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, 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. 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. 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. 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 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 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. 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 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 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. 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 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 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. ▇▇▇▇▇ ▇▇▇▇▇, 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 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. Psychological services may include evaluation, psychological testing, counseling, psychotherapy intervention, or consultation. 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 Possible liabilities include limited predictive validity of psychological assessment procedures and fatigue, especially in the early phases of treatmentpossible disagreement with opinions offered. 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, increased understanding of oneself, solutions to specific problems, and significant reductions in feelings of distress. While the provider will make an effort to develop a treatment intervention on your behalf, 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 will usually 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 shorter/longer or over the telephone) lasting 45 minutesmore/less frequent. 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 hour is scheduled, you will be expected to pay for any professional 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 I spend on your legal matter, even if to reschedule the request comes from another party, at the same $250 per 45-minutes rateappointment. I do am unable to provide 24 hour a day emergency coverage. I will be available for scheduled appointments. Due to my work schedule, I am often not charge for time spent writing reports immediately available by telephone. I probably will not answer the phone when I am with a patient. When unavailable, my telephone is answered by voice mail. I will make every effort to return your calls in a timely manner and progress notes as per the standard routine of to provide emergency sessions when possible. However, if regular emergency coverage is needed, arrangements outside my care of office will need to be made. I will be happy to discuss such arrangements with you. If you are difficult to reach, please inform me of some times when you will be available. In emergencies, you can try my emergency phone number ▇▇▇-▇▇▇-▇▇▇▇. If you are unable to reach me and feel that you can’t wait for me to return your call, contact Lifespan Outpatient Psychiatry and Urgent Care: in East Providence ▇▇▇-▇▇▇-▇▇▇▇; in East Greenwich ▇▇▇-▇▇▇-▇▇▇▇, ▇▇▇▇▇▇ Hospital, your physician or the nearest emergency room. If I also do not charge will be unavailable for any time I may spend collaborating with your other providers. From time to an extended time, I will provide you with the name of a colleague to contact, if necessary and will put contact information for my backup person on my voice mail message. You may institute fee increases contact me by e-mail if you choose, but please understand that I cannot guarantee confidentiality of e-mail contact given the limits of internet privacy. I am the only person in my office who will receive your e-mail and these I will dispose of the e- mail after seven days. By e-mailing me, you are giving me permission to e-mail you and you are taking on the risk that electronic communication can be discussed accessed by sophisticated computer users. The law protects the privacy of all communications between a patient and agreed upon ahead 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 may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of time my patient. Under no circumstances will I reveal your name or identifying information. However, to ensure top quality treatment, I may discuss certain aspects of a case with a new Treatment Contractcolleague who is also legally bound to keep the information confidential. Unless you request notice, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information). ● Although I currently have no administrative staff, you should be aware that I may employ administrative staff. In most cases, I 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. 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. ● I also have a contract with Claims Advantage Electronic Billing Service. I may employ other services as necessary to perform business procedures. As required by HIPAA, I have a formal business associate contract with these businesses, 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, I can provide you with a blank copy of this contract. I make an effort not to include patients names on information sent to these entities. ● Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. 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 a request is made for information concerning your diagnosis and treatment, 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 a court order, or if I receive a subpoena of which you have been properly notified and you have failed to inform me that you oppose the subpoena. 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 I do receive a subpoena or court order, I will make an effort to contact you by phone, if I have a current phone number for you, in order to inform you of the request. ● If a government agency is requesting the information for health oversight activities, within its appropriate legal authority, 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 necessary treatment related to that claim, I must, upon appropriate request, submit treatment reports to the appropriate parties, including the patient’s employer, the insurance carrier or an authorized qualified rehabilitation provider. 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. ▪ If I know, or have reason to suspect, that a child under 18 is abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child’s welfare, the law requires that I file a report with the Department of Child and Family Services. Once such a report is filed, I may be required to provide additional information. ▪ If I know or have reasonable cause to suspect, that a vulnerable adult has been more than one year since our last appointmentor is being abused, then you will re-initiate services at my current standard fee which neglected, or exploited, the law requires that I file a report with the central abuse hotline. Once such a report is filed, I may be higher required to provide additional information. ▪ If I believe that there is a clear and immediate probability of physical harm to the patient, to other individuals, or to society, I may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police or seeking hospitalization of the patient. