiencing, the therapeutic methods used by your clinician, and the personalities of the psychologist clinician and patient, and the particular problems you hope to addressclient. There are many different methods I clinicians may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very an active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about that are discussed both during our your sessions and at homeon your own. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience a variety of uncomfortable feelings like sadnessfeelings. The changes you make in therapy may also affect your relationships in unexpected ways. Also, guiltcertain psychological conditions, angersuch as suicidal states, frustration, loneliness, and helplessnessmay result in death regardless of the interventions of the clinician. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy Psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, and improved sleepmood, functioning, and less fatigueoverall quality of life. But there are no guarantees as to of what you will experience. Our first session will involve an evaluation of your needs. By the end of the evaluation, I will The clinician with whom you meet may be able to offer you some first impressions of what our work will include and supervised by a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you selectsenior clinician. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that is the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participationcase, you will be expected informed about this by your clinician. For professional development, your clinician may request your permission to pay for any professional time I spend audio or video-record your session(s). No recording will be done without your prior knowledge and consent. Only the supervisors or consultants directly involved in consulting on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes ratecase will have access to those recordings. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these The recordings will be discussed and agreed erased upon ahead completion of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed supervision or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:consultation.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It Psychological counseling varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressbring forward. There are many different methods I may use to deal with those problems. Psychotherapy is not like a medical doctor visit. InsteadCounseling will frequently involve discussing your personal concerns, it calls for a very active effort on your partthoughts, and feelings. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at homebetween sessions. We believe that homework assignments are a necessary part of the recovery process, thus we only work with clients who are willing to engage in homework assignments. Psychotherapy can have benefits risks and risksbenefits. Because therapy often involves discussing unpleasant aspects of your life, Initially you may experience uncomfortable feelings like levels of sadness, guilt, anxiety, anger, frustration, loneliness, and helplessness, or other negative feelings. When treating insomnia specificallyWhile you consider these risks, you should also know that the benefits of therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also have been shown to have benefits for people who go through itby scientists in hundreds of well-designed research studies. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleepimprovement in relationships, acquisition of skills to cope with stress, and less fatigueimprovement in overall well-being. But there are no guarantees as to of what you will experience. Our first session few hours together will involve an evaluation of your needs. By the end of the evaluation, I we will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help youtogether. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my our procedures, we should discuss them whenever they arise. If We are happy to provide outside referrals if your doubts concerns persist. We offer both 50-minute “traditional” appointments as well as an “Intensive Therapy” model (e.g., I 2-6 hours at a time; multiple days per week). The exact timing of sessions will be happy determined in consultation with you, based on your needs. A phone consultation is recommended prior to help you set up a meeting with another mental health professional for a second opinionarranging treatment. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest The 15-minute increment (e.g.consultation will be done free of charge. During the consultation, 22 minutes of service we can both decide whether I am the best match to provide the services you need. Once an appointment is scheduled, you will be charged for 15 minutes whereas 23 minutes it unless you provide 48 hours advance notice of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings cancellation (unless we both agree that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying unable to attend due to circumstances beyond your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of servicecontrol), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client/patient in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. Each of our therapists also has corresponding responsibilities to you. These rights and responsibilities are described herein. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, grief, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has scientifically been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen or what results will be gained. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. ! In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first few sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I we will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you selectus. If you have questions about my proceduresany of our procedures or recommendations, we should discuss them whenever they arise. Appointments will ordinarily be 45-50 minutes in duration, several times per month, at a time that we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, we ask that you provide us with at least 24 hours’ notice. If you miss a session without cancelling or cancel with less than 24 hours’ notice, you are agreeing to pay the full fee for that time (unless we both agree that you were unable to attend due to circumstances that were beyond of your doubts persistcontrol). It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, I you will be happy responsible for the standard fee as described above. If it is possible, we will try to help find another time to reschedule the appointment. In addition, you set up a meeting with another mental health professional are responsible for a second opinioncoming to your sessions on time. Please note that If you are late, your appointment will still need to end at the psychological services I provide are not predetermined scheduled time. The standard fee for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee initial intake is $395 for an initial evaluation lasting 90 minutes, 175.00 and $250 for each subsequent psychotherapy session (either in-person is $125.00. You are responsible for paying at the time of your session unless prior arrangements and billing agreements have been made. Payments may be made by credit, checks or over cash. Any checks returned are subject to an additional $25.00 fee to cover the telephone) lasting 45 minutesbank fees the will incur. I If you refuse to pay your debt, we reserve the right to use an attorney or collection agency in the future to secure payment. In addition, to weekly appointments, it is our practice to charge this same $250 per 45-minutes rate amount on a prorated basis (we will break down the hourly costs) for other professional services that you may needrequire or request such as report writing, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone or teleconferencing conversations or email responses lasting that last longer than 15 minutes, and attendance at meetings or consultations, or the time spent performing required to perform any other service which you may request of meus. If you become anticipate becoming involved in legal proceedings a court case, we recommend that require my we discuss this fully before you waive your right to confidentially. If your case requires our participation, you will be expected to pay for any the professional time I spend on your legal matter, required even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for party compels us to testify or participate in any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:proceedings.

PSYCHOLOGICAL SERVICES. I am a Licensed Psychologist offering services in the field of psychology and psychotherapy. Having worked as a Psychologist for over 30 years, I have had vast experience in many areas of psychology. With my training and experience, I am able to offer you psychotherapy as an individual, couple, family, or group. I am also able to offer you consultation and referral services. There are many modalities of psychotherapy that I can offer you including: Cognitive Behavioral Therapy, Somatic Experiencing, Internal Family Systems, Imago Relationship, Emotion Focused Therapy, BrainSpotting, Hypnotherapy, EMDR, EFT, Touch, Interpersonal Neuropsychology, and many others. Please be advised that I do not prescribe medication; I can refer you to someone for medication such as your primary care doctor or a specialist. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems issues you hope to addressare experiencing. There are many different methods I may use to deal with those problemsbring healing, joy and health in your life. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have want to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, angeranger frustration, frustrationshame, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatmenthelplessness or any other emotion. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. The mind and body are very connected. Therapy often leads to better relationships, solutions to specific problems, joy, freedom, growth, physical healing and significant reductions in feelings of distress, improved sleep, . Research has shown significant changes in brain function with psychotherapy. You will get to know not only your mind but also the intricate relationships between your mind and less fatigue. But there are no guarantees as to what you will experiencebody. Our first session few sessions will involve an evaluation of your needsneeds and goals; your hopes and dreams for therapy. By Usually after the end of the evaluationfirst session or two, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable enough working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves can involve a large commitment of time, money, money and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, in spite of my best efforts, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:professional.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities a set of the psychologist and patientpsychological interventions designed to help people resolve emotional, behavioral, and interpersonal problems and improve the particular quality of their lives. There are many different interventions I may use to deal with the problems you hope to address. There are many different methods I may use to deal with those problems. Psychotherapy is not like a medical doctor visit. Instead, it Cognitive-behavioral psychotherapy calls for a very active effort on your part. In order for the therapy to be most successful, it will be important for you will have to work on the things we talk about about, both during our sessions and at home. Psychotherapy can have both benefits and risks. Because therapy Since psychotherapy often involves discussing unpleasant aspects of your life, you may experience transient uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads may lead to better relationships, solutions to specific problems, better relationships, and significant reductions in feelings of distress. During our first few sessions, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve I typically conduct an evaluation of your treatment needs. By the end of the evaluationthis evaluation process, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, follow if you decide to continue with me for therapy. You should are encouraged to evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss can address them whenever as they arise. If your doubts persistShould you request a second opinion, I will be happy to help refer you set up a meeting with to another mental health professional professional. In addition to fees for weekly appointments, I may charge a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either inpre-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate determined amount for other professional services you may need, though I will prorate break down the cost if I work for periods of less than 45 minutes in increments of 15 one hour. Other services for which you may be billed include report writing, conversing with you by telephone if the conversation lasts longer than a few minutes, rounded to the nearest 15-minute increment (e.g.consulting with other professionals with your permission, 22 minutes preparation of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations treatment summaries or email responses lasting longer than 15 minutessimilar records, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any all of my professional time I spend on your legal mattertime, including preparation and transportation costs, even if the request comes from I am called to testify by another party. I typically conduct an evaluation during the first session, at which usually lasts 90-120 minutes. During this time, we can both decide if I am the same $250 per best person to provide the services you need to meet your treatment goals. If psychotherapy has begun, we will usually schedule one 45-minutes rate. I do not charge for 50 minute session per week at a time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to timewe agree on, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which though some sessions may be higher than the fee you were previously payinglonger or more frequent. In addition, if it has been more than one year since our last appointmentUnless an appointment is cancelled 24 hours in advance, you will be charged in full for the missed appointment. I require one full business day’s notice for cancelled or rescheduled appointments. This means that appointments scheduled for another initial evaluation Mondays need to be cancelled or rescheduled by the end of business on the Friday before the scheduled appointment, or you will be charged for the missed appointment. This policy applies to changes in work schedules or childcare arrangements. Documented emergencies (90 minutese.g., going to the Emergency Room) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You or regional weather emergencies are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide the only exceptions to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do sothis policy. However, frequent or repeated cancellations for illness will be aware that the services provided billed at my discretion. Additionally, you will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:late arrivals. It is important to note that insurance carriers do not reimburse for missed appointments.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. There are many different methods I may use to deal with those problems. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to address. There are many different methods I may use to deal with those problems. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. My work may include a variety of activities, and for optimum outcomes to occur, your active participation is essential. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, self-doubt, anxiety, depression, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause There are no guarantees as to what you to experience increased sleepiness and fatigue, especially in the early phases of treatmentwill experience. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. While I am a trained, improved sleeplicensed and experienced psychologist, and less fatigue. But there are no guarantees as I will attempt to what help you achieve your goals, but I cannot guarantee change nor can I promise that all problems will experiencebe resolved. Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and and, if so, I will give you referrals to other practitioners who whom I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another provide names of other mental health professional for professionals with whom you can seek a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergenciesIf we agree to begin psychotherapy, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than usually schedule one 45 minutes in increments of 15 minutes, rounded to the nearest 1555-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another partysession per week or, at the same $250 per 45-minutes ratea time and frequency that we agree on. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I Depending on progress, session lengths may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:vary.

PSYCHOLOGICAL SERVICES. Psychotherapy is an insight-oriented relationship between the psychotherapist and the patient that works in part because of clearly defined rights and responsibilities held by each person. As a patient in psychotherapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your psychotherapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist therapist and patientthe client, and the particular problems challenges the client comes to treatment for. Psychotherapy requires you, the client, to take a very active role in your treatment. Therapy is most successful when you hope make the continued commitment to addressconsider the things, we talk about both during and between session meetings. There are many different methods I Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to feeling less distress, increased satisfaction in relationships, and solutions to specific problems. But there are no guarantees about what you will experience. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for PSYCHOLOGICAL/NEUROPSYCHOLOGICAL ASSESSMENT: You or your child or PATIENT FEEDBACK & COMPLAINTS: If you become dissatisfied with your clinical care, in general, it is important to discuss your concerns and attempt to address them directly. If you decide that my work (or that of another therapist in my office) is not satisfactory, I would be happy to help you determine the therapy best course of action to be most successfultake, you which may include stopping treatment altogether or beginning treatment with another mental health professional in the community. APPOINTMENTS: Your therapist (either me or another therapist in my office), usually conducts an initial comprehensive evaluation that will have last from 1 to 4 sessions. During the evaluations period, I (or the other therapist) will work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause with you to experience increased sleepiness decide if we can best provide the service(s) you need and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what provide you will experience. Our first session will involve with an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions initial impression of what our work together might include. At that point, I (or the other therapist) will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At me or the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you selecttherapist. If you have questions about my our procedures, we you should discuss them with me or the other therapist whenever they arise. If your doubts persist, I (or your therapist) will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might havePROFESSIONAL FEES:

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities particular problem you bring to treatment, the consistency of the psychologist and patientattendance, and the particular problems you hope to addressamount of effort put forth in your work with your therapist. There are many different methods I that may use be used to deal with those problems. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your partthe problem you hope to address. In order for the therapy to be most successful, you will have to work on things we talk about you discuss with your therapist both during our sessions and at homeoutside of sessions. Psychotherapy can have many benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessnessloss. When treating insomnia specifically, therapy might cause you Make sure to experience increased sleepiness discuss these feelings with your therapist in order to effectively manage your ability to cope with these negative feelings and fatigue, especially in the early phases of treatmentexperiences. On the other hand, psychotherapy has also been shown to have significant benefits for people who go through itengage in treatment. Therapy often leads to better relationships, finding solutions to specific problems, personal growth, better relationships, and significant reductions reduction in feelings of distress, improved sleep, and less fatigue. But While there are no guarantees as to what you will experience, most clients report having benefitted greatly from therapy. Our Your first session few sessions will involve an evaluation of your needs. Your therapist will normally conduct an evaluation that can last from one to three sessions. We ask clients to commit to at least three sessions before deciding if the therapist, or therapy in general, is for them. During this time, you and your therapist can decide if they are the right fit to help you achieve your treatment goals. By the end of the this evaluation, I your therapist will be able to offer you some first impressions of what our work the problem, how therapy session will include proceed and a treatment plan to you both will follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about feelings of whether you feel are comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you selectyour therapist. If you have questions about my proceduresany part of this process, we you should discuss them with your therapist whenever they arise. If your doubts persist, I we will be happy to help you set up a meeting with another mental health professional through a referral process. Therapy sessions are typically scheduled between 45 and 60-minutes per week at a time that both you and your therapist will agree on. Some sessions may be longer based on your needs and the frequency of sessions may also vary. Some clients benefit from weekly sessions while others may benefit from bi-weekly sessions. Discuss this with your therapist early in treatment so you have a clear understanding of the rational for a second opinionfrequency of sessions. Please note that Once an appointment is scheduled, you will be expected to attend the psychological services I session unless you provide are notice of cancellation by 5:00 pm the day prior to your appointment. A fee in the amount of $50.00 will be assessed for missed appointments and/or late cancelations if notice is not for emergency situations. For emergencies, call 911 or go given by 5:00 pm the day prior to the nearest emergency roomsession. My Your therapist may be willing to negotiate this fee based on the cost of your individual sessions. We understand that there are instances where emergencies may arise. However, in these situations, your therapist has full digression whether to charge the fee or not. Your therapist will handle missed appointments/late cancelations on a case by case basis and there is $395 for an initial evaluation lasting 90 minutesno guarantee that your particular situation will warrant a waiving of the fees. Professional fees vary between therapist. Session fees may also vary depending on the day, time, and $250 type of your appointments. Make sure to discuss these fees with your therapist prior to beginning treatment. In addition to charges for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I sessions, your therapist may also charge this same $250 per 45-minutes rate fees for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes)they provide. Other professional services include telephone conversations or email responses lasting longer than 15 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of methem. If you become involved in legal proceedings that require my your therapist’s participation, you will be expected to pay for any professional time I spend on your legal mattertheir time, even if the request comes from called to testify by another party. Because of the difficulty of legal involvement, a charge of $300 per hour for preparation and attendance at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these legal proceeding will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:assessed.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. Xxxxx Xxxxx, LCSW as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first 2-4 sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per APPOINTMENTS Appointments will ordinarily be 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 60 minutes in increments of 15 minutesduration, rounded to the nearest 15-minute increment (e.g.once per week at a time we agree on, 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which although some sessions may be higher than the fee you were previously payingmore or less frequent as needed. In addition, if it has been more than one year since our last appointment, you will be The time scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If appointment is assigned to you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:alone.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first 2-4 sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per APPOINTMENTS Appointments will ordinarily be 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 50 minutes in increments of 15 minutesduration, rounded once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, you and the time spent performing any other service you may request of mealone. If you become involved in legal proceedings that require my participation, you will be expected need to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to timecancel or reschedule a session, I may institute fee increases and these will be discussed and agreed upon ahead of time ask that you provide me with a new Treatment Contract24 hours notice. If it has been more than one year since our last is possible, I will try to find another time to reschedule the appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time. PROFESSIONAL RECORDS I am required to keep appropriate records of the full paymentpsychological services that I provide. Your records are maintained in a secure location in the office. I keep brief records noting that you were here, your reasons for seeking therapy, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records I receive from other providers, copies of records I send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have no role in deciding what the right to a copy of your insurance coversfile. Because these are professional records, they may be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them with me, or have them forwarded to another mental health professional to discuss the contents. If I refuse your request for access to your records, you have a right to have my decision reviewed by another mental health professional, which I will discuss with you upon your request. You are responsible for checking also have the right to request that a copy of your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely file be responsible for the full session fee in these instances. If made available to any other health care provider at your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:written request.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist therapist and patient, and the particular problems you hope to address. There are many different methods I your therapist may use to deal with those problems. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy psychotherapy to be most successful, you will have to work on things we you and your therapist talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our Your first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I your therapist will be able to offer you some discuss his or her first impressions of what our work will include and provide a treatment plan to followfor treatment, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I your therapist will notify you if I believe he or she feels this is a good match for both parties. If your therapist concludes that I am he or she may not be the right therapist for you and if soyou, I will give you referrals to other practitioners who I believe are better suited to help youmeet your needs will be provided. It is the Good Life Center for Mental Health, LLC’s policy to obtain relevant past treatment and concurrent information provided by other professionals and at mental health facilities, if applicable. Thus, you may be asked to sign authorizations that allow for these records to be released to us. While we respect your right to refuse access to records, Good Life Center for Mental Health LLC reserves the right not to enter into a therapeutic agreement if access to prior mental health records is denied. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my proceduresyour therapist’s modality of work, we should please discuss them whenever they ariseopenly with him or her. If your doubts persist, I your therapist will be happy to help assist you set up a meeting in securing consultation with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, rage, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and finding resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at homediscuss outside of therapy sessions. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of If you practice using the skills that I will teach you, you should see beneficial changes in your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our The first session few sessions will involve an a comprehensive evaluation of your needsclinical needs and treatment goals. By the end of the evaluationevaluation period, I will be able to offer you some first initial impressions of what our work might include. We will include discuss your treatment goals and a develop an initial, working treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help refer you set up a meeting with to another mental health professional for professional. It is important to feel like you and your therapist are a second opiniongood fit. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either inAppointments will ordinarily be 50-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 55 minutes in increments of 15 minutesduration, rounded typically once per week at a time we agree on, although sessions may be more or less frequent as needed. Trauma processing with EMDR or Brainspotting may at times require a 75 minute session. Couples therapy sessions are typically an hour and a half. The time scheduled for your appointment is assigned to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, you and the time spent performing any other service you may request of mealone. If you become involved need to cancel or reschedule a session, I ask that you provide me with at least 24 hours notice. If you miss a session without canceling, or cancel with less than 24 hour notice, you will still be responsible for full payment for the appointment. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will not be reimbursed. If it is possible, I will try to find another time to reschedule the appointment. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time. As can be expected, my fees vary depending on the service provided and the amount of time spent providing counseling or other services. Payment may made by check, cash or credit card. There is a $5 service fee for credit card processing. We have discussed the current fees and you agree to pay for services provided. You are responsible for paying in legal proceedings that require full at the time of your session unless prior arrangements have been made with me or my participationassistant. If any checks are returned for insufficient funds, you will be expected to fully reimburse me for any fees that I may incur. If you refuse to pay your debt, WBP reserves the right to use an attorney or collection agency to secure payment. If you wish to make alternative arrangements around payments, please discuss this possibility with me. In addition to your appointments, it is my practice to charge an hourly amount on a prorated basis for other professional services that you may require such as report writing, phone conversations that last longer than 15 minutes (I will advise you before charging a fee,) attendance at meetings or consultations which you have requested (if I am available,) or the time required to perform any other service which you may request of me that I agree to perform. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. I am on a number of insurance panels. If you want this office to file a claim with your insurance carrier, contact your insurance company so you can obtain any professional time I spend necessary authorization for your treatment. Managed Health Care plans such as HMOs and PPOs may require advance authorization, without which they may refuse to provide reimbursement for mental health services. If you plan to use your in-network insurance, please contact your insurance company to verify your benefits. You will want to determine the amount of your deductible, copayments and coinsurance for outpatient mental health services in an office setting (ex: CPT psychotherapy code 90837.) Please also contact my office assistant or me prior to our first session to provide us with your insurance information. Please provide us with the information on your legal matterthe financial intake form on xxx.xxxxxxxxxxxxxxxxxxxxxx.xxx. You will be responsible to pay any co-payments, even if the request comes from another party, coinsurance and deductibles at the same $250 per 45-minutes ratetime of service. If you would like to file a claim with your insurance carrier for any out of network benefits, please ask and I will provide you with a billing document of the services provided, dates of sessions, a diagnosis, and fees paid. I do not charge can provide this weekly, monthly or as needed. I am professionally required to keep appropriate records of the psychological services that I provide. The confidentiality of your records and our communications are protected by The Health Insurance Portability and Accountability Act of 1996. Your records are maintained in a secure location. I keep records noting dates that you were here, your reasons for time spent writing reports seeking therapy, the goals we set for treatment, your diagnosis, your progress, topics we discussed, conversations we had including things you said, your medical, social, and progress notes treatment history, records I receive from other providers, copies of records I send to others, and your billing records. Your insurance company may ask me to provide additional clinical information such as per treatment plans or summaries to justify your continued care. You will need to sign a release of information if you wish for me or my office assistant to communicate with your insurer. Any provided information will become part of the standard routine insurance company files. Insurers may share the information with a national medical information database. You have the right to a copy of my care of your medical file, except in unusual circumstances that involve potential emotional damage or danger to yourself. You may request a copy by completing and submitting a release form. Because these are professional records, it is possible that they may be misinterpreted or upsetting to untrained readers. For this reason, if you would like a copy, I recommend that you initially review them with me, or have them forwarded to another mental health professional to discuss the contents with you. I You also do not charge have the right to request that a copy of your file be made available to other health care providers when you request them and sign a Consent to release information form for that provider. Our relationship and conversations are confidential with certain exceptions listed below. Please remember that you may reopen the conversation about confidentiality at any time during our work together. Also, if I see you in public, I am happy to see you but to protect your confidentiality I will not speak to you unless you speak to me first. I will not tell people that you are with how we know each other, but you may. At times, you may want to authorize me to provide diagnostic and treatment updates verbally or in writing to third parties such as your physicians, insurance company, attorney, or family members. You need to provide written or verbal consent for me to provide them any information. · Emergency: If you are involved in in a life-threatening emergency and I cannot ask your permission, I will share information if I believe you would have wanted me to share, or if I believe it will be helpful to you. · Child Abuse Reporting: If I have reason to suspect that a child is abused or neglected, I am required by law to report the matter immediately to the Department of Child and Family Services. I am a mandated reporter of suspected abuse or neglect. · Adult Abuse Reporting: If I have reason to suspect that an elderly or incapacitated adult is abused, neglected or exploited, I am required by law to immediately make a report and provide relevant information to the Department of Child and Family Services. I may spend collaborating use contractors to assist with your other providersadministrative functions. From time to timeContractors must sign a confidentiality and non-disclosure agreement. At times, I may institute fee increases and these will be discussed and agreed upon ahead confidentially discuss details of time your care with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled licensed clinical consultant for another initial evaluation (90 minutes) clinical direction and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companiesassistance. If you decide to submit claims communicate with me via text or email, by doing so you understand that these forms of communication are not secure. I suggest you restrict this type of communication to verifying appointment times. Feel free to call, text or email me to reschedule your insurance company for reimbursement for any out-of-network benefits you might haveappointment. I am not usually immediately available by telephone. I do not answer my phone when I am with clients, after hours, on vacation, or when otherwise unavailable. At these times, you may do so. Howevertext me, email me, or leave a message on my confidential voice mail and your call will be aware that the services provided will still be charged to youreturned as soon as possible, not your insurance company, and you are responsible but it may take a day or two for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, prenon-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwiseurgent matters. I will provide try to reach you a superbill after each session with the following information that as soon as I can. If you are difficult to reach, please leave times you will need be available. If you want me to submit use discretion when calling you or leaving a message for you, please let me know in advance. I will try to your insurance company for reimbursement for any out-of-network benefits contact you might have:if you miss an appointment.