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure only 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 I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes 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 I receive 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 carrier. Except in unusual circumstances that disclosure would physically endanger you and/or others, or makes reference to another person (other than a health care provider) and I believe that access is reasonably likely to cause substantial harm to such other person, 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. A copying fee of $0.25 per page (and for certain other expenses) may be assessed. I may withhold copies of your records until payment of the copying fees has been made. The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you were previously payinghave a right of review, which I will discuss with you upon request. In addition, if it has been more than one year since I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our last appointmentconversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you will may reveal to me that is not required to be scheduled included in your Clinical Record. They also include information from others provided to me confidentially. These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for another initial evaluation (90 minutes) your refusal to provide it. HIPAA provides you with several new or expanded rights with regard to your Clinical Records and charged accordinglydisclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Records 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, 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. Patients under 18 years of age who are 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, emancipated and their parents should be aware that the services provided will still be charged law may allow parents to youexamine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, not your insurance companyparticularly with teenagers, and you are responsible for parental involvement, is also essential, it is usually my policy to request an agreement with minors over 13 and their parents about access to information. This agreement provides that during treatment, I will provide parents only with general information about 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 progress of service)the treatment, 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 otherwisepatient’s attendance at scheduled sessions. I will also provide you parents with a superbill after each session summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the following information child, if possible, and do my best to handle any objections he/she may have. I understand that you the patient is responsible for all psychotherapy fees. At the patient’s request, the psychologist will need file insurance claims and will make an effort to submit assure that services are authorized. However, it is the patient’s responsibility to your pay fees if for any reason the insurance company for reimbursement for any out-of-network benefits you might have:does not cover psychotherapy fees. It is also the patient’s responsibility to assure that authorization requirements are met, to avoid rejection of claims by the insurance Company.

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 you hope to address. Psychotherapy is not like a typical visit to your medical doctor visitdoctor. 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 homewhile you are away. 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 SCHEDULING APPOINTMENTS. Call (▇▇▇) ▇▇▇-▇▇▇▇ 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 speak with me. At the end of the evaluation, I will notify you if I believe that If I am not the right therapist for available, leave a message on my voice mail that you would like to schedule an appointment and if so, I will give you referrals return your call. FEES. The fee for my services is $165 per hour (or 50 minute psychotherapy session). Exceptions to that rate may be made for students or for extenuating circumstances. Reduced rates are subject to review every three months. Any phone calls lasting more than 10 minutes will be billed at a pro-rated amount. Other billable services include but are not limited to: report writing, consulting with other practitioners who I believe are better suited to help you. Therapy involves a large commitment professionals with your permission, preparation of time, moneyrecords or treatment summaries, 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 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 . Because of the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine difficulty of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to timelegal involvement, I may institute fee increases charge $330 per hour for preparation and these will be discussed and agreed upon ahead of time with a new Treatment Contractattendance at any legal proceeding. 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 payingCANCELLATIONS. In addition, if it has been more than one year since our last appointment, you will be scheduled There are no charges for another initial evaluation (90 minutes) and charged accordingly, with subsequent 45-minute psychotherapy sessions thereafter. You that 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 cancelled 24 hours in advance. Charges are negotiable in case of service)sudden illness, and telephone session family emergencies, or accidents. All other missed appointments are not typically covered by insurance companies and therefore you will likely be responsible for the full session fee in these instances. If billed 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:regular fee.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statementsa process where you and your therapist work together to address the goals jointly established for the therapy. It varies depending on the personalities of the psychologist therapist and patient, and the particular problems your family is experiencing. Your therapist will contribute knowledge and expertise in mental health while you hope to addresswill bring specialized personal knowledge about your child and/or family. There are many different methods I they may use to deal assist you in reaching your goals. During your initial consultation(s), you and your therapist will work together to establish the needs, concerns, and goals for your child and/or family. If psychotherapy sessions appear to be appropriate, your first few sessions will involve evaluating the needs of your child and/or family and establishing a treatment plan outlining the issues you will work on and the desired goals/outcomes. You should evaluate this information along with those problemsyour own opinions of whether you feel comfortable working with the therapist. Psychotherapy is not like Therapy involves a medical doctor visit. Insteadlarge commitment of time, it calls for a money, and energy, so you should be very active effort on your partcareful about the therapist you select. In order for the therapy to be most successful, you it will have be essential for your child and/or family to work on things we talk about various skills both during our the sessions and at homehome between sessions. If you have any problems or concerns about the course of treatment, please discuss them with your therapist immediately. If requested or if deemed appropriate, your therapist will help you secure an appropriate consultation with another provider. 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 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 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 In addition to my psychology training, I have extensive training and experience with religious issues. I am quite comfortable discussing and assisting you with any religious concerns. It may be beneficial/necessary to consult your /minister/priest for further assistance. 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 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 24 hours [1 business days] advance notice of cancellation [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. [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 the nearest emergency room. appointment.] My hourly fee is $395 for an initial evaluation lasting 90 minutes130.00. 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 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 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 rate of 300.00 per 45-minutes ratehour. Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by an answering service [machine, voice mail, or by my secretary] [that I monitor frequently, or who knows where to reach me]. I do not charge will make every effort to return your call on the same day you make it, 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 time spent writing reports me to return your call, contact your family physician or the nearest emergency room and progress notes as per ask for the standard routine of my care of youpsychologist [psychiatrist] on call. If I also do not charge will be unavailable for any time I may spend collaborating with your other providers. From time to an extended time, I 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, 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 may institute fee increases occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are 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. I will be discussed note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and agreed upon ahead Practices to Protect the Privacy of time Your Health Information).  I work with a new Treatment Contractgroup of independent mental health professionals. This group is an association of independently practicing professionals which share certain expenses and administrative functions. While the members share office space, I want you to know that I am completely independent in providing you with clinical services and I alone am fully responsible for those services. My professional records are separately maintained and no member of the group can have access to them without your specific, written permission.  You should be aware that since I practice with other mental health professionals and that I employ administrative staff, in most cases, I need to share your 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.  I may also have contracts with business outside of this office (i.e. such as billing and collection services). As required by HIPAA, I have 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, I 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 seriously 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. 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 a request is made for information concerning the professional services I provided to you, such information is protected by the psychologist- patient privilege law. I cannot provide any information without your 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 me to disclose information.  If a government agency is requesting the information for health oversight activities, 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 I am treating a patient who files a worker’s compensation claim, I may, upon appropriate request, be required to provide otherwise confidential information to your employer. 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 have reason to believe that a child who I am evaluating or treating is an abused child, the law requires that I file a report with the appropriate government agency, usually the Department of Public Welfare. Once such a report is filed, I may be required to provide additional information.  If I have reason to believe that an elderly person or other adult is in need of protective services (regarding abuse, neglect, exploitation or abandonment), the law allows me to report this to appropriate authorities, usually the Department of Aging, in the case of an elderly person. Once such a report is filed, I may be required to provide additional information.  If I believe that one of my patients presents a specific and immediate threat of serious bodily injury regarding a specifically identified or a reasonably identifiable victim and he/she is likely to carry out the threat or intent, I may required to take protective actions, such as warning the potential victim, contacting the police, or initiating proceedings for hospitalization If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my 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 I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. You should be aware that, pursuant to HIPAA, I may keep Protected Health Information about you in two sets of professional records. One set constitutes 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 I receive 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 carrier. Except in unusual circumstances that involve danger to yourself and others or where information has been more than one year since our last appointmentsupplied to me by others confidentially, then or the record makes reference to another person (unless such other person is a health care provider) and I believe that access is reasonably likely to cause substantial harm to such other person, 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. [I am sometimes willing to conduct this review meeting without charge.] In most circumstances, I am allowed to charge a copying fee and for certain other expenses. The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your records, you have a right of review (except for information supplied to me confidentially by others) which I will re-initiate services at my current standard fee which may be higher than the fee discuss with you were previously payingupon request. In addition, if it has been more than one year since I may also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our last appointmentconversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you will may reveal to me that is not required to be scheduled included in your Clinical Record. These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for another initial evaluation (90 minutes) your refusal to provide it. 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 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, 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. Patients under 18 years of age who are 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, emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes my 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, I will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. 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 provided will still be charged agreed to youwhen they are requested. [In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan.] If your account has not been 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 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 which you are entitled; however, you (not your insurance company, and you ) are responsible for the full paymentpayment of my fees. 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 should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, deductiblescall your plan administrator. Of course, 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 whatever information that you will need to submit to your insurance company for reimbursement for any out-of-network benefits you might have:I can based on my expe