PSYCHOLOGICAL SERVICES. Psychotherapy is and psychological evaluations are not easily described in general statements. It varies They vary depending on the personalities of the psychologist and patientclient, and the particular problems you hope to addressare experiencing. There are many different methods I your graduate clinician or evaluator may use to deal with those problemsthe problems that you hope to address. Psychotherapy is and assessments are not like a medical doctor visitvisits. Instead, it calls They call for a very active effort on your part. In order for the therapy them to be most successful, you will have to work on things we talk about that are discussed both during our sessions and throughout the week at home. Also, you will have to be honest about the subjects we talk about and put forth good effort on the tests you are asked to complete as part of therapy or your evaluation. Therapy and evaluations involve a commitment of time, money, and energy. Psychotherapy and psychological evaluations can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. Assessment often leads to a better understanding of yourself, improved sleepyour relationships, solutions to specific problems, and less fatiguesignificant reduction in feelings of distress. But However, there are no guarantees as to of what you will experience. Our first session will involve an evaluation of your needs. By the end of the experience when you take part in therapy or a psychological evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either sessions completed in-person or over telehealth, clients will be expected to pay for each session at the telephone) lasting 45 minutestime it is held, unless other arrangements have been determined. I charge this same $250 Therapy clients are charged per 4550-minutes rate minute session. Typically, clients at AUPSC are seen once a week for other professional services you may needone 50-minute session. In the event that a client and clinician decide to meet more than once a week, though I the client will prorate be charged the cost if I work agreed upon therapy fee for periods of less each time that they meet. If a client requests a therapy session longer than 45 minutes in increments of 15 50 minutes, rounded to then they will be billed for the nearest extended time in 15-minute increment (e.g.increments. To maintain active status as a client at AUPSC, 22 minutes payment must be made at the time services are rendered. After 2 consecutive sessions of service nonpayment, clients will need to contact the clinic director to reinitiate services. Therapy fees in person and via telehealth are determined using a sliding scale. In order to be eligible for the sliding scale, clients will be charged asked to provide proof of income at their first visit. Examples of proof of income include one of the following: the most recent tax return, disability letter, food stamp letter, or unemployment benefit letter. Although names must be visible on the proof of income document to confirm eligibility, please mark through social security numbers so that they are not visible. Auburn University students qualify for 15 minutes whereas 23 minutes of service $30 per session fee for individual therapy for themselves. Eligibility for the sliding scale will be charged re-verified at least annually. In the event that a client does not wish to provide documentation of annual family income, the highest income bracket will be assumed. If a financial crisis exists (for 30 minutesexample, loss of job or loss of housing) that causes a client to be unable to pay their weekly therapy fee, the clinician can discuss the need for a temporary fee reduction with their licensed clinical supervisor and the Clinic Director. With written and/or verbal documentation of financial crisis, the client’s therapy fee may be reduced by up to $15 per session for up to 10 sessions. Telephone calls to clinicians are not an effective substitute for regular therapy sessions and should be limited to emergencies. Telephone calls longer than 5 minutes will be billed at the regular session fee in 15-minute increments. In the event that consultation services are required (for example, with school professionals, psychiatrists, primary care physicians, or previous treatment providers), the client will be billed at the regular session fee in 15-minute increments. Other professional services include telephone conversations such as reviewing previous treatment records or email responses lasting longer than 15 minutesconducting school observations will also be billed at the regular session fee (in 15-minute increments). If treatment records are requested, a fee of $20 will be charged to cover the cost of accessing the file, copying the materials, and mailing or faxing the time spent performing any other service you may request of merequested documents. If you become involved in legal proceedings that require my your graduate clinician or your graduate clinician’s supervisor’s participation, you will be expected to pay for any all of your graduate clinician’s and your graduate clinician’s supervisor’s professional time I spend on your legal mattertime, including preparation and transportation costs, even if the request comes from your graduate clinician or your graduate clinician’s supervisor is called to testify by another party, . Full psychological evaluations have a preset charge of $700. Half of this fee is due at the same initial assessment session, and the other half is due at the feedback session. The assessment fee includes all interviews, all assessment measures, all consultations, one written report, and one feedback session. This fee also includes AUPSC mailing or faxing the written report to one professional of the client’s choice. If additional reports are requested, a fee of $250 per 4520 will be charged to cover the cost of accessing the file, copying the materials, and mailing or faxing the requested documents. In the event that a full psychological evaluation is not required, a reduced fee can be determined by the Clinic Director on a case-minutes rateby-case basis. I Assessment measures that are administered as part of therapy without a formal report will be of no additional charge to the normal therapy fee. Assessment costs do not charge for time spent writing reports exceed $700 and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed determined by the extent of testing requested by the client. Therapy clients will be charged up to their regular session fee for missed appointments and agreed upon ahead of time with a new Treatment Contractfor appointments canceled or rescheduled less than 24 hours in advance. Assessment clients will be charged $60 for missed appointments and for appointments canceled or rescheduled less than 24 hours in advance. After 3 missed appointments in one semester, clients will be considered inactive and will need to contact the Clinic Director to reinitiate services. If it has been a client misses 4 consecutive weeks of services with the clinic is open, the client will be considered inactive, and the file will be closed. If clients are more than one year since our last appointment15 minutes late for a session, then you the clinician and supervisor reserve the right to reschedule the appointment and charge up to the session fee. Clients with outstanding balances will receive a financial summary statement at the end of each month, which will detail all transactions that are made. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, AUPSC retains the option of using legal means to secure the payment. After two consecutive sessions of nonpayment, clients will need approval by the clinic director to re-initiate services at my current standard fee services. This may involve hiring a collection agency or going through small claims court which may be higher than the fee you were previously payingwill require AUPSC to disclose otherwise confidential information. In additionmost collection situations, if it has been more than one year since our last appointmentthe only information AUPSC releases regarding a client’s treatment is the client’s name, you the nature of services provided, and the amount due. If such legal action is necessary, its costs will be scheduled included in the claim. Because AUPSC is a training clinic and graduate students who are not licensed clinical psychologists provide the services, third party health insurance will NOT pay for another initial evaluation (90 minutes) and charged accordinglythe services rendered at AUPSC. The only exceptions to this situation are the cases where the Alabama Department of Human Resources or local school systems pays for services rendered at AUPSC. Thus, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any AUPSC will NOT file insurance companiesforms. If you decide wish to submit claims to your insurance company for pursue reimbursement for any out-of-network benefits the services you might havehave received at AUPSC, we will provide you may do sowith a bill that lists the services provided. However, be aware that the services provided will still be charged to you, you (not your insurance company, and you ) are responsible for full payment at the full paymenttime services are rendered, unless alternate arrangements have been made in advance. I have no role in deciding It is very important that you find out exactly what mental health services your insurance policy covers. You are responsible for checking If you have insurance that covers mental health services, AUPSC will be happy to refer you to a licensed therapist who might be covered by your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible company or able to file for the full session fee in these instancesreimbursement. If your insurance company doesn’t reimburse youservices are being paid for by the Alabama Department of Human Resources or a school system, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session your contract with the following Alabama Department of Human Resources or your school system requires that AUPSC provide it with information relevant to the services that are provided to you. AUPSC is also required to provide information regarding clinical diagnosis, when a diagnosis is assigned. Sometimes AUPSC is required to provide additional clinical information, such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, AUPSC will ask that you sign an Authorization Form to Release/Obtain Information in order to release information about you that is necessary for the purpose requested. This information will need become part of the Alabama Department of Human Resources or the school systems records and might be stored in a computer. Though the Alabama Department of Human Resources and schools claim to submit keep such information confidential, AUPSC has no control over what they do with it once it is in their hands. If you refuse to your insurance company allow AUPSC to release information relevant to the services that are provided to you by AUPSC, then the Alabama Department of Human Resources or the school system will not pay for reimbursement for any out-of-network benefits services provided to you might have:by AUPSC.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to address. There are many different methods styles of psychotherapy, and the most appropriate type of therapy for you will depend on your personal preferences, goals, and willingness to change. Although I draw from a variety of perspectives, central to my practice is my belief that our families play a critical role in shaping our stories. I therefore welcome them into the therapy process, both through stories shared about them and as participants. Please note that other therapists may use work differently, and it is important that you find the best fit for you. We will take the first few sessions to deal get to know each other and to evaluate whether I am the best therapist for you. If either of us believes that a referral to another therapist would be in your best interest, I will make every effort to facilitate a referral for you. If you decide to continue therapy with those me, we will set some goals for our time together. As we reach these goals, we will find an appropriate time to conclude our work together. Ending therapy should not be done casually, although either of us may decide to end if we believe it is in your best interest. If you wish to discontinue therapy, I ask that we meet at least one more time to discuss your concerns and conclude our time. You may be able to resume therapy after your case has been closed, depending on your needs and my availability. There are both benefits and risks to psychotherapy. Psychotherapy has been shown to help people feel better, improve their relationships, and discover solutions to difficult problems. Psychotherapy is not like a medical doctor visit. InsteadAt the same time, it calls for a very active effort on your part. In order for delving into the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects more painful parts of your life, you story may experience uncomfortable lead to feelings like of sadness, guilthelplessness, anger, frustration, lonelinessguilt, and helplessnessloneliness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are There is no guarantees guarantee as to what you will experience, or what will result from your time in therapy. Our first session will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer only ask that you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue discuss these feelings with me for therapyso we may work through them together. You should evaluate this information along Appointments are scheduled by phone. I request 24 hours notice to reschedule or cancel the appointment. I charge a $50 late cancellation fee if an appointment is canceled or rescheduled with your own opinions about whether you feel comfortable working with me. At the end of the evaluationless than 24 hours notice, I will notify you if I believe that I am which insurance companies do not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you selectcover. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persistmiss or cancel three appointments with less than 24 hours notice, I will be happy reserve the right to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency roomend your treatment. My fee fees are listed below. Tax is not included. $395 for an initial evaluation lasting 200 Initial Visit 55-90 minutes, and minutes $250 for each subsequent psychotherapy session (either in200 Follow-person or over the telephone) lasting 45 minutes. I charge this same $250 per up Psychotherapy Visit 45-55 minutes Fees for most other services are based on an hourly rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes)$200 per hour. Other professional services may include report writing, telephone conversations or email responses lasting longer than 15 fifteen (15) minutes, authorized consultation, preparation of records or treatment summaries, etc. Additionally, there is a $50 charge for cancellations with less than 24 hours notice, and a $25 bounced check fee. You will be expected to pay for each session at the time spent performing any it is held, unless we have made other service you may request of meagreements. If you become involved in legal proceedings that require my participationwill be using insurance coverage, you will be expected to pay for your co-pay or co-insurance, as well as any professional time I spend on your legal matter, even if the request comes from another partyapplicable taxes, at the same $250 time of your therapy session. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. If you choose to use your health insurance benefits, it is your responsibility to understand your policy, particularly your co-pay or co-insurance amounts, covered benefits, and maximum visits per 45-minutes rateyear. Please call your insurance carrier with any questions about your policy. Health insurance companies often require that I provide them with a clinical diagnosis, and may also require additional information such as treatment plans, treatment summaries, or treatment notes. I do will make every effort to release only the minimum information necessary for the purpose requested. Upon your request, I will provide you with a copy of any report I submit. By signing this Agreement, you agree that I can provide requested information to your insurance company. Some insurance companies will not charge for time spent writing reports and progress notes as per the standard routine of my care of allow me to provide services to you once your benefits end. If this occurs, I will discuss your options with you, which may include self-payment or referral to another mental health provider. I also do am often not charge for any time immediately available by phone. Please leave a message with your name and number and the best times to return your call. I will make every effort to return your call within 2 business days. I will assume I may spend collaborating with leave a message on your other providersvoicemail unless you tell me otherwise. From time If I am unable to reach you by phone, I may send you a letter. I will assume I may send you postal mail to the address listed on your registration form unless you tell me otherwise. If you are unable to reach me and are in crisis, please call the Crisis Line at 000-0000, call 911, or go to your nearest emergency room. If I will be unavailable for an extended time, I will provide you with the name of a colleague who is covering for me in my absence. If I am unable to work due to an unforeseen emergency or illness, a colleague may institute fee increases contact you about your appointments and these care. Please do not attempt to contact me via social networking sites or other public networking forums, as this may compromise your confidentiality and the security of our relationship. Similarly, e-mail communications are retained in the logs of your Internet service provider and are therefore not considered confidential. Please do not attempt to contact me by email. If you choose to email me, know that any email communication will be discussed and agreed upon ahead of time with a new Treatment Contractkept in your clinical record. The best way to reach me between sessions is by phone. If it has been more than one year since our last appointmentnecessary, then you will re-initiate services at my current standard fee which text messaging may be higher than the fee used for scheduling purposes only. If you were previously paying. In addition, if it has been more than one year since our last appointmentchoose to contact me by text, you will be scheduled for another initial evaluation (90 minutes) assuming the risk that our text messages may be read by others and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying may therefore compromise your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:confidentiality.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities Therapy involves discussing aspects of the psychologist and patientyour life that are unpleasant, it may bring up a wide variety of emotions that may be very uncomfortable such as sadness, anger, loneliness, guilt, helplessness, and the particular problems you hope frustration. Therapy can also bring about positive results such as improved interpersonal relationships, significant decrease in negative thoughts/ emotions, and solutions/revelations to addressspecific problems. There are many different methods I may use approaches to deal with those problemspsychotherapy and which one works is dependent upon the individual, client-clinician dynamics, and specific issues you are experiencing. Psychotherapy Once a connection has been established, the method used to assist in addressing your problems is not like a medical doctor visit. Instead, it calls for a very crucial to your active effort on your partparticipation and getting results. In order for rare circumstance, the therapy to continuation of psychotherapeutic services may be most successfulcontingent upon psychopharmacological interventions. At the start of therapy, you we will have to work on things we talk be gathering information about both during our sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of you, your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, lonelinesshistory, and helplessnessreasons for seeking therapy. When treating insomnia specifically, therapy might cause After the initial evaluation we will discuss goals and a general treatment plan that would be attainable and comfortable for you. You should contemplate whether you to experience increased sleepiness are comfortable with your Insightful Direction clinician and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what if you will experience. Our first session will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what manage the time and financial obligations required. Here at Insightful Direction we understand that therapy requires commitment, time, and money and we will try our work will include and a treatment plan best to follow, if you decide assist you. You are not obligated to continue with me for therapy. You should evaluate this information along therapy with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you clinician if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If at any time you have questions about my procedures, we should discuss them whenever they ariseany doubts or issues with your clinician. If your doubts persist, I will We would be happy more than willing to help you set up arrange a meeting with another a different mental health professional for a second opinion. Please note that Appointments are scheduled for 50 minute durations once a week, but may be scheduled more or less within a month. Payments are expected at the psychological services I provide are time of appointments or will be billed in a statement according to rate indicated unless a 48 hour advanced notice of cancellation is provided. No call no shows will be billed the scheduled rate for the appointment missed. In the case of unusual financial hardship, a payment installment plan may be negotiated. Accounts delinquent more than 60 days and payment arrangements has not been made, we have the right to seek through legal means payment. A collection agency may be contracted or small claims court may be utilized which would require disclosure of confidential information. Collection agencies will only be provided a client’s name, service provided, and amount owed to us. Costs for emergency situationslegal actions will be included in addition to amount owed to us. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for There will be an initial evaluation lasting 90 minutesconsultation scheduled through the phone at no cost to you. If you have any questions or need clarification about our professional fees, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutesplease address them with us. I Please be advised we also charge this same $250 per 45-minutes a standard rate for other professional services you may needsuch as communications lasting more than 5 minutes on the phone, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minuteswritten reports, rounded to the nearest 15-minute increment (e.g.consultation with other professionals with your permission, 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutestime utilized performing requested services, and the time spent performing any other service you may request preparation of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports documents and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:records.

PSYCHOLOGICAL SERVICES. The primary mental health service that we provide the public is psychotherapy for individuals (adults, adolescents, and children), couples, families, and groups. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist counselor/psychotherapist and patientclient(s), and the particular problems you hope to addressare experiencing. There are many different methods I your individual treatment provider at SLC may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor physician visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about issues discussed, both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But the practice of psychotherapy is not an exact science and therefore there are no guarantees as to regarding what you will experience. Our first session will involve an evaluation experience as the outcome of your needstreatment. By It is important that you, the end client, understand that the SLC counselors/psychotherapists are not medical doctors; therefore, they do not prescribe medications and are not authorized to practice medicine. If you or your individual treatment provider at SLC thinks that medication should be considered as a part of your treatment, after discussing medication as a treatment option, your individual treatment provider at SLC might refer you to a physician with whom they would work to provide coordinated services. Psychological problems can have medical or biological origins and you should have regular physical exams and speak with a physician about all psychological symptoms. It may also be important to note that the evaluationclinicians at SLC, I LLC are individual private practitioners and each is liable only for their own actions and/or for those actions of any specific individual for whom they provide legal supervision or whom is employed by your specific private practitioner. Psychotherapy appointments/sessions are typically scheduled once a week for a total of 45 – 50 minutes at an agreed upon time with your individual treatment provider at SLC. However, some sessions may be longer or more frequent depending upon the necessity of treatment and in agreement between you and your individual treatment provider. Once an appointment hour is scheduled, you will be able expected to offer pay for it unless you some first impressions provide at least 24Rhours advance notice of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for cancellation (unless you and if soyour individual treatment provider at SLC both agree that you were unable to attend due to circumstances beyond your control). It is important to note that insurance companies do not provide reimbursement for cancelled sessions. If it is possible, I your individual treatment provider will give you referrals try to other practitioners who I believe are better suited find another time to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about reschedule the therapist you selectappointment. If you have questions about my proceduresmissed a scheduled appointment and you do not call your therapist within 7 days, we should discuss them whenever they ariseyour therapist will accept that as your notice that you have terminated this agreement and that you wish to discontinue services. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional The agreed upon fee for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent 45 – 50bminute psychotherapy session is $ 135.00. (either in-person or over This fee includes time for appropriate note taking and other services associated with regular, weekly sessions). In addition to weekly appointments, SLC and/or your individual treatment provider at SLC reserves the telephone) lasting 45 minutes. I right to charge this same $250 a fee per 45-minutes rate hour for other professional services you may need, though I we will prorate break down the hourly cost if I we work for periods of less than 45 minutes in increments of 15 minutesone hour, rounded to the nearest 15-minute increment (e.g., 22 minutes of service and this fee will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes)discussed with you prior to providing the service. Other professional services include report writing, telephone conversations or email responses lasting longer than 15 10 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of meSLC and/or your individual treatment provider at SLC. If you become involved in legal proceedings that require my participationthe participation of SLC and/or your individual treatment provider at SLC, you will be expected to pay for any all of our professional time I spend on your legal mattertime, including preparation and transportation costs, even if the request comes from an SLC representative and/or your individual treatment provider at SLC is called to testify by another party, . SLC and/or your individual treatment provider at SLC will charge a fee per hour for preparation and will charge a fee per hour for attendance at any legal proceeding; the same $250 per 45-minutes ratelatter is charged from the time of leaving the office until return. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these These fees will be discussed with you prior to providing any services and agreed upon ahead will be considerably higher than tradition therapy fees. All fees must be paid prior to legal proceedings. Please initial here to acknowledge that you have read and understand the above section on Professional Fees. The law protects the privacy of time with all communications between you, the client, and SLC and/or your individual treatment provider at SLC. In most situations, SLC and/or your individual treatment provider at SLC can only release information about your treatment to others if you sign a new Treatment Contractwritten authorization form that meets certain legal requirements by HIPAA. There are other situations that do not require your authorization, including the following: • Ultimately, SLC will have therapist that are working as candidates for licensure. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointmentyour provider is a candidate, you should be aware that they will be scheduled under the supervision of licensed mental health professionals. As such, they will be meeting regularly with their supervisors to discuss each of their cases, to receive appropriate supervision of their work, and to obtain necessary consultation in order to provide you with the most helpful and effective mental health services. If information regarding your case is to be shared in a group consultation no identifying information would be utilized. Candidates are required by law to tape occasional sessions as a part of their licensure process. Your permission must be sought and obtained in writing prior to any taping. Tapes are used for another initial evaluation supervisory purposes only and are destroyed once supervision is complete. They are never maintained as a part of your record. Your individual treatment provider will seek your permission and inform you when tapings and/or observations are taking place. • As is common professional practice, your individual treatment provider at SLC may occasionally find it helpful to consult with other health professionals about your case. No identifying information will be utilized during said consultation unless you have given specific written consent. Other professionals are also legally bound to keep the information confidential. • You should be aware that your provider may employ administrative staff to assist in filing and other miscellaneous officebrelated activities. These personnel may need to have access to protected information in order to perform their duties. All staff members have been given training about protecting your privacy and have signed nondisclosure agreements agreeing to protecting your confidentiality. ● Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. There are some other situations where SLC and/or your individual treatment provider at SLC are permitted or can be required to disclose information without your consent of Authorization: ● If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologistbclient law. SLC and/or your individual treatment provider at SLC cannot provide any information without your (90 minutesor your personal or legal representative’s) and charged accordinglywritten authorization, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companiesor a court order. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might haveare involved in/or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order SLC and/or your individual treatment provider at SLC to disclose information. ● If a government agency is requesting the information for health oversight activities, SLC and/or your individual treatment provider at SLC may do sobe required to provide it for them. However● If a client files a complaint or lawsuit against SLC and/or your individual treatment provider at SLC, we may disclose relevant information regarding that client in order to defend against the complaint or lawsuit. ● If a client files a worker’s compensation claim, SLC and/or your individual treatment provider at SLC may disclose information relevant to that claim to the appropriate parties, including the Administrator of the Worker’s Compensation Court These are some situations in which SLC and/or your individual treatment provider at SLC is legally obligated to take actions, which we believe are necessary to attempt to protect others from harm and, as such, may have to reveal some information about a client’s treatment. These situations are unusual, but may occur: ● If SLC and/or your individual treatment provider at SLC has reason to believe that a child under the age of 18 years is the victim of abuse or neglect, the law requires we report to the appropriate government agency, usually the Department of Human Services. Once such a report is filed, SLC and/or your individual treatment provider at SLC may be aware required to provide additional information. ● If SLC and/or your individual treatment provider at SLC has reason to believe that a vulnerable adult is suffering from abuse, neglect, or exploitation, the law requires that we report to the appropriate government agency, usually the Department of Human Services. Once such a report is filed, SLC and/or your individual treatment provider at SLC may be required to provide additional information. ● If a client communicates an explicit threat to kill or inflict bodily injury upon a reasonably identifiable victim and he/she has the apparent intent and ability to carry out the threat, or if a client has a history of violence and SLC and/or your individual treatment provider at SLC has reason to believe that there is a clear and imminent danger that the services provided client will still be charged attempt to youkill or inflict serious bodily injury upon a reasonably identified person, not your insurance companywe may need to take protective actions. These actions may include notifying the potential victim, and you are responsible contacting the police, and/or seeking hospitalization for the full paymentclient. I have no role ● If the client threatens to harm herself/himself, SLC and/or your individual treatment provider at SLC is obligated to seek hospitalization for her/him, or to contact family members or others who can help provide protection. ● If such a situation arises, SLC and/or your individual treatment provider at SLC will make every effort to fully discuss it with you before taking any action and we will limit our disclosure to what is necessary. ● Information from clients’ files may be compiled to study various issues such as treatment outcomes and client satisfaction to improve the services offered by SLC. Your name or any identifying information will not be used in deciding what such research. ● All clients that consent to group psychotherapy will be informed about the importance of maintaining confidentiality. It is important to understand, however, that neither SLC, nor your insurance coversindividual treatment provider at SLC can guarantee that all group members will keep any and/or all information provided by clients in the group setting confidential. You are responsible for checking your insurance coverageWhile this written summary of expectations to confidentiality should prove helpful in informing you about potential problems, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you it is important that we discuss any payment you expected to be reimbursed questions or otherwise. I will provide you a superbill after each session with the following information concerns that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:may have now or in the future. In situations where specific advice is required, formal legal advice may be needed.

PSYCHOLOGICAL SERVICES. As a Licensed Psychologist, I provide services to adults, couples and occasional group therapy. My training has been in a broad range of approaches including life-span devel- opment, cognitive behavioral therapies, motivational interviewing, mindfulness-based therapies, and trauma-focused therapy. I individualize treatment programs in order to optimally accommodate the needs of each individual. My clinical work with adults (18 years + ) focuses on issues of anxiety, depression, trauma, bipolar disorders, co-occurring substance problems, chronic illness, and physi- cal pain. I also help the people make peace with issues of the past, build coping skills for stress, maximize their personal and career potential, and make difficult life transi- tions with as much grace and awareness as possible. I work with couples using Emo- tionally Focused Therapy to address relationship problems, family conflict, communica- tion skills, and parenting decisions. I also offer occasional group therapy for people with bipolar problems. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist therapist and patientthe client, and as well as the particular problems you hope which the client brings. My approach to address. There are many different methods I may use to deal with those problems. Psychotherapy treatment is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for evidence-based and balances the support inherent in the therapy relationship with specific treatment interventions. For a success- ful outcome, therapy involves the client!s work outside of sessions to be most successful, you will have to work on things we talk about both during our sessions and at homeimplement changes in their daily lives. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant un- pleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, and improved sleep, and less fatigueemotion regulation. But there are no guarantees as to of what you will experience. Our first session one or two sessions will involve an a diagnostic evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and suggest a treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with your own opinions about whether you feel comfortable sense of comfort in working with me. At the end of the evaluation, I will notify you if I believe It is important to identify your goals for therapy to ensure that I am not the right therapist this is a useful and beneficial process for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should it!s important to be very careful about the therapist you select. If Please feel free to ask questions because you have questions about my procedures, should also be evaluating how comfortable you are with the direction we should discuss them whenever they ariseare taking. If your doubts persist, or if I find that I am not able to meet your clinical needs, I will be happy to help refer you set up a meeting with to another mental health professional for to assist you with your goals. I usually schedule sessions once a second opinionweek at a time we agree on, although some ses- sions may be longer or more frequent in the beginning or as the need arises. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go make every effort to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutesbegin and end sessions on time, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded not be able to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and extend the time spent performing any other service of your session if you may request of mearrive late. If Once you have met some your goals and are feeling bet- ter, sessions usually become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You less frequent until they are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full paymentno longer needed. I have no role been involved in deciding what your insurance covers. You are responsible for checking your insurance coveragetraining, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service)teaching, and telephone session are not typically covered by insurance companies and therefore you will likely be responsible research in the field of Psychology for the full session fee 30 years. In addition to my Private Practice in these instances. If your insurance company doesn’t reimburse youdowntown Seattle, I am not responsible currently supervise doc- toral students in psychology at Antioch University in Seattle. My degrees are: PhD in Clinical Psychology Master!s degree in Psychology Master!s degree in Counseling Master!s degree in Nutrition Bachelor!s degree in Anthropology All degrees are with highest honors Psychology licensure provides that psychologists have passed examinations adminis- tered by the Examining Board of Psychology for refunding you any payment you expected Washington State and attests that Psy- chologists are qualified to engage in the independent practice of psychology. The Washington State licensure law provides complaint and discipline recourse procedures for clients. Inquiries about a psychologist!s professional qualifications and/or treatment may be reimbursed or otherwisedirected to the Examining Board of Psychology, Division of Professional Licens- ing, P.O. Box 9649, Olympia, WA 98504. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:My WA State license number is PY 60025556.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first 2-4 sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note APPOINTMENTS Appointments will ordinarily be 50 minutes (individual) or 80 mins (EMDR, couple) in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. If you need to cancel or reschedule a session, I ask that you provide me with advanced notice. If you miss a session without canceling, or cancel later than 8am on the psychological services day of your appointment, my policy is to collect a $25.00 fee (unless we both agree that you were unable to attend due to circumstances beyond your control). If it is possible, I provide will try to find another time to reschedule the appointment. You are not allowed two “no show” appointments, after which we will discuss transferring you to another clinician. In addition, you are responsible for emergency situationscoming to your session on time; if you are late, your appointment will still need to end on time. For emergencies, call 911 or go to the nearest emergency room. My PROFESSIONAL FEES The standard fee for each session is $395 for an initial evaluation lasting 90 minutes200 (individual, and EMDR), or $250 (couple) unless otherwise agreed-upon. You are responsible for each subsequent psychotherapy paying at the time of your session (either in-person unless prior arrangements have been made. Payment can be made by check, cash, or over credit card. Any checks returned to my office are subject to an additional fee of up to $25.00 to cover the telephone) lasting 45 minutesbank fee that I incur. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment. In addition to weekly appointments, it is my practice to charge this same $250 per 45-minutes rate amount on a prorated basis (I will break down the hourly cost) for other professional services that you may needrequire such as report writing, though I will prorate the cost if I work for periods of less telephone conversations that last longer than 45 minutes in increments of 15 5 minutes, rounded to the nearest 15-minute increment (e.g.attendance at meetings or consultations which you have requested, 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing required to perform any other service which you may request of me. If you become anticipate becoming involved in legal proceedings a court case, I recommend that require we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for any the professional time I spend on your legal matter, required even if the request comes from another partyparty compels me to testify. INSURANCE All insurance information is handled by Psychotherapy Billing Services, at LLC. This company adheres to the same $250 per 45HIPAA practices used at this office and all information provided related to billing will be handled in a professional and confidential manner. For any questions related to insurance billing, contact Xxxxx Xxxxxxx at (541) 343-minutes rate8122 ext. 4. PROFESSIONAL RECORDS I am required to keep appropriate records of the psychological services that I provide. Your records are maintained in a secure location in the office. I do not charge keep brief records noting that you were here, your reasons for time spent writing reports seeking therapy, the goals and progress notes as per the standard routine of my care of you. we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, any correspondence between us, records I also do not charge for any time I may spend collaborating with your receive from other providers, copies of records I send to others, and your billing records. From time Except in unusual circumstances that involve danger to timeyourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and / or upsetting to untrained readers. For this reason, I may institute fee increases and these will be discussed and agreed upon ahead of time recommend that you initially review them with a new Treatment Contractme, or have them forwarded to another mental health professional to discuss the contents. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointmentI refuse your request for access to your records, you have a right to have my decision reviewed by another mental health professional, which I will be scheduled for another initial evaluation (90 minutes) and charged accordingly, discuss with subsequent 45-minute psychotherapy sessions thereafteryou upon your request. You are responsible for paying also have the right to request that a copy of your full session fee. I am not in-network with file be made available to any insurance companies. If you decide to submit claims to other health care provider at your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:written request.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to address. There are many different methods I may use to deal with those problemsbring forward. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy While psychotherapy has been shown to have significant benefits for most people who apply themselves to it, no outcome is guaranteed, and it can have benefits and risksbe unpleasant, difficult work. Because therapy it often involves discussing unpleasant troublesome aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session few sessions will involve be an evaluation of how best to meet your needs. By the end of the evaluation, I will be able to offer you some first impressions an assessment of what our work will include your situation and a treatment plan to follow, if you decide to continue with me for therapymoving forward. You should evaluate this information along with your own opinions about whether sense of how comfortable you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you Most clients have questions about my proceduresthe process of therapy, and I encourage you to raise those so we should can discuss them whenever when they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note I am often not immediately available by telephone. I check voicemail daily, except weekends and holidays, and will make every effort to return your call as soon as I get it. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and feel that the psychological services I provide are not you can’t wait for emergency situations. For emergenciesme to return your call, call 911 or go to contact your family physician, the nearest emergency room, or Psychiatric Emergency Services at (000) 000-0000. My fee is $395 If I will be unavailable for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to extended time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need name of a colleague to submit to your insurance company for reimbursement for any out-of-network benefits you might have:contact, if necessary.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities a set of the psychologist and patientpsychological interventions designed to help people resolve emotional, behavioral, and interpersonal problems and improve the particular quality of their lives. There are many different interventions I may use to help you with the problems that you hope to address. There are many different methods I may use to deal with those problemsspecialize in Cognitive Behavioral Therapy (CBT). Psychotherapy is not like a medical doctor visit. Instead, it This type of therapy calls for a very active effort on your part. In order for the therapy to be most successful, it will be important for you will have to work on the things we I talk about about, both during our sessions and at home. Psychotherapy can *CONFIDENTIALITY: The information provided by you as a client during therapy sessions is legally confidential. This means that I cannot disclose information about you or your treatment to others without for full payment of my fees. If you have benefits and risks. Because therapy often involves discussing unpleasant aspects of your lifea health insurance policy, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of it will usually provide some coverage for mental health treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there If you are no guarantees as to what you will experience. Our first session will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if sousing insurance, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, monthly billing statements so that you should can be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If reimbursed by your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutesinsurance company. I charge this same $250 per 45-minutes rate for other professional services recommend that you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to contact your insurance company for reimbursement for any to inquire about out-of-network benefits coverage for mental health services. Because you might havewill be paying me each session for their services, any later reimbursement from the insurance company should be sent directly to you. Please do not assign any insurance company payment to our practice. Additionally, I reserve the right to use a collection agency to collect fees that are more than 120 days past due, unless I have agreed on an alternative payment plan. *PROFESSIONAL RECORDS: The laws and standards of our profession require that psychologists keep Protected Health Information (PHI) about you in your clinical record. You may examine and/or receive a copy of this clinical record if you request it in writing. In unusual circumstances in which disclosure is reasonably likely to endanger the life or physical safety of you or another person, I may refuse your request. In those situations, you may do sohave a right to a summary and to have your record sent to another mental health provider. HoweverBecause these are professional records, they can be aware misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in our presence, or have them forwarded to another mental health professional so you can discuss the services provided contents. If I refuse your request for access to your records, you have a right of review, which I will still discuss with you upon request. *CANCELLATION POLICY: Please contact me at least 24 hours ahead of time on the preceding business day if you need to cancel an appointment. Without this notice, you will be charged to you, not your insurance company, and you are responsible for the full paymentfee for that appointment. *FEEDBACK: Your input in your treatment is invaluable. I have no role expertise in deciding anxiety disorders and cognitive behavioral treatment, but YOU are the expert on you. Therefore, I hope that I can collaborate together to help you meet your goals. Please keep informed about what your insurance coversyou feel works for you/does not work for you in our sessions. Please give me feedback about anything about our work together that causes you distress or makes you feel uncomfortable. You are responsible for checking welcome and encouraged to ask questions about my theory of psychotherapy, any of our clinic policies, your insurance coveragebill, deductiblesor any other concerns that arise. The better informed you are, payment ratesthe more effective our work together will be. I have a 24-hour cancellation policy, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within which means that any appointment cancelled with less than 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you notice will likely be responsible charged the full fee for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:appointment.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist Therapist and patient, and the particular problems you hope to addressare experiencing. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please I normally conduct an evaluation that will last from 1 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. Sessions will be scheduled at a time and frequency we agree on. Most therapy sessions will last for 45-50 minutes unless we have agreed upon a longer session. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. [If it is possible, I will try to find another time to reschedule the psychological services appointment.] You will be informed as to my current fee schedule regarding the initial diagnostic interview session, follow up 45-50 minute therapy sessions and other services. I provide are not for emergency situationsonly accept payment in the form of check or cash. For emergenciesPlease make checks payable to “Xxxxxxx Xxxxxxxx, call 911 or go to the nearest emergency roomLSCSW, Inc”. My fee is $395 schedule provides a listing of rates for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include report writing, telephone conversations or email responses lasting longer than 15 10 minutes, consulting with other professionals with your permission, preparation of records of treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any all of my professional time I spend on your legal mattertime, including preparation and transportation costs, even if the request comes from I am called to testify by another party. [Because of the difficulty of legal involvement, at the same I charge $250 per 45-minutes ratehour for preparation and attendance at any legal proceeding.] Due to my work schedule, I am often not immediately available by telephone. My telephone is answered by my confidential voice mail system. I do not charge for time spent writing reports will make every effort to return your call on the same day you make it, with the exception of weekends and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contractholidays. If it has been more than one year since our last appointmentyou are difficult to reach, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, please inform me of some times when you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companiesavailable. If you decide have an emergency, call 000-000-0000 and follow the voice mail prompts. The answering service will assist you. The answering service will attempt to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do soreach me. However, be aware that the services provided will still be charged to you, not your insurance company, and If you are responsible unable to reach me and feel that you can’t wait for me to return your call, contact your physician or the nearest emergency room and ask for the full paymentpsychologist or psychiatrist on call. If you have a life-threatening emergency, call 911. If I have no role in deciding what will be unavailable for an extended time, we may discuss your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible need for the full session fee name of a colleague to contact in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:my absence.

PSYCHOLOGICAL SERVICES. Psychotherapy Psychological Assessment Through the use of a variety of standard psychological tests we will attempt to answer the questions that have brought you here for this assessment. Throughout the assessment you have the right to inquire about the nature or purpose of all procedures. You have the right to withdraw from the testing session at any time. You also have the right to know the test results, interpretations and recommendations. The assessment process generally involves a clinical interview followed by the administration of standardized psychological tests. Although it is not easily described preferable to complete the testing process in general statementsone sitting, it may be necessary to schedule more than one evaluation session to complete the necessary testing. It varies depending on Once testing is completed and the personalities data has been analyzed, a copy of the psychologist report will be made available to you as well as any referring party for continuity of care purposes. Psychotherapy/Psychoeducational Group Treatment Therapy is a relationship between people that works in part because of clearly defined rights and patientresponsibilities held by each person. As a client in psychotherapy, you have certain rights and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work implement changes discussed in therapy in your everyday life. APPOINTMENTS Psychological assessment appointments vary in length, depending upon the referral question Name: Acct#: MR#: Current Date: and ability of the participant to engage in the task at hand. These appointments will be scheduled for a specified time, depending on things we talk about both during our sessions and at homethe referral question, subsequent appointments will be scheduled as necessary. Psychotherapy can have benefits appointments and risks. Because therapy often involves discussing unpleasant aspects of your lifepsychoeducational groups will ordinarily be once per week for 45 minutes at a time we agree on, you some appointments may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and be more or less fatigue. But there are no guarantees frequent as to what you will experience. Our first session will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you selectneeded. If you have questions about my procedures, need to cancel or reschedule an appointment we should discuss them whenever they arise. If your doubts persist, I will be happy to help ask that you set up a meeting provide us with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me24 hours notice. If you become involved in legal proceedings that require my participationmiss an appointment without canceling or cancel with less than 24 hour notice, you we will be expected discuss this with treatment interfering behavior at your next appointment. If possible we will try to pay for any professional time I spend on your legal matter, even if the request comes from find another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last reschedule the appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for coming to your session on time; if you are late your appointment will still need to end on time. Consistent attendance concerns, despite feedback, will lead to termination of services. PROFESSIONAL RECORDS We maintain records of the full paymentservices that we provide. I have no role Your records are maintained in deciding what your insurance coversa secure location in the office. You have the right to a copy of your file. However, these are responsible professional records and may be misinterpreted by untrained readers. For this reason, only records that are appropriate for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you release will likely be responsible for the full session fee in these instancesgiven directly to a patient. If you would like another professional to have these records, the appropriate records can be released to them for their review and assistance with continuity of care. You also have the right to request that a copy of your insurance company doesn’t reimburse you, I am not responsible for refunding you file be made available to any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to other health care provider at your insurance company for reimbursement for any out-of-network benefits you might have:written request.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It Psychological counseling varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressbring forward. There are many different methods I may use to deal with those problems. Psychotherapy is not like a medical doctor visit. InsteadCounseling will frequently involve discussing your personal concerns, it calls for a very active effort on your partthoughts, and feelings. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at homebetween sessions. We believe that homework assignments are a necessary part of the recovery process, thus we only work with clients who are willing to engage in homework assignments. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through ittremendous benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experienceAll experiences differ. Our first session few hours together will involve an evaluation of your needs. By the end of the evaluation, I we will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help youtogether. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my our procedures, we should discuss them whenever they arise. If We are happy to provide outside referrals if your doubts concerns persist. We offer both 50-minute “traditional” appointments as well as an “Intensive Therapy” model (e.g., I 2-6 hours at a time; multiples days per week). The exact timing of sessions will be happy determined in consultation with you, based on your needs. A phone consultation is recommended prior to help arranging treatment. The 15-minute consultation will be done free of charge. During the consultation, we can both decide whether we are the best match to provide the services you set up a meeting with another mental health professional for a second opinionneed. Please note that the psychological services I provide are not for emergency situations. For emergenciesIf an appointment of 50 minutes, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 75 minutes, 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-110 minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participationduration is scheduled, you will be expected to pay for any professional it unless you provide 48 hours advance notice of cancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. If we schedule an Intensive Therapy session of greater than 110 minutes, then a deposit will be required at the time I spend on the appointment is booked. This is necessary due to the large number of hours blocked for your legal matter, even services. This deposit is only refundable if the request comes from another party, at appointment is cancelled 14 days prior to the same $250 per 45-minutes rateappointment start time. I do not Signing this agreement authorizes us to charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your credit card on file if other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session arrangements are not typically covered by insurance companies and therefore you will likely be responsible made for payment for appointments cancelled or missed within the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with guidelines of the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:cancellation policy.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statementsand counseling have both risks and benefits associated with them, and there are many varieties of therapy that can be provided. It varies depending on the personalities The nature of the psychologist therapy you experience will vary depending upon your personality, treatment history, severity and patientchronicity of concerns, and other factors. All psychotherapy and counseling requires the particular problems you hope client to address. There are many different methods I may use be active and to deal with those problems. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for invest time and energy into tasks and reflections both during and outside of the therapy to be most successful, you will have to work on things we talk about both during our sessions and at homesessions. Psychotherapy The more common risks are that therapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncover or stir some uncomfortable feelings like sadness, guilt, anger, frustration, lonelinessemotions, and helplessnessmay lead to changes in relationships, or a worsening of symptoms. When treating insomnia specificallyHowever, often these uncomfortable periods are followed with improvements in functioning and movement toward treatment goals. Often therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, relationships and solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are There is no guarantees as to what guarantee about how you will experiencerespond to treatment. Our It is common for the first session will involve an (or maybe few) sessions to be a time for evaluation of your needs. By the end It is important for us to consider whether we feel this is a match in terms of the evaluationexpertise, I will and comfort so that we can be able to offer you some first impressions of what effective in our work will include and together. If it is not a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to match we can discuss appropriate referral or other practitioners who I believe are better suited to help youadjustments. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, Sometimes you will be expected asked to pay complete homework (reading, or practicing a skill) that you and I agree could be helpful in moving you toward outcomes that you have identified. If we agree on a treatment plan, it could involve initial weekly meetings, and sometimes, the meetings become spread out to allow for any professional time practice of new skills, or other learning, to be reported upon in session, and when appropriate and financially necessary sessions might be spaced to accommodate budgetary needs of the client. It is also important to know that it may be necessary in some instances that I spend on may recommend you seek a medical or psychiatric evaluation to best meet your legal matterhealth outcome needs or goals. And, even if the request comes from another partyyou have had prior treatment it can be very helpful for you to give me permission to access those records for consideration during my overall evaluation of your situation and to inform design of treatment outcomes. Also, sometimes a client may become frustrated with pace of change, or with a direction in treatment. It is often vitally useful to discuss such reactions and perceptions with me so that we can make necessary adjustments to better meet your expectations. Clinical experience has suggested that often such moments create real opportunities for improvement. Finally, if at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time you wish stop treatment or to timerequest a referral, I may institute fee increases let me know and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide assist you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:in those processes.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressare experiencing, and the reasons for which you are seeking treatment. For example, if you are seeking Sport Psychology treatment the therapy may be much different than if you are seeking Clinical Psychology treatment. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It Psychotherapy varies depending on the personalities of the psychologist and patient, and the client as well as the particular problems the client is experiencing. I might use a variety of methods to deal with the problems you hope to address. There are many different methods I may use to deal with those problems. Psychotherapy is not like a medical doctor visitintervention. Instead, it psychotherapy calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about during both during our sessions and at homebetween our sessions. Psychotherapy can have benefits include both risks and risksbenefits. Because therapy often involves discussing discussion unpleasant aspects of your life, you may might experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better improved relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to Yet participation in psychotherapy cannot guarantee what you will experienceexperience or the end results. Our first session will few sessions involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what the general process of our work will include and a treatment plan to follow, if so that you decide can make an informed decision about whether to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, moneyenergy, and energymoney, so you should be very careful about the therapist you select. If you have questions about my procedures, we should can discuss them these questions whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with assist your finding another mental health professional practitioner. I usually conduct an evaluation that lasts from 2-4 sessions. During this time, we can both decide whether I am the best person to provide the services you need in order to meet your treatment goals. Once psychotherapy is begun, I usually schedule one 50- to 6-minute session per week at a time we agree upon; sometimes sessions are more frequent or are longer than 50-60 minutes. Once an appointment time is scheduled, you are expected to pay for a second opinionit unless you provide advance notice 24 hours prior to your appointment time. Please note If we both agree that you were unable to attend due to circumstances beyond your control, I will not charge for the psychological services session. Insurance companies do not provide reimbursement for canceled sessions. Because of my limited practice, I provide are will probably not for emergency situations. For emergencies, call 911 or go be able to offer you an alternative appointment in the nearest emergency roomsame week. My hourly fee is $395 $ for an initial evaluation lasting 90 minutesindividuals, $ for couples and families, and $250 $ _ for each subsequent psychotherapy session (either in-person or over clinical supervision/consultation. When I increase these fees, I will offer a month’s notice during which we can discuss the telephone) lasting 45 minutesimpact of this increase. In addition to weekly appointments, I charge this same $250 per 45-minutes rate fee for other professional services you may might need, though although I will prorate the cost if I work fee for periods of less than 45 minutes one hour; I charge a minimum fee of 50% your usual fee for any time in increments excess of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include report writing, telephone conversations or email responses lasting longer than 15 minutesconversations, consulting with other professionals (with your permission), and the time spent performing any other service you may request of me. If you become involved in with legal proceedings that require my participation, you will be expected to pay for any all of my professional time I spend on your legal mattertime, including preparation and transportation costs, even if the request comes from I am called to testify by another party. Due to my work schedule (I am in my Olympia practice one day per week; I am in my Seattle practice two days per week), at the same $250 per 45-minutes rateI am often not immediately available by telephone. I am in my Olympia office on Mondays and my Seattle practice on Thursdays, Fridays, and/or Saturdays. I do not charge for answer my phone when I am in appointments with clients. You can leave me a message on my cell phone answering service any time spent writing reports and progress notes as per during the standard routine of my care of youday or night. I also do not charge for any time I may spend collaborating with make every effort to return your other providerscall within 24 hours. From time Please leave your area code and phone number as well as possible times that you are available to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at take my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companiesreturn call. If you decide are unable to submit claims reach me or cannot wait for me to return your insurance company for reimbursement for any out-of-network benefits you might havecall, you may do so. However, be aware that please contact one of the services provided will still be charged to you, not following resources: your insurance company, and you are responsible family physician; 911; the nearest emergency room for the full paymentpsychologist/psychiatrist on call; the Crisis Clinic at (000) 000-0000 or (000) 000-0000. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, When I am not responsible away from the office for refunding you any payment you expected to be reimbursed or otherwise. an extended period of time, I will provide you with a superbill after each session with the following information that you will need name and contact number of a colleague to submit to your insurance company for reimbursement for any out-of-network benefits you might have:contact in case of emergency.

PSYCHOLOGICAL SERVICES. Psychotherapy Psychological treatment is not easily described in general statements. It varies depending on the personalities of the psychologist and patientclient, and the particular problems you hope to addressare experiencing. There are many different methods I may use that can be used to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, in that it calls for a very active effort on your part. In order for the therapy to be most successful, you will may have to work on things we talk about both during our sessions and at home. Psychotherapy Psychological treatment can have both benefits and risks. Because therapy Treatment often leads to significant reductions in feelings of distress, as well as improvements in specific problems and relationships. But there are no guarantees of what you will experience, and it is possible that you may not become happier. Since psychotherapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially helplessness in the early phases course of treatment. On the In some cases there may be increased conflict or other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better undesirable changes in relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session initial discussions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to followinclude, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about judgment of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting secure an appropriate consultation with another mental health professional if you desire one. For reasons of professional ethics, I generally avoid multiple relationships with clients, such as doing assessments (beyond those needed for treatment) or forensic services with therapy clients. I normally conduct an evaluation that will last from 1 to 4 sessions. During this time, we can both decide if I am the right person to provide the services that you need. If treatment is begun, I will usually schedule one 45-minute session per week at a second opinionmutually agreed time, although sometimes sessions may be longer or scheduled at other intervals. Please As much as possible, I expect all matters, including financial, to be discussed during sessions. Once an appointment is scheduled, you will be expected to pay for it unless you call or write me (not text) at least 24 hours in advance to cancel, unless we both agree that you were unable to attend and unable to provide 24 hours notice due to circumstances beyond your control. In the latter case there will be a $20 late cancellation fee. Otherwise, if you miss or cancel an appointment with less than 24 hours advance notice, you will need to pay for the appointment in full (not just your insurance co-payment). It is important to note that the psychological services I insurance companies almost never provide are not reimbursement for emergency situations. For emergencies, call 911 or go to the nearest emergency roomcancelled sessions. My usual fee is $395 150 for an initial evaluation lasting 90 minutesa 45-minute individual psychotherapy, and $250 for each subsequent psychotherapy session (either in-person hypnosis or over the telephone) lasting 45 minutescouple/family session. In addition to regular appointments, I charge this same $250 per 45-minutes rate 150/hr on a prorated basis for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutessuch as psychological testing, rounded to the nearest 15-minute increment (e.g.preparing letters or other documents, 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 10 minutes, meetings or consultations which you have authorized, review or preparation of records or treatment summaries, and the time spent performing any other service you may request of me. A discounted fee may apply if an insurance plan or Employee Assistance Program in which I participate covers the services. If you become involved in legal proceedings that require my participation, you will be expected to pay for any all of my professional time I spend on your legal mattertime, including preparation and transportation costs, even if the request comes from I am called to testify by another party. I will not voluntarily appear in court on your behalf unless we have discussed the matter thoroughly, and we both agree that the court appearance will not interfere with the treatment relationship. Because of the difficulties of legal involvement, I charge $300 per hour for participation in any legal proceeding, and I generally require payment of all or part of such fees in advance. I can provide you with a detailed schedule of my professional fees in legal matters. You will be expected to pay for each session at the same $250 per 45-minutes ratetime it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. I do not You agree to pay the full charge for time spent writing reports missed appointments, not just the copayment or coinsurance, unless you cancel 24 hours in advance or are unable to cancel 24 hours in advance. If your account has not been paid for more than 60 days and progress notes as per the standard routine of my care of you. I also do arrangements for payment have not charge for any time I may spend collaborating with your other providers. From time to timebeen agreed upon, I have the option of using legal means to secure the payment. This may institute fee increases and these involve using a collection agency or small claims court which will require me to disclose otherwise confidential information. If such legal action is necessary, its costs will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than included in the fee you were previously payingclaim. In additionorder for us to set realistic treatment goals and priorities, if it has been more than one year since our last appointment, is important to evaluate what resources you will be scheduled have available to pay for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companiestreatment. If you decide have a health insurance policy, it is likely to submit claims provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to your insurance company for reimbursement for any out-of-network benefits which you might haveare entitled; however, you may do so. However, be aware that the services provided will still be charged to you, (not your insurance company, and you ) are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coveragepayment of my fees, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), unless this is prohibited by a contract between me and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse youor other healthcare organization that covers your behavioral-health benefits. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, I am not responsible for refunding you any payment you expected to be reimbursed or otherwiseshould call your plan and inquire. Of course, I will provide you a superbill after each session with whatever information I can, based on my experience, and will help you in understanding the following information that you will need to submit to receive from your insurance company. I may be willing to call the company for reimbursement for any out-of-network benefits on your behalf. However, because of the complexity of insurance claim processing, you might have:cannot assume that my understanding of your coverage will always be correct.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist psychotherapist and patientclient, and the particular problems you hope to addressare experiencing. There are many different methods I your therapist may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we you talk about about, both during our while you are at sessions and at homewhen you are not. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our Your first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will your therapist should be able to offer you some first impressions of what our your therapy work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help youyour therapist. Therapy involves can involve a large commitment of time, money, and energy, so you should be very use careful judgment about the therapist you select. If you have questions about my the therapy procedures, we should discuss them with your therapist whenever they arise. If your doubts persist, I we will be happy to help assist you set up a meeting to secure an appropriate consultation with another mental health professional for a second opinion. Please note that the psychological services I provide Appointments are not often scheduled for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 1550-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend sessions on your legal matter, even if the request comes from another party, at the same $250 a once per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do soweek basis. However, be aware that ongoing therapy is a negotiated process between you and the services provided will still be charged to you, not your insurance companytherapist, and frequency of sessions is partially the decision of the client. Both you are responsible for and your therapist should periodically evaluate and discuss the full payment. I have no role in deciding what your insurance coversprogress and the process of therapy, and re-negotiate the need and frequency of further appointments. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etchave the right to terminate therapy at any time. Missed appointments, late cancellations (i.e., cancellations within 24 hours A termination session may be suggested in order to discuss progress made or areas of service)concern, and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for to allow the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you therapist to make any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:recommendations deemed necessary.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressare experiencing. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional psychologist for a second opinion. (Please note initial here after reading this page ) I normally conduct an evaluation that will last from 2 to 4 sessions. During this time, we can both decide if I am the psychological best person to provide the services you need in order to meet your treatment goals. If psychotherapy is begun, I provide are not for emergency situationswill usually schedule one session per week at a time that we agree on. For emergencies60-minute, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes45-minute, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes30- minute sessions are available. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participationOnce an appointment is scheduled, you will be expected to pay for any professional time it unless you provide 24-hours advance notice of cancellation (unless we both agree that you were unable to attend due to circumstances beyond your control.) Due to my work schedule, I spend on your legal matteram often not immediately available by telephone. While I am usually in my office between 12 p.m. to 6:00 p.m., even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge answer the phone when I am with a patient. When I am unavailable, my telephone is answered by voice mail. I return phone calls Monday through Friday from noon to 1 p.m. with the exceptions of holidays and scheduled vacation days. If you are unable to reach me and feel that you can’t wait for time spent writing reports me to return your call, contact your psychiatrist, family physician, nearest emergency room, or Crisis Services of North Alabama at 000 000-0000. The law protects the privacy of all communication between a patient and progress notes a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as per follows: • I may occasionally find it helpful to consult other health and mental health professions about a case. During consultation, I make every effort to avoid revealing the standard routine identity of my care of youpatient. The other professionals are legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I also do not charge for any time I may spend collaborating with will note all consultations in your other providersClinical Record (PHI). From time • Disclosures required to timecollect overdue fees are discussed elsewhere in this Agreement. • If a patient threatens to harm himself/herself, I may institute fee increases be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations where I am permitted or required to disclose information without either your consent or Authorization: • If you are involved in a court proceeding and these will be discussed a request is made for information concerning your diagnosis and agreed upon ahead of time with a new Treatment Contracttreatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or by court order. If it you are involved or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, I may disclose information relevant to that claim to the patient’s employer or the insurer. (Please initial here after reading this page ) There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm, and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice. • If I know or suspect that a child under the age of 18 has been more than one year since our last appointmentabused or neglected, then you will re-initiate services at my current standard fee which the law requires that I file a report with the appropriate governmental agency, usually the Alabama Department of Human Resources. Once such a report is filed, I may be higher than required to provide additional information. • If I know that an elderly or disabled adult has been physically, emotionally or sexually abused, neglected, or exploited, the fee law requires that I file a report with the appropriate governmental agency, usually the Alabama Department of Human Resources. Once such a report is filed, I may be required to provide additional information. • If I believe that disclosing information about you were previously payingis necessary to prevent or lessen a serious and imminent threat to the health and safety of an identifiable person(s), I may disclose that information, but only to those reasonably able to prevent or lessen the threat. If one of these situations arises, I will make every effort to fully discuss it with you before taking any action and I will try to limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should be helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In additionsituations where specific advice is required, if it has been more than one year since our last appointmentformal legal advice may be needed. The laws and standards of my profession require that I keep Protected Health Information about you in your Clinical Record. Except in unusual circumstances that involve danger to yourself or others, you may examine and/or receive a copy of your Clinical Record if you request it in writing. Because these are professional records they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In most situations, I am allowed to charge a copying fee of $1.00 per page (and for certain other expenses). If I refuse your request for access to your records, you have a right of review, which I will be scheduled for another initial evaluation (90 minutes) discuss with you upon request. HIPAA provides you with several new or expanded rights with regard to your Clinical Record and charged accordinglydisclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected health information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session feethe attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. (Please initial here after reading this page ) Please note that only ADA-compliant service dogs are allowed in this office. The Americans with Disabilities Act (ADA) does not in-network with mandate any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations action regarding emotional support animals (i.e., cancellations within 24 hours of serviceESA), and telephone session emotional support animals are not typically covered allowed in this office. Two federal laws, the Fair Housing Act and the Air Carrier Access Act, require reasonable accommodations for ESA in housing and air travel only. Professional offices are not required by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected law to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:allow emotional support animals.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities personality of both the psychologist therapist and patient, the patient and the particular problems which the patient brings. There are a number of different approaches which can be utilized with the problems you hope to address. There are many different methods I may use to deal with those problems. Psychotherapy is not like visiting a medical doctor visit. Insteaddoctor, in that it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. In the process of psychotherapy, there are some predictable experiences. It is common to feel a wide range of feelings. You should not expect to immediately feel better. The process can intensify certain feelings which brought you to therapy. As therapy proceeds, you may begin to question some of your beliefs and attitudes. Strong positive and negative feelings toward this therapist may surface. Share these, as you feel ready. Psychotherapy is more than simply applying a Band-Aid to your emotional wounds. It can be a painful but rewarding process of self-inquiry, which may at times become an all-consuming preoccupation. Feel free to share all of your feelings and thoughts regarding your therapy experiences. At times you may lose interest or question the value of your therapy. This is a natural part of the process and can be a valuable signal of certain issues which may be difficult to deal with. Should you begin to think of terminating or feel that you have reached a plateau and are “stuck,” share these feelings with me so we can deal with them together. A very important part of the therapy process is the relationship we will have together. It is important to be honest and open. You can expect me to demonstrate honesty, concern and the skillful means to help you learn about yourself. The adventure of psychotherapy can be one of the most valuable experiences of your life. Psychotherapy has both benefits and risks. Because therapy often involves discussing unpleasant aspects Risks sometimes include experiencing uncomfortable levels of your life, you may experience uncomfortable feelings like sadness, guilt, angeranxiety, anger and frustration, loneliness, loneliness and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases Psychotherapy often requires recalling unpleasant aspects of treatmentyour life. On the other hand, psychotherapy Psychotherapy has also been shown to have benefits for people who go through undertake it. Therapy It often leads to better relationships, solutions to specific problems, a significant reductions in reduction of feelings of distress, improved sleepresolutions of specific problems, and less fatigue. But better relationships, but there are no guarantees as to about what you will experiencehappen. Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work will include and a an initial treatment plan to followplan, if you decide to continue with me for therapycontinue. You should might evaluate this information along with your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should are wise to be very careful about the therapist you select. If you have questions about my procedures, we should ask to discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting secure an appropriate consultation with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressare experiencing. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially There is no guarantee that entering treatment will reduce your symptoms or resolve your problems in the early phases of treatmentyour desired direction. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have any questions about my procedures, we should discuss them whenever they arise. If Psychotherapy sometimes involves consulting with other professionals, and if necessary, transferring your doubts persistcare to another professional to help you. For example, I do not do court work (such as, but not limited to testifying in divorce and custody disputes, injuries, lawsuits, etc.). So if you need these services I will give you referrals to forensic psychologists who specialize in these cases. I will usually schedule one 50-minute session per week at a time we agree on, although some sessions may be longer or more frequent. If they are shorter or longer for some reason, the fee will be happy adjusted according to help you set up a meeting with another mental health professional the quarter hour. The frequency can vary depending upon need, schedules and finances. The fee for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee regular individual therapy session is $395 for an initial evaluation lasting 90 minutes150 and I accept cash, check and $250 for each subsequent psychotherapy session credit cards (either in-person or over the telephone) lasting 45 minutesVISA & MasterCard). In addition to weekly appointments, I charge this same $250 per 45-minutes rate 150 an hour for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include psychological testing, report writing, telephone conversations or email responses lasting longer than 15 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. I request that you pay the whole fee at the end of each session, unless we have a written agreement otherwise. If you become involved in legal proceedings that require my participationpass a check on insufficient funds, you will be expected liable for the amount of the check and a service charge of twenty- five dollars ($25) for the first check and a thirty-five dollars ($35) service charge for each subsequent check passed on insufficient funds. A scheduled appointment means that time has been reserved only for you. Although it is best to pay for any professional time I spend on your legal matterkeep regular appointments, even if there may be times when you cannot come in. You must call the request comes from another party, above phone number at least 24 hours in advance to cancel the same $250 per 45-minutes rateappointment. I If you do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been cancel more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment24 hours in advance, you will be scheduled charged the full normal fee for another initial evaluation (90 minutes) that session. The exceptions to this policy are sudden major illnesses or accidents in which you may be involved. It is important to note that insurance companies do not pay for missed or late-cancelled appointment fees and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are the patient/responsible party is held fully accountable for paying your full session feethis charge. I am not inhave opted-network out of Medicare in accordance to the Balance Budget Act of 1997 (Section 1802(b) of the Social Security Act). This law allows me to enter into a private contract with any insurance companiesMedicare beneficiaries. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might haveare 65 or older, or will turn 65 within the next year, you may do so. However, will be aware that required to review and sign two copies of the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, preseparate MEDICARE OPT-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwiseOUT CLIENT AGREEMENT provided. I will provide you sign both and we will each keep a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:signed copy.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist Therapist and patient, and the particular problems you hope to addressare experiencing. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please I normally conduct an evaluation that will last from 1 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. Xxxxxxxx will be scheduled at a time and frequency we agree on. Most therapy sessions will last for 45-50 minutes unless we have agreed upon a longer session. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. [If it is possible, I will try to find another time to reschedule the psychological services appointment.] You will be informed as to my current fee schedule regarding the initial diagnostic interview session, follow up 45-50 minute therapy sessions and other services. I provide are not for emergency situationsonly accept payment in the form of check or cash. For emergenciesPlease make checks payable to “Xxxxxx Xxxxxx, call 911 or go to the nearest emergency room. Ph.D.” My fee is $395 schedule provides a listing of rates for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include report writing, telephone conversations or email responses lasting longer than 15 10 minutes, consulting with other professionals with your permission, preparation of records of treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any all of my professional time I spend on your legal mattertime, including preparation and transportation costs, even if the request comes from I am called to testify by another party. [Because of the difficulty of legal involvement, at the same I charge $250 per 45-minutes ratehour for preparation and attendance at any legal proceeding.] Due to my work schedule, I am often not immediately available by telephone. My telephone is answered by my confidential voice mail system. I do not charge for time spent writing reports will make every effort to return your call on the same day you make it, with the exception of weekends and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contractholidays. If it has been more than one year since our last appointmentyou are difficult to reach, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, please inform me of some times when you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companiesavailable. If you decide have an emergency, call 000-000-0000 and follow the voice mail prompts. The answering service will assist you. The answering service will attempt to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do soreach me. However, be aware that the services provided will still be charged to you, not your insurance company, and If you are responsible unable to reach me and feel that you can’t wait for me to return your call, contact your physician or the nearest emergency room and ask for the full paymentpsychologist or psychiatrist on call. If you have a life-threatening emergency, call 911. If I have no role in deciding what will be unavailable for an extended time, we may discuss your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible need for the full session fee name of a colleague to contact in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:my absence.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. THE PROCESS OF THERAPY The therapy process can be very helpful in promoting and enhancing emotional well-being, such as improving interpersonal relationships and resolving issues and concerns that led you to seek therapy. Motivation is a key factor that predicts improvement; therefore, it requires your active involvement and openness in order to create change. The therapy process involves various stages, including assessment and exploration, goal setting, working stage, and termination. Each of the stages may use need to deal with those problemsbe revised from time to time as the process and issues unfold. While the benefits of therapy are tremendous, there are some risks that can cause pain or discomfort despite its benefit. Psychotherapy may result in behavior and lifestyle changes that have the possibility of being seen as negative by someone you closely relate to. There is not like no guarantee that psychotherapy will yield positive or intended results. Within a medical doctor visit. Instead, it calls for a very active effort on your part. In order for reasonable period of time after the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases initiation of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer discuss with you some first impressions my understanding of what our work might involve. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note APPOINTMENTS Appointments will ordinarily be 50 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours notice. If you miss a session without canceling, or cancel with less than 24 hour notice, my policy is to collect the psychological services I provide are not full amount. PROFESSIONAL FEES The standard fee for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee each session is $395 175.00. You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by check, credit card or cash. Any checks returned to my office are subject to an initial evaluation lasting 90 minutesadditional fee of up to $25.00 to cover the bank fee that I incur. If you refuse to pay your debt, and $250 for each subsequent psychotherapy session (either in-person I reserve the right to use an attorney or over the telephone) lasting 45 minutescollection agency to secure payment. I In addition to weekly appointments, it is my practice to charge this same $250 per 45-minutes rate amount on a prorated basis (I will break down the hourly cost) for other professional services that you may needrequire such as report writing, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting that last longer than 15 minutes, and attendance at meetings or consultations which you have requested, or the time spent performing required to perform any other service which you may request of me. If you become anticipate becoming involved in legal proceedings a court case, I recommend that require we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for any the professional time I spend on your legal matter, required even if another party compels me to testify. PROFESSIONAL RECORDS I am required to keep appropriate records of the request comes from another party, at psychological services that I provide. Your records are maintained in a secure location in the same $250 per 45-minutes rateoffice. I do not charge keep brief records noting that you were here, your reasons for time spent writing reports seeking therapy, the goals and progress notes as per the standard routine of my care of you. we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records I also do not charge for any time I may spend collaborating with your receive from other providers, copies of records I send to others, and your billing records. From time Except in unusual circumstances that involve danger to timeyourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and / or upsetting to untrained readers. For this reason, I may institute fee increases and these will be discussed and agreed upon ahead of time recommend that you initially review them with a new Treatment Contractme, or have them forwarded to another mental health professional to discuss the contents. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointmentI refuse your request for access to your records, you have a right to have my decision reviewed by another mental health professional , which I will be scheduled for another initial evaluation (90 minutes) and charged accordingly, discuss with subsequent 45-minute psychotherapy sessions thereafteryou upon your request. You are responsible for paying also have the right to request that a copy of your full session fee. I am not in-network with file be made available to any insurance companies. If you decide to submit claims to other health care provider at your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:written request.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressare experiencing. There are many different methods I your doctor may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I your doctor will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help youyour doctor. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my our procedures, we you and your doctor should discuss them whenever they arise. If your doubts persist, I your doctor will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide Our professional fees are not $198.00 for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, a 45 minute session and $250 298.00 for each subsequent psychotherapy a 60 minute session (either in-person or over the telephone) lasting 45 minutesplus general excise tax. I charge In addition to appointments, your doctor charges this same $250 per 45-minutes rate amount for other professional services you may need, though I your doctor will prorate break down the hourly cost if I work s/he works for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes)one hour. Other professional services include report writing, telephone conversations or email responses lasting longer than 15 10 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of mehim/her. If you become involved in legal proceedings that require my requires your doctor’s participation, you will be expected to pay for any all of his/her professional time I spend on your legal mattertime, including preparation and transportation costs, even if the request comes from your doctor is called to testify by another party. Because of the difficulty of legal involvement, your doctor charges $200.00 to $350.00 plus general excise tax per hour for preparation and attendance at any legal proceeding. Due to his/her work schedule, your doctor is often not immediately available by telephone. When s/he is in the same $250 per 45-minutes rateoffice during regular business hours the telephone is answered by the office staff or by voice mail that is monitored frequently. I do not charge for time spent writing reports Your doctor will make every effort to return your call within 48 hours, with the exception of weekends and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contractholidays. If it has been more than one year since our last appointmentyou are difficult to reach, then you will re-initiate services at my current standard fee which may be higher than please inform the fee you were previously paying. In addition, if it has been more than one year since our last appointment, office of times when you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companiesavailable. If you decide have a crisis contact the Crisis Line at 000-0000, dial 911 or go to submit claims the nearest emergency room. If your doctor will be unavailable for an extended time, s/he will provide you with the name of a colleague to contact, if necessary. The law protects the privacy of all communications between a patient and a psychologist. In most situations, your doctor can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows:  Your doctor may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, your doctor will make every effort to avoid revealing the identity of his/her patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, your doctor will not tell you about these consultations unless s/he feels that it is important to the work you do together. Your doctor will note all consultations in your Clinical Record (which is called “PHI” in his/her Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information).  You should be aware that your doctor practices with other mental health professionals and that s/he employs administrative staff. In most cases, your doctor needs to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member.  Your doctor also has contracts with professional business service providers such as an accountant and Information Technology consultant. As required by HIPAA, your doctor has a formal business associate contract with this/these business(es), in which it/they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, your doctor can provide you with the names of these organizations and/or a blank copy of this contract.  Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.  If a patient threatens to harm himself/herself, your doctor may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations where your doctor is permitted or required to disclose information without either your consent or Authorization:  If you are involved in a court proceeding and a request is made for information concerning my professional services, such information is protected by the psychologist-patient privilege law. Your doctor cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order your doctor to disclose information.  If a government agency is requesting the information for health oversight activities, your doctor is required to provide it for them.  If a patient files a complaint or lawsuit against the doctor, s/he may disclose relevant information regarding that patient in order to defend him/her.  If a patient files a worker’s compensation claim, your doctor may be required to file a report of the patient’s injury or treatment. There are some situations in which your doctor is legally obligated to take actions, which s/he believes are necessary to attempt to protect others from harm and s/he may have to reveal some information about a patient’s treatment. These situations are unusual in our clinic.  If your doctor has reason to believe that child abuse or neglect has occurred or that there exists a substantial risk that child abuse or neglect may occur in the reasonably foreseeable future, the law requires that s/he file a report with the appropriate governmental agency, usually the Department of Human Services. Once such a report is filed, your doctor may be required to provide additional information.  If your doctor has reason to know or has reason to believe that a dependent adult has been abused and is threatened with imminent abuse, the law requires that s/he file a report with the appropriate governmental agency, usually the Department of Human Services. Once such a report is filed, s/he may be required to provide additional information.  If a patient indicates that s/he presents a clear and imminent danger of violence to an individual or to society, your doctor may be required to take protective actions. These actions may include notifying appropriate professional workers, contacting the police, or seeking hospitalization for the patient. If such a situation arises, your doctor will make every effort to fully discuss it with you before taking any action and s/he will limit disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and your doctor is not an attorney. In situations where specific advice is required, formal legal advice may be needed. You should be aware that, pursuant to HIPAA, your doctor keeps Protected Health Information about you in your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that s/he receives from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance company for reimbursement for any out-of-network benefits you might havecarrier. Except in unusual circumstances that involve danger to yourself and others or makes reference to another person (unless such other person is a health care provider) and your doctor believes that access is reasonably likely to cause substantial harm to such other person, you may do soexamine and/or receive a copy of your Clinical Record, if you request it in writing. HoweverBecause these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, your doctor recommends that you initially review them in his/her presence, or have them forwarded to another mental health professional so you can discuss the contents. In most situations, your doctor is allowed to charge a copying fee of $1.00 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If your doctor refuses your request for access to your records, you have a right of review except for information provided to him/her confidentially by others, which s/he will discuss with you upon your request. HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that your doctor amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our clinic’s policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and our privacy policies and procedures. Your doctor is happy to discuss any of these rights with you. Patients under 18 years of age who are not emancipated and their parents should be aware that the services provided law allows parents to examine their child’s treatment records unless the doctor decides that such access is likely to injure the child or we agree otherwise. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes our policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, the doctor will still be charged to you, not your insurance companyprovide them only with general information about the progress of the child’s treatment, and you are responsible for his/her attendance at scheduled sessions. The doctor will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the full paymentchild’s Authorization, unless the doctor feels that the child is in danger or is a danger to someone else, in which case, s/he will notify the parents of his/her concern. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverageBefore giving parents any information, deductiblesthe doctor will discuss the matter with the child, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service)if possible, and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for do his/her best to handle any objections the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might child may have:.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of interactive exchange between you and the psychologist and patientPsychologist or Psychological Associate to identify, express, and the particular problems resolve significant issues causing distress for you hope to addressor others. There are many This process is different methods I may use to deal with those problems. Psychotherapy is not like than visiting a medical doctor visitin that it requires active participation by the client. Instead, it calls for a very active effort on your part. In order for For the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects Therapy varies depending on the personalities of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, lonelinessthe Psychologist or Psychological Associate, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleeppatient, and less fatiguethe problems you bring forward. But there There are no guarantees many different methods a Psychologist or Psychological Associate may use to deal with the problems and as the client you are encouraged to what you will experienceask questions and discuss approaches with the Psychologist or Psychological Associate. Our first session few sessions will involve an evaluation or diagnostic assessment conducted initially to gain an overall perspective of your needsemotional, cognitive, behavioral, somatic, and relational functioning. Some psychological testing may be used in this process to examine your reasons for seeking psychological services, your current situation, past experiences, and any referral information. A treatment plan will be developed for you to identify goals and methods of therapy that will be used in helping you achieve these goals. A diagnosis is developed which is a means of describing symptoms and is useful in communicating your emotional, cognitive, and behavioral state to other professionals, planning treatment options, and for you to obtain financial reimbursement from third- party payers should you choose to submit your costs for reimbursement. By the end of the evaluation, I your Psychologist or Psychological Associate will be able to offer you some first impressions of what our work will include and a treatment plan to follow, follow if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help youPsychologist or Psychological Associate. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my proceduresthe treatment process, we should please discuss them whenever they arise. If necessary, your doubts persist, I will be happy Psychologist or Psychological Associate can assist in a referral to help another professional if that is your desire. If you set up a meeting with are already seeing another mental health professional for a second opinion. Please note that the psychological professional, please inform your therapist so services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will can be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companiescoordinated. If you decide to submit claims discontinue therapy, please inform your therapist. The period for which informed consent is effective shall not exceed 15 months from the time the consent is given and signed. The client has the right to withdraw the informed consent at any given time by submitting a written request. Psychotherapy has both benefits and risks. But there are no guarantees of what you will experience. Risks sometimes include experiencing uncomfortable levels of feelings, such as sadness, guilt, anxiety, anger, grief, frustration, loneliness, or helplessness. Psychotherapy often requires recalling and focusing on unpleasant aspects of your history. Psychotherapy has also been shown to have benefits for people who undertake it; this often leads to a significant reduction in feelings of distress, improved relationships, and more effective problem-solving skills. Every effort will be made to obtain the goals set forth in the treatment plan. It is often important to draw upon support from your family, friends, and community resources. In some cases, especially with children, an increase in disruptive behaviors may develop while confronting this distress. Safety is important, especially when confronting issues of relationships. It may be necessary to address this safety before beginning therapy; this is especially true for domestic violence, child neglect, and sexual, physical, or emotional abuse situations. You authorize contact at your home address and by letter or telephone unless you have requested not to do so in writing. It is sometimes necessary for the therapist to reschedule an appointment, send billing information and other correspondence may be sent to your insurance company for reimbursement for any out-of-network benefits home. In some cases, where safety is an issue, it is best not to contact you might have, you may do soat your home. However, be aware that the services provided will still be charged to you, not Please let your insurance company, and you are responsible for the full payment. I have no role in deciding what Psychologist or Psychological Associate know your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:preference.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressbring forward. There are many different methods I your clinician may use to deal with those problemsthe problems that you hope to address. We draw on a number of approaches including, but not limited to, cognitive-behavioral, psychodynamic, humanistic-existential, family systems, emotionally-focused therapy, and eye-movement desensitization and reprocessing (EMDR). Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. You should evaluate this information along with your own opinions of whether you feel comfortable working with your clinician. Therapy involves a large commitment of time, money, and energy, so you should be selective about the therapist you choose. If you have questions about our procedures, please discuss them with your clinician whenever they arise. If your doubts persist, your clinician will be happy to help you set up a meeting with another mental health professional for a second opinion. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But but there are no guarantees as to of what you will experience. Our The first session 2 to 4 sessions will involve an evaluation of your needs. By the end of the evaluation, I your clinician will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate During this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluationtime, I will notify you if I believe that I am not the right therapist for you and your clinician can both decide if so, I will give that person the best person to provide the services you referrals need in order to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you selectmeet your treatment goals. If you have questions about my proceduresare being seen for couples/relationship therapy, we should the first session typically occurs between the couple, followed by 1-2 individual sessions with each partner, before resuming conjoint sessions to discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, treatment planning and $250 for each begin subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of metreatment. If you become involved are being seen for psychological evaluation, the initial session involves obtaining a thorough history, followed by several multi-hour sessions involving face-to-face test administration, and a feedback session 3-4 weeks later to review evaluation results. The feedback session is scheduled at a later date to provide us with appropriate time to score and interpret test data as well as complete the report. Please note, feedback sessions will not be scheduled until all necessary forms, including parent and teacher questionnaires, are completed and returned to your clinician. If psychotherapy begins, your clinician will usually schedule one 55-minute session (one appointment hour of 55 minutes duration) per week at a time you and your therapist agree on, although some sessions may be longer or more frequent. Sessions will need to end promptly in legal proceedings that require my participationorder for the therapist to document the session, return phone calls, etc. Once an appointment hour is scheduled, you will be expected responsible for paying for it unless you provide 24 hour advance notice of cancellation. If you are able to pay for any professional time I spend on your legal matter, even if reschedule the request comes from another party, at appointment within the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointmentweek, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to youfor your missed appointment. Your first late cancelation/no show within one calendar year is not charged, not your insurance companygiven a variety of circumstances can occur. A second late cancelation/no show within a calendar year is charged at half of the typical session rate, and you third and subsequent late cancelations/no shows in a calendar year are responsible for charged at the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone typical session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:rate.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first few sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persistpersist or if you wish to terminate the relationship, I will be happy to help you set up a meeting with another mental health professional professional. APPOINTMENTS Appointments will ordinarily be 45-50 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a second opinionsession, I ask that you provide me with 24 hours-notice. Please note If you miss a session without canceling, or cancel with less than 24 hour notice, my policy is to collect the amount designated on the financial agreement (depending on the source of funding for your treatment), unless we both agree that you were unable to attend due to circumstances beyond your control. If it is possible, I will try to find another time to reschedule the psychological services I provide appointment. In addition, you are not responsible for emergency situationscoming to your session on time; if you are late, your appointment will still need to end on time. For emergenciesPROFESSIONAL FEES If you are self-paying, call 911 or go to the nearest emergency room. My standard fee for the initial intake is $395 for an initial evaluation lasting 90 minutes, 100.00 and $250 for each subsequent psychotherapy session (either in-person is $100.00. You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by credit card or over the telephone) lasting 45 minutescash. I In addition to weekly appointments, it is my practice to charge this same you $250 100 per 45-minutes rate hour for other professional services that you may needrequire such as report writing, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting that last longer than 15 minutes, and attendance at meetings or consultations which you have requested, or the time spent performing required to perform any other service which you may request of me. If you become anticipate becoming involved in legal proceedings a court case, I recommend that require we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for any the professional time I spend on your legal matter, required even if another party compels me to testify. PROFESSIONAL RECORDS I am required to keep clinical records of the request comes from another party, psychological services that I provide. Your records are maintained in a secure location in the office and will be kept for at the same $250 per 45-minutes rateleast seven years. I do not charge keep brief records noting that you were here, your reasons for time spent writing reports seeking therapy, the goals and progress notes as per the standard routine of my care of you. we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records I also do not charge for any time I may spend collaborating with your receive from other providers, copies of records I send to others, and your billing records. From time Except in unusual circumstances that involve danger to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointmentyourself, you will be scheduled for another initial evaluation (90 minutes) have the right to a copy of your file. These records are not transcripts of the visits we have and charged accordinglyare not intended to be, with subsequent 45-minute psychotherapy sessions thereafterbut contain my overall impressions and summaries. You are responsible for paying also have the right to request that a copy of your full session fee. I am not in-network with file be made available to any insurance companies. If you decide to submit claims to other health care provider at your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:written request.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods also legal limitations to those rights that you should be aware of. As your therapist, I have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. However, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first 1-3 sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy glad to help you set up a meeting with another mental health professional for a second opinionopinion or to obtain their services for subsequent care. Please Appointments will ordinarily be 45-50 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours notice. If you miss a session without canceling, or cancel with less than 24-hour notice, my policy is to collect the full session amount [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the psychological services portion of the fee as described above. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still end on time. If you have no-showed and have not scheduled an appointment after 30 days, I provide will assume you are ending treatment and may close your file at that time. I will consider you no longer an active client if 1) 60 days have passed, 2) you do not have an appointment with me, and 3) you have not responded to my three attempts to reach you via phone or email. You may contact me to set up an appointment to become an active client again. The fees per session are as follows: $170 for emergency situations. For emergenciesa 45-minute neurofeedback session, call 911 or go to the nearest emergency room. My fee is $395 200 for an initial evaluation lasting 90 minutesa 45-minute psychotherapy session, and $250 265 for each subsequent psychotherapy a 60-minute individual, couples, or family session. You are responsible for paying at the time of your session (either in-person unless we have discussed prior arrangements via cash, check, credit card, or over automatic bank payment processing. Any checks returned to my office are subject to an additional fee of up to $25.00 to cover the telephone) lasting 45 minutesbank fee incurred. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment. In addition to weekly appointments, I charge this same $250 per 45-minutes rate amount on a prorated basis for other professional services that you may needrequire such as report writing, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting that last longer than 15 minutes, and attendance at meetings or consultations which you have requested, or the time spent performing required to perform any other service which you may request of me. If you become anticipate becoming involved in legal proceedings a court case, I recommend that require we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for any the professional time I spend on your legal matter, required even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time party compels me to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:testify.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patientDuring our first few sessions, and the particular problems you hope to address. There are many different methods I may use to deal with those problems. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you we will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause discuss what brought you to experience increased sleepiness and fatigue, especially in the early phases of treatmenttherapy. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you These sessions will experience. Our first session will involve an evaluation of your needstypically include informal (unstructured) assessment. By the end of the evaluation, I we will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you selectyour doctor. If you have questions about my our procedures, we should discuss them whenever they arise. If A few things to remember: ∙ Psychotherapy is not like a medical doctor visit. It calls for a very active effort on your doubts persistpart. You will likely have "homework" to complete between sessions. ∙ Sometimes undesirable behaviors increase in intensity before they lessen when you start addressing them. This is normal and usually temporary. ∙ Psychotherapy can have benefits and risks. These may vary depending on your reason for coming to therapy. While there are no guarantees of what you will experience, I will most people benefit from therapy. Benefits may include improved sleep, better relationships, solutions to specific problems, and significant reductions in feelings of distress. However, because therapy may involve discussing challenging aspects of your life, you could at times experience difficult emotions or discomfort. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a patient and a psychologist. In most situations, we can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows:  You should be happy to help you set up a meeting with another aware that the office includes other mental health professionals and administrative staff. In most cases, we need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality.  We have a contract with Medical Billing Associates. As required by HIPAA, we have a formal business associate contract with this business, in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, we can provide you with a blank copy of this contract.  Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.  If a patient threatens to harm himself/herself, the doctor may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. There are some situations where your doctor is permitted or required to disclose information without either your consent or Authorization:  If you are involved in a court proceeding and a request is made for information concerning our professional for services, such information is protected by the psychologist-patient privilege law. We cannot provide any information without your written authorization, or a second opinioncourt order. Please note that the psychological services I provide If you are not for emergency situationsinvolved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information. For emergencies, call 911 or go If you do request your information to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes be shared in increments of 15 minutes, rounded to the nearest 15-minute increment a legal matter (e.g., 22 minutes Social Security Case, Xxxxxxx'x Comp Case prior to the claim decision, divorce or other proceedings), a charge of service $185.00/hour will be charged applied for 15 minutes whereas 23 minutes preparation of service will a clinical summary, as it is our policy not to share  If a government agency is requesting the information for health oversight activities, we may be charged required to provide it for 30 minutes)them. Other professional services include telephone conversations  If a patient files a complaint or email responses lasting longer than 15 minuteslawsuit against either doctor or the practice, we may disclose relevant information regarding that patient in order to defend ourselves.  If a patient files a worker’s compensation claim, and we are providing treatment related to the time spent performing any claim, we must, upon appropriate request, furnish copies of all medical reports and bills. There are some situations in which we are legally obligated to take actions, which we believe are necessary to attempt to protect others from harm and we may have to reveal some information about a patient’s treatment. These situations are unusual in this practice.  If your doctor has reason to believe that a child has been abused, the law requires that she file a report with the appropriate governmental agency, usually the Department of Human Resources. Once such a report is filed, we may be required to provide additional information.  If your doctor has reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or elder person, other service you than by accidental means, or has been neglected or exploited, she must report to an agency designated by the Department of Human Resources. Once such a report is filed, she may request be required to provide additional information.  If your doctor determines that a patient presents a serious danger of meviolence to another, she may be required to take protective actions. These actions may include notifying the potential victim, and/or contacting the police, and/or seeking hospitalization for the patient. If such a situation arises, your doctor will make every effort to fully discuss it with you become involved before taking any action and she will limit her disclosure to what is necessary. PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that your doctor amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about policies and procedures recorded in legal proceedings that require my participationyour records; and the right to a paper copy of this Agreement, you the attached Notice form, and our privacy policies and procedures. We are happy to discuss any of these rights with you. BILLING AND PAYMENTS You will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, each session at the same $250 per 45-minutes ratetime it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. I do not charge Payment schedules for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these professional services will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You to when they are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instancesrequested. If your insurance company doesn’t reimburse youaccount has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I am not responsible for refunding you any payment you expected we have the option of using legal means to be reimbursed secure the payment. This may involve hiring a collection agency or otherwisegoing through small claims court which will require us to disclose otherwise confidential information. I will provide you In most collection situations, the only information we release regarding a superbill after each session with patient’s treatment is his/her name, the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:nature of services provided, and the amount due. INTERNET CONTACT

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statementsa confidential exploration, discussion and mutually agreed upon plan for change. It varies depending on You and the personalities of therapist will define the psychologist and patientproblem, possible causes, and several treatment approaches. The risks of treatment will be discussed. You and the particular problems you hope to address. There are many different methods I may use to deal with those problemstherapist will discuss what helps solve the challenge and what isn’t working. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very is active effort on your part. In order for , often with homework assignments to clarify what is discussed during the therapy to be most successful, you will have to work on things we talk about both during our sessions and at homeoffice sessions. Psychotherapy can have has benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specificallyHowever, therapy might cause you to research on the efficacy of psychotherapy outweighs the temporary feelings of distress one may experience increased sleepiness and fatigue, especially in the early phases of treatmentwhile working on emotional challenges. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy Psychotherapy often leads to better relationships, solutions to specific problems, and significant reductions reduction in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will may experience. Our The first session few sessions will involve an evaluation of be assessment and treatment planning. During this time, you and the therapist decide if they are the best person to provide the service that you need in order to meet your needstreatment goals. By the end of these first few sessions, the evaluation, I therapist will be able to offer you some first preliminary impressions of your problem, what our the work will include include, and a treatment plan and treatment modality to follow, decide if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help youtherapist. Therapy involves a large commitment of time, money, money and energy, energy so you should need to be very careful about the therapist you selectselection of your therapist. If you have questions about my the therapist’s procedures, we should discuss please bring them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of metheir attention. If you become involved in legal proceedings that require my participationwant a second opinion regarding your diagnosis or treatment, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I therapist will provide you a superbill after with names of other professionals. Once psychotherapy has begun, you and the therapist determine the intervals between sessions that best support the treatment plan. Sessions are 50 minutes, unless you schedule additional time. Your commitment to the therapeutic process is crucial and is demonstrated by your understanding and written agreement to the following. Please initial by each session with item representing your having read, understood, and agreed to the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:content therein.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressare experiencing. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy Your active participation is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at homealso an essential part of treatment. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our first session will involve an evaluation At the beginning of your needs. By the end of the evaluation, therapy I will be able to offer evaluating your needs and getting information from you some first impressions about your history and reasons for seeking therapy. Based on that, we will discuss the general plan for treatment, including an estimate of what our work will include and a treatment plan to follow, if you decide to continue with me for therapyduration. You should evaluate this information along with your own opinions about of whether you feel comfortable working with meme and whether the cost and time involved are manageable. At If you will be using insurance, we should also make sure we understand the end details of the evaluation, I what it will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help youcover (see “Insurance Reimbursement” below). Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please I will usually schedule one 50-minute session (one appointment hour of 50 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 48 hours advance notice of cancellation. It is important to note that the psychological services I insurance companies do not provide are not reimbursement for emergency situationscanceled sessions. For emergencies, call 911 or go to the nearest emergency room. My fee An initial consultation is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or generally scheduled over the telephone) lasting 45 minutesphone. Fees for this initial consultation and subsequent services may be discussed at this time or during our first meeting. Please be sure to ask for clarification for any questions you might have regarding my professional fees. In addition to weekly appointments, I charge this same $250 per 45-minutes rate the hourly session fee for other professional services you may need, though I will prorate break down the hourly cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes)one hour. Other professional services include report writing, telephone conversations or email responses lasting longer than 15 5 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first 1-3 sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note APPOINTMENTS Appointments will ordinarily be 45-50 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours notice. If you miss a session without canceling, or cancel with less than 24 hour notice, my policy is to collect my fee [unless we both agree that you were unable to attend due to circumstances beyond your control]. If it is possible, I will try to find another time to reschedule the psychological services I provide appointment. In addition, you are not responsible for emergency situationscoming to your session on time; if you are late, your appointment will still need to end on time. For emergencies, call 911 or go to PROFESSIONAL FEES The standard fee for the nearest emergency room. My fee initial intake is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session is $90. You are responsible for paying at the time of your session unless prior arrangements have been made. Payment may be made by cash or check; I am also able to process credit card charges as payment (either in-person MasterCard or over Visa). Any checks returned to my office are subject to an additional fee of up to $25.00 to cover the telephone) lasting 45 minutesbank fee that I incur. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment. In addition to weekly appointments, it is my practice to charge this same $250 per 45-minutes rate amount (I will break down the hourly cost) for other professional services that you may needrequire such as report writing, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting that last longer than 15 minutes, and attendance at meetings or consultations which you have requested, or the time spent performing required to perform any other service which you may request of me. If you become anticipate becoming involved in legal proceedings a court case, I recommend that require we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for any the professional time required even if another party compels me to testify. My charge for court appearance is $150, including travel time, waiting time and appearance time. PROFESSIONAL RECORDS I spend on am required to keep appropriate records of the psychological services that I provide. Your records are maintained in a secure location in the office. I keep brief records noting that you were here, your reasons for seeking therapy, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records I receive from other providers, copies of records I send to others, and your billing records. You have the right to review or request a copy of your file. Because these are professional records, they may be misinterpreted and / or upsetting to untrained readers. For this reason, I recommend that you initially review them with me. You also have the right to request that a copy of your file be made available to any other health care provider at your written request. In some circumstances, I have the right to refuse your inspection or request for a copy of your file. Should I deny your right to inspect or copy your records, you will receive, in writing, the reason for the denial. CONFIDENTIALITY In general, the privacy of all communications between a patient and a psychologist is protected by law, and I can only release information about our work to others with your written permission. But there are a few exceptions. In most legal matterproceedings, you have the right to prevent me from providing any information about your treatment. In some proceedings involving child custody and those in which your emotional condition is an important issue, a judge may order my testimony if he/she determines that the issues demand it. There are some situations in which I am legally obligated to take action to protect others from harm, even if I have to reveal some information about a patient's treatment. For example, if I believe that a child [elderly person, or disabled person] is being abused, I must file a report with the appropriate state agency. If I believe that a patient is threatening serious bodily harm to another, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient. If the patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. These situations have rarely occurred in my practice. If a similar situation occurs, I will make every effort to fully discuss it with you before taking any action. I may occasionally find it helpful to consult other professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The consultant is also legally bound to keep the information confidential. If you don't object, I will not tell you about these consultations unless I feel that it is important to our work together. PARENTS & MINORS While privacy in therapy is crucial to successful progress, parental involvement can also be essential. It is my policy not to provide treatment to a child under age 13 unless s/he agrees that I can share whatever information I consider necessary with a parent. For children 14 and older, I request comes from another partyan agreement between the client and the parents allowing me to share general information about treatment progress and attendance, at as well as a treatment summary upon completion of therapy. All other communication will require the same $250 per 45-minutes ratechild’s agreement, unless I feel there is a safety concern (see also above section on Confidentiality for exceptions), in which case I will make every effort to notify the child of my intention to disclose information ahead of time and make every effort to handle any objections that are raised. [See sample Adolescent Consent Form, to be signed by both adolescent and parent(s).] CONTACTING ME I am often not immediately available by telephone. I do not charge for time spent writing reports and progress notes as per the standard routine of answer my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. phone when I am not in-network with any insurance companiesclients or otherwise unavailable. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might haveAt these times, you may leave a message on my confidential voice mail and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters. If, for any number of unseen reasons, you do so. However, be aware that the services provided will still be charged not hear from me or I am unable to reach you, not your insurance company, and you are responsible feel you cannot wait for a return call or if you feel unable to keep yourself safe, 1) contact El Dorado County Mental Health in Diamond Springs at 530 621-6290 2) go to your Local Hospital Emergency Room, or 3) call 911 and ask to speak to the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwisemental health worker on call. I will make every attempt to inform you in advance of planned absences, and provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:name and phone number of the mental health professional covering my practice.

PSYCHOLOGICAL SERVICES. The psychological services that are provided at Xxxxx Creek Psychology include psychotherapy as well as psychological and neuropsychological testing. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patientclient, and the particular problems you hope to addressare experiencing. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you or your child will have to work on things we talk about both during our sessions and at home. Psychotherapy and psychological/neuropsychological assessment can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy and assessment has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. Assessment can lead to a greater understanding of the child’s problems and lead to recommendations to improve functioning at home, improved sleepschool, and less fatigueor socially. But there are no guarantees as to of what you will experience. Our For psychotherapy, our first session few sessions will involve an evaluation assessment of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting obtain an appropriate consultation with another mental health professional professional. If your child is here for psychological and neuropsychological testing, you have the right to an explanation of what the test or tests being administered are for. You also have the right to a summary of the test results. I do not serve as an advocate for clients obtaining or keeping disability or in legal matters such as lawsuits, custody evaluations, divorce proceedings or criminal cases. Information will be released with your written permission and direction as determined appropriate for a second opinionsituation. Please note You will be expected to pay for all of my professional time, including preparation and transportation costs, if I am court ordered to participate in a specific case. No insurance reimbursement will be applicable to that the psychological time and my fees for legal services I provide are not for emergency situationswill be greater than customary fees. For emergenciespsychotherapy, call 911 I normally conduct an assessment that will last from 2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you or go your child need in order to the nearest emergency roommeet your treatment goals. My fee is $395 Each session usually lasts for an initial evaluation lasting 90 45 to 50 minutes, and $250 for each subsequent psychotherapy is typically scheduled once per week, although some sessions may be longer or more frequent. For testing services, the first 50 minute session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though will be a diagnostic interview during which I will prorate gather background information and discuss the cost if I work concerns you have about your child with you. The second session will be the evaluation, which typically will last between two and five hours, depending on the particular problems identified as well as the age and developmental level of the child. Following the evaluation, a feedback session will be conducted, which will last for periods of less than 45 minutes in increments of 15 50 minutes, rounded to during which the nearest 15-minute increment (e.g., 22 minutes results of service testing and recommendations will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes)discussed. Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participationOnce an appointment is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. If we do not have any professional contact with you in six months, our therapeutic relationship will be terminated, and your file will be closed. After this time period, you are welcome to contact us to discuss restarting your treatment. Due to my work schedule, I spend on your legal matteram often not immediately available by telephone. While I am usually in my office regular hours, even if I probably will not answer the request comes from another partyphone when I am with a client. When I am unavailable, at the same $250 per 45-minutes ratemy telephone is answered by voice mail that I monitor frequently. I do not charge will make every effort to return your call within 24 to 48 hours, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If I will be unavailable for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to an extended time, I may institute fee increases and these will be discussed and agreed upon ahead of time with have a new Treatment Contract. If it has been more than one year since our last appointment, then colleague available for you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In additionto contact, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companiesnecessary. If you decide are unable to submit claims to reach me and have a mental health emergency, contact your insurance company for reimbursement for any out-of-network benefits you might havefamily physician, you may do so. Howeveror call 911, be aware that or call the services provided will still be charged to you, not your insurance company, nearest emergency room and you are responsible ask for the full payment. I have no role in deciding what your insurance coverspsychologist or psychiatrist on-call. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours can also contact one of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company mental health emergency resources: Ridgeview Institute at 000-000-0000, Peachford Hospital at 000-000-0000, or Summitridge Center for reimbursement for any outPsychiatry and Addictions at 000-of000-network benefits you might have:0000.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patientclient(s), and the particular problems you hope to addressare experiencing. There are many different methods I may use to deal with those problemsthe problems you hope to address for yourself, your family, or on behalf of your minor. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you you, your family or your minor will have to work on things we talk about both during our sessions the session and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves thinking about and discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, loneliness and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. However, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our first session will involve an evaluation of your needs, whether it is for individual therapy, family therapy or therapy of a minor for whom you have legal custody. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, money and energy, so you should be very careful about the therapist you select. If you have questions or concerns about my proceduresanything that happens in therapy, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please You can also request that I refer you to someone else if you decide that I am not the right therapist for you. I normally conduct a clinical evaluation that will last from 2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If psychotherapy is begun, I will usually schedule one appointment hour of 45 to 50 minutes duration per week at a time we agree on, although some sessions may be longer or more/less frequent. You are responsible for coming to your session on time and at the time we have scheduled. If you are late, we will end on time and not run over into the next person’s session. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours notice of cancellation, except in the case of sudden illness, injury, or severe weather conditions. It is important to note that insurance companies or school districts do not provide reimbursement for cancelled sessions. If it is possible, I will try to find another time to reschedule the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to appointment in the nearest emergency roomsame week. My fee is $395 200.00 for an the initial evaluation lasting 90 minutes, (usually our first meeting) and $250 175.00 for each subsequent psychotherapy 45- 50 minute session (either in-person or over the telephone) lasting 45 minutesthereafter. In addition to weekly appointments, I charge this same $250 per 45-minutes rate amount for other professional services you may need, though I will prorate break down the hourly cost if I work for periods of less than 45 minutes in increments of 15 one hour. Other services include report writing, telephone conversations lasting longer than 10 minutes, rounded to the nearest 15-minute increment consulting with other professionals or organizations (e.g., 22 minutes schools) with your authorization, preparation of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations records or email responses lasting longer than 15 minutes, treatment summaries and the time spent performing any other service services you may request of me. If you, your family, or your minor for whom you become have legal custody becomes involved in legal proceedings that might require my participation, you will be expected to pay for any all of my professional time I spend on your legal mattertime, including preparation and transportation costs, even if the request comes from am called to testify by another party. Because of the difficulty of legal involvement, I charge $375.00 per hour for preparation, travel and attendance at any legal proceeding. Be informed that insurance companies generally do not reimburse for court related costs, making you fully responsible for the same $250 per 45-minutes ratecost of these services. It is also important to note that I ethically cannot offer any professional opinion with regard to custody considerations, should they arise, while working with any minors for whom legal custody becomes a question. I do not charge for time spent writing reports conduct the necessary forensic/parenting evaluations designed to help clarify custody matters. Due to my work schedule and progress notes as per that I am often working in different settings on different days, I am often not immediately available by telephone. While I am usually reachable via telephone, I probably will not answer the standard routine of phone when I am with a client. When I am unavailable my care of youtelephone is answered by voice mail that I monitor frequently. I also do not charge for any time I may spend collaborating will make every effort to return your call on the same day you make it, with your other providersthe exception of Fridays, weekends and holidays. From time to timeWhen you call, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, please tell me some times when you will be scheduled available. In emergencies, you can attempt to reach me via my phone number at 000-000-0000. However, if you are unable to reach me and feel that you cannot wait for another initial evaluation (90 minutes) me to return your call, contact your family physician of the nearest emergency room and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible ask for paying your full session feethe mental health professional on call. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company away approximately three or four times yearly for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwisevacations. I will tell you well in advance of any planned absences, and provide you a superbill after each session with the following information that you name and phone number of the therapist who will need be available to submit to your insurance company for reimbursement for any out-of-network benefits you might have:handle emergencies in my absence. That person’s name and number will also be on the outgoing message of my voicemail.

PSYCHOLOGICAL SERVICES. Psychotherapy Counseling is not easily described in general statements. It varies depending on the personalities of the psychologist counselor and patient, and the particular problems you hope to addressare experiencing. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy Counseling is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy Counseling can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy counseling has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our first session will involve I normally conduct an evaluation of your needsthat will last the first 2-4 sessions. By the end of the evaluationDuring this time, either you or I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you can decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for best person to provide the services you and if so, I will give you referrals need in order to other practitioners who I believe are better suited to help youmeet your treatment goals. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If either you have questions about my procedures, we should discuss them whenever they arise. If or I decide that I will not be your doubts persisttherapist, I will be happy to help provide you set up a meeting with another the names of other mental health professional professionals. The initial session lasts approximately one hour and is $105. After this session, I usually schedule one 45-50 minute session per week, and whether individual or conjoint, is $105. If you request a longer session, please discuss the fee with my secretary. You will be expected to pay a $40 fee if you do not cancel within 8 hours or if you fail to show for a second opinion. Please note scheduled appointment, unless we both agree that you were unable to attend the psychological services I provide are not for emergency situations. For emergencies, call 911 or go session due to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes)circumstances beyond your control. Other professional services include which require payment includes report writing, telephone conversations conversations, consulting with other professionals with your permission, preparation of records or email responses lasting longer than 15 minutestreatment summaries, and the time spent performing any other service you may request of me. If you become involved Any emergency appointment that is made after hours or on weekends is $175 for 50 minutes. Any check returned from the bank results in legal proceedings that require my participation, you will be a $30 redeposit fee. You are expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, each session at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session feeis held. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full paymenta South Carolina Licensed Professional Counselor. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours a Bachelors Degree from University of service)Maryland, and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee Masters degree in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any outPsychology-of-network benefits you might have:Clinical Counseling from The Citadel.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statements. It varies depending on the personalities part because of the psychologist clearly defined rights and patient, responsibilities held by each person. This framework helps to create the safety to take risks and the particular problems support to become empowered to create change. As a client in psychotherapy, you hope have certain rights and responsibilities that are important for you to addressknow about. There are many different methods I may use also legal limitations to deal with those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These respective rights are described in the following section. Psychotherapy has both benefits and risks. Risks sometimes include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness. Psychotherapy often requires discussing unpleasant aspects of your life. However, it has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress, and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things that we talk about both during our discuss outside of sessions. The first few sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work may include. At that point, we will include discuss your treatment goals and create a personalized, initial treatment plan to followplan, if you decide to continue with me for therapycontinue. You should evaluate this information along with very seriously, as well as your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. For the first few months of therapy, we will check in regularly about the initial treatment plan which may lead to new or different paths for treatment and therapy. If you have questions about my proceduresprocedures or plans, we should discuss them whenever as soon as they arise. If As much as possible be honest with me about how your doubts persist, I will be happy to help you set up a meeting are experiencing your psychotherapy with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If There are many ways of doing therapy and it is your job to tell me how you become involved in legal proceedings that require my participation, would like to use the sessions and what you will think might be expected most helpful to pay for any professional time I spend on your legal matter, even if the request comes you from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:me.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist psychotherapist and patient, patient and the particular problems you hope to addressare experiencing. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our first session will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should can discuss them whenever they arise. Each individual session lasts either 45 or 60 minutes and family sessions are 60-80 minutes. If you are late for a session, that time is lost from your doubts persistsession. If I am late for a session, we will extend the session if you are willing to do so or we will make other arrangements by mutual consent. Please note my snow policy: I do not follow Montgomery County’s snow policy. Unless you hear from me in the morning, I will assume that we will be happy meeting. If you cannot make it to help the appointment for weather reasons, please call or email me by 8:00 a.m. (000-000-0000 or xxxx@xxx-xxxxxxxxx-xxxxx.xxx) and I will waive the 24-hour cancellation fee. If you set up a meeting do not reschedule an appointment within one month of our last session, I will assume that you have decided to discontinue treatment with another mental health professional for a second opinionme. Please note be assured that you are always welcome to return regardless of how much time has lapsed since our last session. Please confirm current fees with therapist: ______ for 75-minute sessions Additional time is billed at $50 per quarter hour. These fees are also billed for services such as telephone calls not related to scheduling, special reports, and collateral consultation. You are responsible for payment for each therapy session at the psychological time of the session by cash, check or credit card. I do not participate in health insurance programs however I will provide you with an invoice with all the information needed should you wish to file a claim directly with the insurance company. It is your responsibility to contact your insurance company to determine if an authorization for treatment is required and to communicate that requirement to me. Please note, I am not a Medicare provider and therefore my services are not covered by Medicare. Should you want services from me and you are a Medicare recipient, this will serve as a separate private contract so that you may pay me out of pocket. Under this circumstance, you understand that you (or your beneficiaries or legal representatives) are waiving the right to submit claims or be reimbursed by Medicare for any services I provide are that would otherwise be covered by Medicare if there was no private contract and a proper claim was submitted. You have every right to obtain similar services from a provider who has not opted out of Medicare. You understand that Medigap does not pay for emergency situationsservices not covered by Medicare. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge The period of this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service agreement will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and 2 years from the time spent performing any other service you of signature. This language is legalese required of me by Medicare guidelines! During the course of treatment, it may request become necessary to increase fees. Fees are reviewed in January and June of meeach year. If you become involved in legal proceedings that require my participation, you will be expected to pay for any all of my professional time I spend on your legal matterand expenses, including preparation costs, transportation costs, and attorney’s fees, even if the request comes from I am called to testify by another party. My professional time related to these activities is $350 per hour. Due to my work schedule, at I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call on the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then day you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordinglymake it, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companiesthe exception of weekends and holidays. If you decide are unable to submit claims reach me and feel that you can’t wait for me to return your insurance company for reimbursement for any out-of-network benefits you might havecall, you may do so. However, be aware that contact your family physician or the services provided will still be charged to you, not your insurance company, nearest emergency room and you are responsible ask for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instancespsychologist or psychiatrist on call. If your insurance company doesn’t reimburse youI will be unavailable for an extended time, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following name of a colleague to contact, if necessary. It is very important to be aware that computers and email and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. If you communicate confidential or private information via email or text, I will assume that you have made an informed decision, will need view it as your agreement to submit take the risk that such communication may be intercepted, and will honor your desire to your insurance company communicate on such matters via email or text. Please do not use email or text for reimbursement for any out-of-emergencies. Due to computer or network benefits you might have:problems, emails and texts may not be deliverable, and I may not check my emails or faxes frequently.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first 2 sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please APPOINTMENTS Appointments will ordinarily be 45-60 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24-hours notice. If you miss a session without canceling, or cancel with less than 24-hour notice, my policy is to collect the amount of your payment [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the psychological services portion of the fee as described above. If it is possible, I provide will try to find another time to reschedule the appointment. In addition, you are not responsible for emergency situationscoming to your session on time; if you are late, your appointment will still need to end on time. For emergencies, call 911 or go to PROFESSIONAL FEES The standard fee for the nearest emergency room. My fee initial intake is $395 for an initial evaluation lasting 90 minutes, 150.00 and $250 for each subsequent psychotherapy session (either in-person is $100.00. You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by before the session Any checks returned to my office are subject to an additional fee of up to $25.00 to cover the bank fee that I incur. If you refuse to pay your debt, I reserve the right to use an attorney or over the telephone) lasting 45 minutescollection agency to secure payment. I In addition to weekly appointments, it is my practice to charge this same $250 per 45-minutes rate amount on a prorated basis (I will break down the hourly cost) for other professional services that you may needrequire such as report writing, though I will prorate the cost if I work for periods of less telephone conversations that last longer than 45 minutes in increments of 15 5 minutes, rounded to the nearest 15-minute increment (e.g.attendance at meetings or consultations which you have requested, 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing required to perform any other service which you may request of me. If you become anticipate becoming involved in legal proceedings a court case, I recommend that require we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for any the professional time I spend on your legal matter, required even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time party compels me to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:testify.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first 2-4 sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate consider this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persistpersist and you desire a referral to another psychotherapist, please let me know and I will be happy to help honor your request. APPOINTMENTS Typically, appointments are 50-60 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. Fees may be adjusted in the future and you set up will be provided advanced notice of any increase in fees. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a meeting session, I ask that you provide me with another mental health professional 24 hours notice in advance of the scheduled session. If you miss a session without canceling, or cancel with less than 24 hours notice (unless we both agree that you were unable to attend due to circumstances beyond your control), you agree to pay the rate of $100 for a second opinionthe missed session / late cancellation. Please It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the psychological services portion of the fee as described above. If it is possible, I will try to find another time to reschedule the appointment. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time. PROFESSIONAL FEES My standard fee for the initial intake and each subsequent session is $180.00. You are responsible for paying at the time of your session unless prior arrangements have been made. For telepsychology appointments the fee is due prior to the start of the intake or session. Payments may be made by check, cash, Visa, Mastercard, Discover or American Express. Should you request that I provide are not for emergency situations. For emergenciesother professional services that last longer than 15 minutes (e.g., call 911 meetings or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutesconsultations which you have requested; report or letter writing; telephone, and $250 for each subsequent psychotherapy session (either videoconference or in-person or over the telephone) lasting 45 minutes. conversations), I will charge this same $250 per 45-minutes rate for amount on a prorated basis unless other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of mearrangements have been made. If you become anticipate becoming involved in legal proceedings a court case, I recommend that require we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for any the professional time I spend on your legal matter, required even if the request comes from another party, at the same $250 per 45-minutes rateparty compels me to testify. Please know that I do not charge permit clients to carry a balance of more than two sessions. Should you be unable to pay your balance, you agree to discuss whether it makes sense to pause your care or develop another strategy for time spent writing reports and progress notes care so that you may avoid incurring additional debt. You agree to inform me if any problem arises during the course of therapy regarding your ability to make timely payments. Should any checks be returned to my office due to insufficient funds or any other reason resulting in nonpayment, you agree to cover bank fees I incur as per a result of the standard routine of my care of youinvalid check. I also do not charge for any time I may spend collaborating with Should your other providers. From time to time, I may institute fee increases and these will be account become 90 days past due without us having discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointmentalternative arrangements for payment, you will be scheduled for another initial evaluation (90 minutes) agree to authorize the release of your name, address, dates of services and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide account information to submit claims an attorney or collection agency to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, secure payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:on my behalf.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first 2-4 sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note APPOINTMENTS Appointments will ordinarily be 50 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. If you need to cancel or reschedule a session, I ask that you provide me with advanced notice. If you miss a session without canceling, or cancel later than 8am on the psychological services day of your appointment, my policy is to collect a $25.00 fee (unless we both agree that you were unable to attend due to circumstances beyond your control). If it is possible, I provide will try to find another time to reschedule the appointment. You are not allowed two “no show” appointments, after which we will discuss transferring you to another clinician. In addition, you are responsible for emergency situationscoming to your session on time; if you are late, your appointment will still need to end on time. For emergencies, call 911 or go to the nearest emergency room. My PROFESSIONAL FEES The standard fee for each session is $395 80 (EMDR), $100 (individual), or $120 (couple). You are responsible for paying at the time of your session unless prior arrangements have been made. Payment can be made by check, cash, or credit card. Any checks returned to my office are subject to an initial evaluation lasting 90 minutesadditional fee of up to $25.00 to cover the bank fee that I incur. If you refuse to pay your debt, and $250 for each subsequent psychotherapy session (either in-person I reserve the right to use an attorney or over the telephone) lasting 45 minutescollection agency to secure payment. I In addition to weekly appointments, it is my practice to charge this same $250 per 45-minutes rate amount on a prorated basis (I will break down the hourly cost) for other professional services that you may needrequire such as report writing, though I will prorate the cost if I work for periods of less telephone conversations that last longer than 45 minutes in increments of 15 5 minutes, rounded to the nearest 15-minute increment (e.g.attendance at meetings or consultations which you have requested, 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing required to perform any other service which you may request of me. If you become anticipate becoming involved in legal proceedings a court case, I recommend that require we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for any the professional time I spend on your legal matter, required even if the request comes from another party, at the same $250 per 45-minutes rateparty compels me to testify. INSURANCE I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to accept insurance at this time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide experience substantial financial difficulties during the period of our sessions that make therapy cost-prohibitive, we can discuss a sliding scale fee option. PROFESSIONAL RECORDS I am required to submit claims keep appropriate records of the psychological services that I provide. Your records are maintained in a secure location in the office. I keep brief records noting that you were here, your reasons for seeking therapy, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, any correspondence between us, records I receive from other providers, copies of records I send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and / or upsetting to untrained readers. For this reason, I recommend that you initially review them with me, or have them forwarded to another mental health professional to discuss the contents. If I refuse your request for access to your insurance company for reimbursement for any out-of-network benefits you might haverecords, you may do so. Howeverhave a right to have my decision reviewed by another mental health professional, be aware that the services provided which I will still be charged to you, not discuss with you upon your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance coversrequest. You are responsible for checking also have the right to request that a copy of your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely file be responsible for the full session fee in these instances. If made available to any other health care provider at your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:written request.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statements. It varies depending on the personalities part because of the psychologist clearly defined rights and patient, responsibilities held by each person. This frame helps to create the safety to take risks and the particular problems support to become empowered to create change. As a client in psychotherapy, you hope have certain rights and responsibilities that are important for you to addressknow about. There are many different methods I may use also legal limitations to deal with those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These respective rights are described in the following section. Psychotherapy has both benefits and risks. Risks sometimes include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness. Psychotherapy often requires discussing unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress, and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things that we talk about both during our discuss outside of sessions. The first few sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work may include. At that point, we will include discuss your treatment goals and create a personalized, initial treatment plan to followplan, if you decide to continue with me for therapycontinue. You should evaluate this information along with as well as your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If APPOINTMENTS I normally conduct an evaluation that will last from 2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your doubts persisttreatment goals. Once psychotherapy has begun, I we will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy schedule one 50-minute session (either in-person one appointment hour of 50 minutes duration) per week at a time we agree on, although some sessions may be longer or over the telephone) lasting 45 minutesmore frequent. I charge this same $250 per 45-minutes rate CANCELLATION Psychological services are most effective when meeting times are regular and consistent. The time scheduled for other professional services your appointment is assigned to you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of mealone. If you become involved in legal proceedings need to cancel or reschedule a session, it is required that require my participationyou provide more than 24 hours notice. If you miss a session without canceling, or cancel with less than 24 hours notice, you will be expected must pay the full fee for the missed session. It is important to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I note that insurance companies do not charge provide reimbursement for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously payingcancelled sessions. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for coming to your session on time and at the time scheduled. If you are late, your appointment will still need to end on time. Psychotherapy sessions are 50 minutes. Session fees or insurance co- pays are payable at time of service unless alternative arrangements have been arranged. Fees will be reevaluated periodically. You will be responsible for paying the entire fee if your full session feeinsurance fails to authorize units of service or if no units of service are available to you. Should a balance accrue and no payment is received, Xxxxxx Psychological Services, P.C. reserves the right to seek remuneration by any means legally possible including, but not limited to, the retention of a collection agency. I accept payment directly from insurance companies. In the event that I am not in-network a participating provider in your managed care plan, my services are typically reimbursable and I will provide you with any insurance companies. If a monthly statement that you decide to may submit claims to your insurance company for reimbursement for any to obtain out-of-network benefits reimbursement. Insurance companies sometimes require a formal diagnosis with their claims. Diagnoses are technical terms that describe the nature of you might haveproblems and whether they are short-term or long-term problems. All diagnoses come from a book entitled the DSM-IV. There is a copy in my office and I will be glad to let you see it to learn more about your diagnosis, if applicable. I am required to keep appropriate records of the psychological services that I provide. Although psychotherapy often includes discussions of sensitive and private information, normally very brief records are kept noting that you may do so. Howeverhave been here, be aware that the services provided will still be charged to you, not your insurance companywhat was done in session, and you are responsible for a mention of the full payment. I have no role in deciding what your insurance coverstopics discussed. You have the right to a copy of your file at any time. You have the right to request that a copy of your file be made available to any other health care provider at your written request. Your records are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for maintained in a secure location in the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:office.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patientDuring our first few sessions, and the particular problems you hope to address. There are many different methods I may use to deal with those problems. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you we will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause discuss what brought you to experience increased sleepiness and fatigue, especially in the early phases of treatmenttherapy. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you These sessions will experience. Our first session will involve an evaluation of your needstypically include informal (unstructured) assessment. By the end of the evaluation, I we will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you selectyour doctor. If you have questions about my our procedures, we should discuss them whenever they arise. If A few things to remember: ∙ Psychotherapy is not like a medical doctor visit. It calls for a very active effort on your doubts persistpart. You will likely have "homework" to complete between sessions. ∙ Sometimes undesirable behaviors increase in intensity before they lessen when you start addressing them. This is normal and usually temporary. ∙ Psychotherapy can have benefits and risks. These may vary depending on your reason for coming to therapy. While there are no guarantees of what you will experience, I will most people benefit from therapy. Benefits may include improved sleep, better relationships, solutions to specific problems, and significant reductions in feelings of distress. However, because therapy may involve discussing challenging aspects of your life, you could at times experience difficult emotions or discomfort. LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a patient and a psychologist. In most situations, we can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • You should be happy to help you set up a meeting with another aware that the office includes other mental health professional professionals and administrative staff. In most cases, we need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. • We have a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergenciescontract with Azalea Health, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minuteswhich administers our electronic health records, and $250 Gateway EDI, our insurance filing service. As required by HIPAA, we have a formal business associate contract with this business, in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, we can provide you with a blank copy of this contract. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If a patient threatens to harm himself/herself, the doctor may be obligated to seek hospitalization for each subsequent psychotherapy session (him/her or to contact family members or others who can help provide protection. There are some situations where your doctor is permitted or required to disclose information without either inyour consent or Authorization: • If you are involved in a court proceeding and a request is made for information concerning our professional services, such information is protected by the psychologist-person patient privilege law. We cannot provide any information without your written authorization, or over the telephone) lasting 45 minutesa court order. I charge this same $250 per 45-minutes rate for other professional services If you may needare involved in or contemplating litigation, though I will prorate the cost if I work for periods of less than 45 minutes you should consult with your attorney to determine whether a court would be likely to order us to disclose information. If you do request your information to be shared in increments of 15 minutes, rounded to the nearest 15-minute increment a legal matter (e.g., 22 minutes Social Security Case, Xxxxxxx'x Comp Case prior to the claim decision, divorce or other proceedings), a charge of service $185.00/hour will be charged applied for 15 minutes whereas 23 minutes preparation of service will be charged a clinical summary, as it is our policy not to share clinical notes with anyone besides other healthcare professionals. This is for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutesyour protection, as they are written in clinical, not legal language, and the time spent performing any information contained in them could be misinterpreted. • If a government agency is requesting the information for health oversight activities, we may be required to provide it for them. • If a patient files a complaint or lawsuit against either doctor or the practice, we may disclose relevant information regarding that patient in order to defend ourselves. • If a patient files a worker’s compensation claim, and we are providing treatment related to the claim, we must, upon appropriate request, furnish copies of all medical reports and bills. • If a patient leaves one of the doctors or the practice a negative review online, we reserve the right to respond at that site. We will make every effort to not disclose protected health information other service you than what we did to address the problem that prompted the review. There are some situations in which we are legally obligated to take actions, which we believe are necessary to attempt to protect others from harm and we may request have to reveal some information about a patient’s treatment. These situations are unusual in this practice. ▪ If your doctor has reason to believe that a child has been abused, the law requires that she file a report with the appropriate governmental agency, usually the Department of meHuman Resources. Once such a report is filed, we may be required to provide additional information. ▪ If your doctor has reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means, or has been neglected or exploited, she must report to an agency designated by the Department of Human Resources. Once such a report is filed, she may be required to provide additional information. ▪ If your doctor determines that a patient presents a serious danger of violence to another, she may be required to take protective actions. These actions may include notifying the potential victim, and/or contacting the police, and/or seeking hospitalization for the patient. If such a situation arises, your doctor will make every effort to fully discuss it with you become involved before taking any action and she will limit her disclosure to what is necessary. PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that your doctor amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about policies and procedures recorded in legal proceedings that require my participationyour records; and the right to a paper copy of this Agreement, you the attached Notice form, and our privacy policies and procedures. We are happy to discuss any of these rights with you. BILLING AND PAYMENTS You will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, each session at the same $250 per 45-minutes ratetime it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. I do not charge Payment schedules for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these professional services will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You to when they are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instancesrequested. If your insurance company doesn’t reimburse youaccount has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I am not responsible for refunding you any payment you expected we have the option of using legal means to be reimbursed secure the payment. This may involve hiring a collection agency or otherwisegoing through small claims court which will require us to disclose otherwise confidential information. I will provide you In most collection situations, the only information we release regarding a superbill after each session with patient’s treatment is his/her name, the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:nature of services provided, and the amount due. INTERNET CONTACT

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It ; it varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressbring forward. There are many different methods I may use to deal with those problemsthe problems that you hope to address. My primary methods are rooted in my ABPP Board Certification in Behavioral and Cognitive Psychology (awarded in 2014) as well as being a Founding Fellow in the Academy of Cognitive Therapy (awarded in 1999). I will often utilize other Evidence-based procedures. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about about, both during our sessions and at home. home Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have many health benefits for people who go through it. Therapy Psychotherapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. These aforementioned concerns, improved sleepif not treated, and less fatiguehave often been correlated with negative health concerns. But Nevertheless, there are no guarantees as to of what you will experience. Our first session will involve an evaluation of your needsI am often not immediately available by telephone nor email. By the end of the evaluationWhile I am usually nearby my home-office telephone, I will be able to offer not answer not answer the phone when I am with a client, so please leave me a voice message on 000-000-0000. If you some first impressions of what our work will include and send an email, please still leave me a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe voice message so that I am not the right therapist for you and if socertain to see your transmission. Please note, I would prefer that you do not send an email containing personal NOR urgent information. I will give make every effort to return your call on the same day you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you selectmake it. If you have questions about my proceduresdo not hear from me in 24 hours, we should discuss them whenever they ariseplease try calling me again. If your doubts persistyou are difficult to reach, please inform me os times when you will be available, as well as a telephone number. Although xxxxxxxx@xxxxxxxxxxxx.xxx. is a Hush mail encrypted, HIPPA compliant service, I would prefer that confidential information is conveyed over my land line office number 000-000-0000, sent to my land line facsimile 000-000-0000, or mailed directly to my office, 000 Xxxx Xxxxxx Xxxx, Xxxxxxxxxx, XX 00000-0000. My preferred general, NOT HIPPA compliant, email address is xx.xxxxxxxx@xxxxx.xxx If you are an established patient of mine, I do have a digital pager 000-000-0000 near me 24/7 for emergencies. However, please leave a message on my office line first, leaving your telephone number, as it is not unusual for me to receive only 9 digits on my pager You will be happy need to help you set up a meeting with another mental health professional dial 000-000-0000 and wait for a second opinionbeep, which is generally preceded by instructions, then digitally enter a telephone number where you can be reached before hanging up. Please note that However if you do not hear back from me within a few minutes after you digitally entered in the psychological services I provide are not for emergency situations. For emergencies, number to reach you then IMMEDIATELY call 911 or go proceed to the nearest emergency roomroom and ask for the psychologist/psychiatrist on call. My fee is $395 If I will be unavailable for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to extended time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need name of a colleague to submit to your insurance company for reimbursement for any outcontact, if necessary. -of-network benefits you might have:

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first 2-4 sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note APPOINTMENTS Appointments will ordinarily be 50 minutes (individual) or 80 mins (EMDR, couple) in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. If you need to cancel or reschedule a session, I ask that you provide me with advanced notice. If you miss a session without canceling, or cancel later than 8am on the psychological services day of your appointment, my policy is to collect a $25.00 fee (unless we both agree that you were unable to attend due to circumstances beyond your control). If it is possible, I provide will try to find another time to reschedule the appointment. You are not allowed two “no show” appointments, after which we will discuss transferring you to another clinician. In addition, you are responsible for emergency situationscoming to your session on time; if you are late, your appointment will still need to end on time. For emergencies, call 911 or go to the nearest emergency room. My PROFESSIONAL FEES The standard fee for each session is $395 for an initial evaluation lasting 90 minutes200 (individual, and EMDR), or $250 (couple) unless otherwise agreed-upon. You are responsible for each subsequent psychotherapy paying at the time of your session (either in-person unless prior arrangements have been made. Payment can be made by check, cash, or over credit card. Any checks returned to my office are subject to an additional fee of up to $25.00 to cover the telephone) lasting 45 minutesbank fee that I incur. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment. In addition to weekly appointments, it is my practice to charge this same $250 per 45-minutes rate amount on a prorated basis (I will break down the hourly cost) for other professional services that you may needrequire such as report writing, though I will prorate the cost if I work for periods of less telephone conversations that last longer than 45 minutes in increments of 15 5 minutes, rounded to the nearest 15-minute increment (e.g.attendance at meetings or consultations which you have requested, 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing required to perform any other service which you may request of me. If you become anticipate becoming involved in legal proceedings a court case, I recommend that require we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for any the professional time I spend on your legal matter, required even if the request comes from another partyparty compels me to testify. INSURANCE All insurance information is handled by Psychotherapy Billing Services, at LLC. This company adheres to the same $250 per 45HIPAA practices used at this office and all information provided related to billing will be handled in a professional and confidential manner. For any questions related to insurance billing, contact Xxxxx Xxxxx at (541) 343-minutes rate8122 ext. 4. PROFESSIONAL RECORDS I am required to keep appropriate records of the psychological services that I provide. Your records are maintained in a secure location in the office. I do not charge keep brief records noting that you were here, your reasons for time spent writing reports seeking therapy, the goals and progress notes as per the standard routine of my care of you. we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, any correspondence between us, records I also do not charge for any time I may spend collaborating with your receive from other providers, copies of records I send to others, and your billing records. From time Except in unusual circumstances that involve danger to timeyourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and / or upsetting to untrained readers. For this reason, I may institute fee increases and these will be discussed and agreed upon ahead of time recommend that you initially review them with a new Treatment Contractme, or have them forwarded to another mental health professional to discuss the contents. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointmentI refuse your request for access to your records, you have a right to have my decision reviewed by another mental health professional, which I will be scheduled for another initial evaluation (90 minutes) and charged accordingly, discuss with subsequent 45-minute psychotherapy sessions thereafteryou upon your request. You are responsible for paying also have the right to request that a copy of your full session fee. I am not in-network with file be made available to any insurance companies. If you decide to submit claims to other health care provider at your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:written request.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities personality of both the psychologist therapist and patient, the client and the particular problems that the client brings. There are a number of different approaches, which can be utilized to deal with the problems you hope to address. There are many different methods I may use to deal with those problems. Psychotherapy It is not like visiting a medical doctor visit. Insteaddoctor, it calls for in that psychotherapy requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have has both benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience Risks sometimes include experiencing uncomfortable feelings like such as sadness, guilt, angeranxiety, anger and frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases Psychotherapy often requires discussing unpleasant aspects of treatmentyour life. On the other hand, psychotherapy Psychotherapy has also been shown to have benefits for people who go through undertake it. Therapy often leads to better relationships, solutions to specific problems, a significant reductions reduction in feelings of distress, improved sleepbetter relationships, and less fatigueresolutions of specific problems. But there are no guarantees as to about what you will experiencehappen. Our Your first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I your therapist will be able to offer you some first initial impressions of what our your work will include and a an initial treatment plan to follow, if you decide to continue with me for therapycontinue. You should evaluate this information along with your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help youyour therapist. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my our procedures, we should discuss them whenever they arise. If your any doubts persist, I your therapist will be happy to help you set up a meeting to secure an appropriate consultation with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:professional.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressare experiencing. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. However, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please I normally conduct an evaluation that will last from 2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If psychotherapy is begun, I will usually schedule one 45-minute session (one appointment hour of 45 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide at least 24 hours advance notice of cancellation. It is important to note that the psychological services I insurance companies do not provide are not reimbursement for emergency situations. For emergencies, call 911 cancelled sessions or go to the nearest emergency roomunkept appointments. My hourly fee is $395 for an initial evaluation lasting 90 minutes200.00 per 60-minute hour, and which means that I charge $250 for each subsequent psychotherapy 300.00 per 90-minute session (either ine.g., initial interview), $200.00 per 60-person or over the telephone) lasting 45 minutesminute session, $150.00 per 45-minute session. In addition to weekly appointments, I charge this same $250 per 45-minutes rate amount for other professional services you may need, though I will prorate break down the hourly cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes)one hour. Other professional services include report writing, telephone conversations or email responses lasting longer than 15 five (5) minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any all of my professional time I spend on your legal mattertime, including preparation and transportation costs, even if the request comes from I am called to testify by another party. Because of the difficulty of legal involvement, I charge $400.00 per hour for preparation and attendance at any legal proceeding. You will be expected to pay for each session at the same $250 per 45-minutes ratetime it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. I do not charge Payment schedules for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these professional services will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You to when they are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instancesrequested. If your insurance company doesn’t reimburse youaccount has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I am not responsible for refunding you any payment you expected have the option of using legal means to be reimbursed secure the payment. This may involve hiring a collection agency or otherwisegoing through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the information I will provide you release regarding a superbill after each session with patient’s treatment is his/her name, address, phone numbers, social security numbers, first and last dates of service, the following amount of debt, and the minimal amount of information that you will need necessary to submit to your insurance company for reimbursement for any out-of-network benefits you might have:collect the debt.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to addressbring forward. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like anxiety, sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specificallyFurther, therapy might cause you I predominantly practice Cognitive Behavioral Therapy (CBT), which may require some clients to experience increased sleepiness engage in exposures to “face their fears,” as a way to overcome their anxiety. Such exposure may increase anxiety before the anxiety improves. Research has demonstrated CBT to be an effective way to manage and fatigue, especially in the early phases of treatmentovercome one’s anxiety. On the other hand, psychotherapy Psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience, and therapy does not work for everyone. Our first session is considered a consultation during which we discuss the reason(s) for why you seek treatment. The next few sessions will involve an a further evaluation of your needs. By the end of the evaluation, I will be able to offer you some first my impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful thoughtful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist therapist and patient, and the particular problems issues you hope to addressbring forward. There are many different methods I we may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we you and your treatment provider talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, loneliness and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. There are, improved sleephowever, and less fatigue. But there are no guarantees as to of what you will experience. Our Your first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I your therapist will be able to offer you some first impressions of what our your work will include and a treatment plan to follow, follow if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help youyour provider. Therapy involves a large commitment of time, money, money and energy, so you should be very careful about the therapist you select. If you have questions about my our procedures, we you and your treatment provider should discuss them whenever they arise. If your you doubts persist, I your treatment provider will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to address. There are many different methods I may use to deal help with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy has been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. However, psychotherapy can also have benefits and risksrisks as well as benefits. Because Since therapy often involves discussing unpleasant aspects of your one’s life, you the patient may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session few sessions will involve an evaluation of your (or your child’s) needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, follow if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful thoughtful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note In order for therapy to be effective, it must take place under circumstances in which the participants feel that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, they can speak freely and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods openly without fear of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full paymentlater disclosure. I have no role an ethical obligation to maintain the confidentiality of my patients, including statements made by the persons involved in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), the treatment and telephone session are not typically covered by insurance companies my own observations and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:impressions.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first 2-4 sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please APPOINTMENTS Appointments will ordinarily be 50 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours notice. If you miss a session without canceling, or cancel with less than 24 hour notice, my policy is to collect the amount of your co-payment [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the psychological services portion of the fee as described above. If it is possible, I provide will try to find another time to reschedule the appointment. In addition, you are not responsible for emergency situationscoming to your session on time; if you are late, your appointment will still need to end on time. For emergencies, call 911 or go to PROFESSIONAL FEES The standard fee for the nearest emergency room. My fee initial intake is $395 for an initial evaluation lasting 90 minutes, 150.00 and $250 for each subsequent psychotherapy session (either in-person is $90.00. You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by cash, credit or over debit card. Unfortunately, we are unable to accept personal checks. If you refuse to pay your debt, Bound Together Counseling reserves the telephone) lasting 45 minutesright to use an attorney or collection agency to secure payment. I In addition to weekly appointments, it is my practice to charge this same $250 per 45-minutes rate amount on a prorated basis (I will break down the hourly cost) for other professional services that you may needrequire such as report writing, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting that last longer than 15 minutes, and attendance at meetings or consultations which you have requested, or the time spent performing required to perform any other service which you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, Please be aware that the services provided Bound Together counselors do not testify on behalf of any party in a court proceeding. We will still be charged require you to you, not sign a statement of confidentiality acknowledging this policy prior to beginning your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:treatment.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in psychotherapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our discuss outside of sessions. The first 2-4 sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session will involve an a comprehensive evaluation of your needs. By the end of the evaluation, I will be able to offer you some first initial impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please APPOINTMENTS Appointments will ordinarily be 45-50 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours notice. If you miss a session without canceling, or cancel with less than 24 hour notice, my policy is to collect the amount of your session [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the psychological services portion of the fee as described above. If it is possible, I provide will try to find another time to reschedule the appointment. In addition, you are not responsible for emergency situationscoming to your session on time; if you are late, your appointment will still need to end on time. For emergencies, call 911 or go to PROFESSIONAL FEES The standard fee for the nearest emergency room. My fee initial intake and each subsequent session is $395 125, unless you have received a fee reduction, in which case you will owe the amount we agreed upon, written at the bottom of this form. You are responsible for paying at the beginning of your session unless prior arrangements have been made. Payment must be made by check, cash, or credit. Any checks returned to my office are subject to an initial evaluation lasting 90 minutesadditional fee of up to $25.00 to cover the bank fee that I incur. If you refuse to pay your debt, and $250 for each subsequent psychotherapy session (either in-person I reserve the right to use an attorney or over the telephone) lasting 45 minutescollection agency to secure payment. I In addition to weekly appointments, it is my practice to charge this same $250 per 45-minutes rate amount on a prorated basis (I will break down the hourly cost) for other professional services that you may needrequire such as report writing, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting that last longer than 15 minutes, and attendance at meetings or consultations which you have requested, or the time spent performing required to perform any other service which you may request of me. If you become anticipate becoming involved in legal proceedings a court case, I recommend that require we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for any the professional time I spend on your legal matter, required even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time party compels me to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:testify.

PSYCHOLOGICAL SERVICES. As a licensed psychologist I provide psychotherapeutic services, including psychotherapy and assessment services, to adolescents and adults through individual and group psychotherapy. I utilize a variety of approaches including cognitive-behavioral therapy, mindfulness, acceptance and commitment therapy, cognitive processing therapy. Every individual and situation is unique and requires an individualized approach to treatment. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patientclient, and the particular problems you hope to addressbring forward. There are many different methods I may use to deal with those problemsthe problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and benefits, but also has potential risks. Because It may be painful to approach thoughts and feelings that you have tried to avoid for a long time. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, or frustration. Making changes in your life, lonelinessyour beliefs, or behaviors can be uncomfortable and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatmentscary at times. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant increased self-understanding, reductions in feelings of distress, improved sleepand an improvement in quality of life. Unfortunately, and less fatigue. But there are no guarantees as to of what you will experience. Because of this, it is important that you carefully evaluate whether these potential risks outweigh the potential benefits of participating in therapy. Our first session two to three sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include include. Together we will identify your specific goals for therapy and will develop a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my proceduresprocedures or any other aspect of therapy, we should discuss them whenever they arise. If your you have doubts persistabout working with me, I will be happy to help you set up a meeting with find another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:therapist.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you hope to address. There are many different methods I may use to deal with those problems. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and and, if so, I will give you referrals to other practitioners who whom I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It The psychotherapy experience varies depending on the personalities of psychologist, the psychologist and patient, and the particular problems you hope to address. There are many different methods I may use to deal with those problemsone is experiencing. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our first session one or two sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please Therapy usually entails one 45 to 50­minute session per week although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation. It is important to note that the psychological services I insurance companies do not provide are not reimbursement for emergency situations. For emergencies, call 911 or go to the nearest emergency roomcancelled sessions. My hourly fee is $395 for an initial evaluation lasting 90 minutes160.00 In addition to weekly appointments, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate amount for other professional services you may need, though I will prorate break down the hourly cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes)one hour. Other professional services include report writing, telephone conversations or email responses lasting longer than 15 10 minutes, preparation of records, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any all of my professional time I spend on your legal mattertime, including preparation and transportation costs, even if the request comes from I am called to testify by another party, at the same $250 per 45-minutes rate. I am often not immediately available by telephone because I do not charge for time spent writing reports and progress notes as per answer the standard routine of phone when I am with a patient. When I am unavailable, my care of youtelephone is answered by a confidential voice mail service that I monitor frequently. I also do not charge am the only person that will listen to your message. I will make every effort to return your call within 24 hours, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and feel that you can’t wait for any time me to return your call, contact your family physician or the nearest emergency room and ask for the mental health professional on call. If I may spend collaborating with your other providers. From time to will be unavailable for an extended time, I will provide you with the name of a colleague to contact with emergencies. The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows: • I occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I do not reveal names or other identifying information. The other professionals are also legally bound to keep the information confidential. I will note all consultations in your Clinical Record. • I practice with other mental health professionals and I employ administrative staff. In most cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as billing. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy. • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. • If a patient threatens to harm himself/herself, I may institute fee increases be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection. There are some situations where I am permitted to disclose information without either your consent or Authorization. In all the cases below, I will discuss the disclosure with you prior to release and these will be discussed and agreed upon ahead make every effort to obtain your consent. PLEASE NOTE THAT IN THE PAST 17 YEARS OF PRACTICE, I HAVE NEVER YET RELEASED INFORMATION WITHOUT A PATIENT’S CONSENT. • Psychologist­patient privilege covers most cases of time with a new Treatment Contractcourt ordered requests for information. However, there have been rare exceptions. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information. • If a government agency is requesting the information for health oversight activities (e.g. disability assessment), I may be required to provide it for them. • If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself. • If a patient files a worker’s compensation claim, and I am providing treatment related to the claim, I must, upon appropriate request, furnish copies of all medical reports and bills. There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are rare in my practice and I have NEVER YET been required to violate a patient’s confidentiality. ▪ If I have reason to believe that a child has been more than one year since our last appointmentabused, then you will re-initiate services at my current standard fee which the law requires that I file a report with the appropriate governmental agency, usually the Department of Human Resources. Once such a report is filed, I may be higher required to provide additional information. ▪ If I have reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon them, other than by accidental means, or has been neglected or exploited, I must report to an agency designated by the fee Department of Human Resources. Once such a report is filed, I may be required to provide additional information. ▪ If I determine that a patient presents a serious danger of violence to another, I may be required to take protective actions. These actions may include notifying the potential victim, and/or contacting the police, and/or seeking hospitalization for the patient. If such a situation arises, I will make every effort to fully discuss it with you were previously payingbefore taking any action and I will limit my disclosure to what is necessary. In additionWhile this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws and standards of my profession require that I keep Protected Health Information about you in your Clinical Record. Except in unusual circumstances that involve danger to yourself and others or makes reference to another person and I believe that access is reasonably likely to cause substantial harm to such other person or where information has been supplied to me confidentially by others, you may examine and/or receive a copy of your Clinical Record, if you request it has been more than one year since our last appointmentin writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you will be scheduled for initially review them in my presence, or have them forwarded to another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session feemental health professional so you can discuss the contents. I am sometimes willing to conduct this review meeting without charge. In most situations, I am allowed to charge a copying fee of $3.00 per page. If I refuse your request for access to your records, you have a right of review (except for information provided to me confidentially by others) which I will discuss with you upon request. HIPAA provides you with rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. If your account has not in-network with any insurance companiesbeen paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you decide have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to submit claims to your insurance company for reimbursement for any out-of-network benefits which you might haveare entitled; however, you may do so. However, be aware that the services provided will still be charged to you, (not your insurance company, and you ) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the full paymentsection in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Insurance benefits can be very complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services and may restrict the number of sessions they will pay for. Many patients feel that they need more services after insurance benefits end. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files.. Though all insurance companies claim to keep such information confidential, I have no role control over what they do with it once it is in deciding what your insurance coverstheir hands. You are responsible for checking your insurance coverageIn some cases, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for they may share the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwiseinformation with a national medical information databank. I will provide you with a superbill after each session copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the following information benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above. Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. Name Signature Date Rev. 06/06 Name Date Social Security Number Phone Numbers: Date of Birth Height Weight Place of Employment Occupation Referred by Do you give permission for Xx. Xxxxxx to contact the person who referred you? High Schools Attended: (Name) ( City) (State) Colleges Attended: (Name) (City) (State) Marital Status (check one): single married/living together widowed divorced/separated How long married/living together? Have you been married before? Partner's business or position Partner's age Number of children Ages and genders Local physician Date and nature of previous significant physical problems Any current physical problems, symptoms, or concerns Current prescription medications (name & dosage) Prescribed by: (Physician name & number) Currently in counseling or psychotherapy? Yes No Previous counseling or psychotherapy? Yes No If yes, Name of therapist For how long? When? Medication prescribed Previous psychiatric hospitalization Yes No If yes, where? When? Length of stay Have any family members been hospitalized for psychiatric purposes? Yes No If yes, who? When? How long? Father Deceased Mother Deceased If living, Father's Age If Not, Year of Death Mother's Age Year of Death Highest educational level attained by: Father Mother Father's last business or position Mother's last business or position Are/were either of your parents alcoholic or drug addicted? Yes No Age and Sex of brothers and sisters: Are/were any of your siblings alcoholic or drug addicted? Yes No Are/were any of your grandparents alcoholic or drug addicted? Yes No Person to contact in case of medical or psychological emergency: Name Relationship Address Home Phone Work Phone Note: This person would only be contacted upon your consent, or upon life threatening circumstances. Name of insurance carrier Claim Address Phone number of insurer Name of insured Policy # (usually Social Security #) Group # Briefly describe what you hope will need happen or be different as a result of your psychotherapy: Is there anything else you feel it might be important for your therapist to submit to your insurance company know? If so, please explain: Please complete the following checklist. Check only those items which are TRUE or mostly true for reimbursement for any out-of-network benefits you might have:you.

PSYCHOLOGICAL SERVICES. Psychotherapy Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the personalities of the psychologist As a client in therapy, you have certain rights and patient, and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. In therapy, there are both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness; because the process of therapy often requires discussing the unpleasant aspects of your life. However, therapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress, and resolutions to specific problems. Psychotherapy is not like a medical doctor visitBut, there are no guarantees about what will happen. Instead, it calls for Therapy requires a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at homediscuss outside of sessions. Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to what you will experience. INDIVIDUAL THERAPY SESSIONS Our first initial session will involve an evaluation of defining your needsneeds and goals for us working together. By the end of the evaluationthis assessment of your needs, we will both have a clear picture of what we can benefit from working on together; and I will be able to offer you some first initial impressions of what our work might include. At that point, we will include and a discuss your treatment plan to follow, if you decide to continue with me goals. We can collaborate on which objectives will be the most beneficial for therapyyou. The objectives for reaching your goals can be adjusted at any time during our sessions. You should have the right to evaluate this information along with information, and make your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, please feel free to bring them up so we should can discuss them whenever they arise. If your doubts in our working together persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that the psychological services I provide are not TELEMENTALHEALTH COUNSELING SERVICES My telephone and connection is secured for emergency situationsyour privacy during a telephone session. For emergenciesonline video sessions, call 911 I use a HIPPA-compliant platform for your confidentiality. APPOINTMENTS Individual appointments will ordinarily be 30 minutes in duration, once per week, at a time we agree on--although some sessions may be more or go less frequent as needed, or based on what we agree upon together. Once we have had our first session together, and this agreement is signed, if you find you need to cancel or reschedule a session, my policy is to have 24-hours notice. If you miss a session without canceling, or cancel or reschedule with less than a 24-hour notice, my policy is to collect the nearest emergency roomamount of your payment for your session. My This is in place due to working by appointment only, if someone may have wanted to come in for an appointment, or is on my waiting list that may be in need of an appointment time. The fee for canceling without 24-hours notice, rescheduling, or not showing for your appointment is your regular session fee. If paying by credit card, the aforementioned fee will be automatically charged the day of your session time. [unless we both agree that you were unable to attend due to circumstances beyond your control]. If you are able to cancel prior to 24-hours of your scheduled session time, and we are able to communicate and reschedule your session within the same week, you will then not lose your session, nor your fee for your session. If we have a late start to your appointment, we will still need to end on time to accommodate for an appointment time following yours. PROFESSIONAL FEES For individual sessions, in-person, by secure video, or by telephone, the standard fee for each session is $395 for an initial evaluation lasting 90 minutes95.00 per 50 minute session. If we find more time is needed at the end of your hour session, and $250 for each subsequent psychotherapy session (either in-person or over I can prorate the telephone) lasting 45 minutesadditional time if it is open to do so. Payment is due at the time of your session. I accept Venmo, PayPal, or Zelle bank transfer. As mentioned above, in addition to your appointments, it is my practice to charge this same $250 per 45-minutes rate amount on a prorated basis (I will break down the hourly cost) for additional sessions time, or other professional services that you may needrequire such as report writing, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting that last longer than 15 minutes, and attendance at meetings, or consultations which you have requested, or the time spent performing required to perform any other service which you may request of me. If you become anticipate becoming involved in legal proceedings a court case, I recommend that require we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for any the professional time I spend on your legal matter, required even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time party compels me to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:testify.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statementsdescribed. It varies depending on the personalities of the psychologist therapist and patientclient, and the particular problems you hope to addressthe client is experiencing. There are many different methods I may use to deal with those help address different problems. Psychotherapy is not like a typical medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during in and outside of our sessions and at homesessions. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and or helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through itmany benefits. Therapy often leads to better improved relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there are no guarantees as to of what you will experience. Our first session few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to followmay include. However, if during the initial assessment period I determine, in my professional judgment, that I am not a good fit for your particular treatment needs, I will provide possible referral sources for you decide to continue with me for therapycontact. You In addition, you should evaluate this information along with your own opinions about of whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help youme is a good fit. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my proceduresany questions, we should discuss please feel free to ask them whenever as they arise. If your doubts persistpsychotherapy is begun, I will usually schedule one 55-minute session (one appointment hour of 55 minutes duration) per week at a time we agree on, although this may vary. It is extremely important that you attend your appointments regularly. Multiple missed appointments decrease your chances of getting better and inhibits our ability to care for you. We require one business days notice if you decide to cancel or reschedule your appointment (24 hours). This will allow us to schedule another client into that time who may need to be happy seen quickly, since our schedules are often booked several weeks in advance. We consider a late-canceled appointment (i.e., an appointment canceled with less than one business days notice) to help you set up be the same as a meeting missed appointment. Late-cancellations or missed appointments are, in our experience, most often due to a client not considering their treatment a priority or being dissatisfied in some way with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situationstheir treatment provider. For emergencies, call 911 missed appointments or go to late cancellations a fee may be assessed: for the nearest emergency roomfirst event a 50% charge of the scheduled fee. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person Additional late cancellations or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service missed appointments will be charged for 15 minutes whereas 23 minutes at 100% of service the provider’s fee. With this in mind, it is our policy that if you miss or have two (2) late- cancellations or missed appointments within a twelve (12) month period, we will be charged for 30 minutes). Other professional services include telephone conversations refer you to another clinic or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for any professional time I spend on your legal matter, even if the request comes from another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last appointment, then you will re-initiate services at my current standard fee which provider who may be higher than the fee you were previously payinga better match. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45rev. 11-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in3-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full payment. I have no role in deciding what your insurance covers. You are responsible for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If your insurance company doesn’t reimburse you, I am not responsible for refunding you any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:14

PSYCHOLOGICAL SERVICES. Psychotherapy Psychological Assessment Through the use of a variety of standard psychological tests we will attempt to answer the questions that have brought you here for this assessment. Throughout the assessment you have the right to inquire about the nature or purpose of all procedures. You have the right to withdraw from the testing session at any time. You also have the right to know the test results, interpretations and recommendations. The assessment process generally involves a clinical interview followed by the administration of standardized psychological tests. Although it is not easily described preferable to complete the testing process in general statementsone sitting, it may be necessary to schedule more than one evaluation session to complete the necessary testing. It varies depending on Once testing is completed and the personalities data has been analyzed, a copy of the psychologist report will be made available to you as well as any referring party for continuity of care purposes. Psychotherapy/Psychoeducational Group Treatment Therapy is a relationship between people that works in part because of clearly defined rights and patientresponsibilities held by each person. As a client in psychotherapy, you have certain rights and the particular problems responsibilities that are important for you hope to addressunderstand. There are many different methods I also legal limitations to those rights that you should be aware of. These rights and responsibilities are described in the following sections. Psychotherapy has both benefits and risks. Risks may use include experiencing uncomfortable feelings such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with those have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. Psychotherapy is not like a medical doctor visit. Instead, it calls for requires a very active effort on your part. In order for the therapy to be most successful, you will have to work implement changes discussed in therapy in your everyday life. APPOINTMENTS Psychological assessment appointments vary in length, depending upon the referral question and ability of the participant to engage in the task at hand. These appointments will be scheduled for a specified time, depending on things we talk about both during our sessions and at homethe referral question, subsequent appointments will be scheduled as necessary. Psychotherapy can have benefits appointments and risks. Because therapy often involves discussing unpleasant aspects of your lifepsychoeducational groups will ordinarily be once per week for 45 minutes at a time we agree on, you some appointments may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, significant reductions in feelings of distress, improved sleep, and be more or less fatigue. But there are no guarantees frequent as to what you will experience. Our first session will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with me. At the end of the evaluation, I will notify you if I believe that I am not the right therapist for you and if so, I will give you referrals to other practitioners who I believe are better suited to help you. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you selectneeded. If you have questions about my procedures, need to cancel or reschedule an appointment we should discuss them whenever they arise. If your doubts persist, I will be happy to help ask that you set up a meeting provide us with another mental health professional for a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutes, and the time spent performing any other service you may request of me24 hours notice. If you become involved in legal proceedings that require my participationmiss an appointment without canceling or cancel with less than 24 hour notice, you we will be expected discuss this with treatment interfering behavior at your next appointment. If possible we will try to pay for any professional time I spend on your legal matter, even if the request comes from find another party, at the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to time, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If it has been more than one year since our last reschedule the appointment, then you will re-initiate services at my current standard fee which may be higher than the fee you were previously paying. In addition, if it has been more than one year since our last appointment, you will be scheduled for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims to your insurance company for reimbursement for any out-of-network benefits you might have, you may do so. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for coming to your session on time; if you are late your appointment will still need to end on time. Consistent attendance concerns, despite feedback, will lead to termination of services. PROFESSIONAL RECORDS We maintain records of the full paymentservices that we provide. I have no role Your records are maintained in deciding what your insurance coversa secure location in the office. You have the right to a copy of your file. However, these are responsible professional records and may be misinterpreted by untrained readers. For this reason, only records that are appropriate for checking your insurance coverage, deductibles, payment rates, pre-authorization procedures, etc. Missed appointments, late cancellations (i.e., cancellations within 24 hours of service), and telephone session are not typically covered by insurance companies and therefore you release will likely be responsible for the full session fee in these instancesgiven directly to a patient. If you would like another professional to have these records, the appropriate records can be released to them for their review and assistance with continuity of care. You also have the right to request that a copy of your insurance company doesn’t reimburse you, I am not responsible for refunding you file be made available to any payment you expected to be reimbursed or otherwise. I will provide you a superbill after each session with the following information that you will need to submit to other health care provider at your insurance company for reimbursement for any out-of-network benefits you might have:written request.