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities encompasses a variety of the psychologist services and patient, and the particular problems you hope to addresstechniques. There are many different methods I your therapist may use to deal help you 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 Successful outcomes rely on your part. In order for being active in the therapy to be most successfulprocess, and you will might have to work on things we talk about both during our at home between sessions. The therapist’s job is not to “fix” your problem; rather, to be a guide and teacher to help you navigate a new way of thinking about and dealing with troubling issues. Techniques and strategies learned in therapy sessions and at homeonly begin to work when they are used in your daily life. 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 your therapist will be able to offer you some first impressions of what our work will include and include, along with a suggested 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 selecttherapist. If you have questions about my our procedures, we they should discuss them be discussed whenever they arise. If your doubts persist, I we will be happy to help you set up a meeting with another mental health professional for a second opinionrecommend other clinicians. 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 We will usually 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 or less frequent, as agreed upon between you and your therapist. 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 I spend on it unless you provide 24 hours advance notice of cancellation (unless you and your legal mattertherapist both agree that you were unable to attend due to circumstances beyond your control). Notice of cancellation may be given by phone, 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 Contractemail or text message. If it has been more than one year since our last is possible, we 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 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 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 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 50-minute session (one appointment hour of 50 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. 2-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in15-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:10

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist therapist and the patient, and the particular problems you hope to addressare experiencing. 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 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 evaluationfirst few sessions, I your therapist will be able to offer you some first impressions of what our work your therapy 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 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 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 doubts persist, I we will be happy to help you set up a meeting with another mental health professional for a second opinion. Please note that At the psychological end of the initial one-hour session, you can decide along with your therapist if he or she is the best person to provide the services I provide you or your child or family need in order to meet treatment goals. If psychotherapy is begun, we will usually schedule one 45 to 50-minute individual session per week at a time we agree on, although in some cases sessions may be longer or more frequent. Family sessions 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 minuteslonger, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I charge this same $250 per 45may be between 60-minutes rate for other professional services you may need, though I will prorate the cost if I work for periods of less than 45 and 90- minutes in increments of 15 minutes, rounded to the nearest 15-minute increment (e.g., 22 duration. Group sessions are 75 minutes of service will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes)in duration. 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 I spend on your legal matter, even if the request comes from another party, at the same $250 per 45a late cancellation or “no-minutes rateshow” fee unless you provide 24 hours advance notice of cancellation. I We do not charge for time spent writing reports and progress notes as per the standard routine of my care of youif we both agree that you were unable to attend due to circumstances beyond your control. I also It is important to note that insurance companies do not charge provide reimbursement for any time I may spend collaborating with your other providerscancelled or “no-show” sessions. From time Due to timeour work schedules, I may institute fee increases and these will be discussed and agreed upon ahead of time we are often not immediately available by telephone. We do not answer the phone when we are with a new Treatment Contractpatient. When we are unavailable, our telephones are answered by voice mail, which we monitor frequently. We will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. 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 us 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 are unable to submit claims reach us and feel that you can’t wait for us 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 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 coverspsychiatrist on call. You are responsible for checking your insurance coverage, deductibles, payment rates, precan also contact the ▇▇▇▇▇ ▇▇▇▇ Respond Line at ▇▇▇-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 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 ▇▇▇-▇▇▇▇, 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 ; 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 ▇▇▇-▇▇▇-▇▇▇▇. 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 ▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. is a Hush mail encrypted, HIPPA compliant service, I would prefer that confidential information is conveyed over my land line office number ▇▇▇-▇▇▇-▇▇▇▇, sent to my land line facsimile ▇▇▇-▇▇▇-▇▇▇▇, or mailed directly to my office, ▇▇▇ ▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇, ▇▇▇▇▇▇▇▇▇▇, ▇▇ ▇▇▇▇▇-▇▇▇▇. My preferred general, NOT HIPPA compliant, email address is ▇▇.▇▇▇▇▇▇▇▇@▇▇▇▇▇.▇▇▇ If you are an established patient of mine, I do have a digital pager ▇▇▇-▇▇▇-▇▇▇▇ 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 ▇▇▇-▇▇▇-▇▇▇▇ 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 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 The therapy experience varies depending on the personalities personality of both the psychologist therapist and patient, the client and the particular problems you hope which the client brings to addresstreatment. There are many a number of different methods I theoretical approaches in the field of psychotherapy. All are designed to address the problems that you are coming here to work on, but therapy may use look very different from one approach to deal with those problemsanother. 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. Voicing opinions, thoughts, and feelings honestly and openly to your therapist, including about the therapeutic process, is an important part of the overall treatment outcome. Psychotherapy and cognitive behavioral therapy (CBT) can have benefits and risks. Because Since therapy involves addressing difficult and often involves discussing unpleasant aspects fearful issues, during the course of your life, therapy you may experience uncomfortable feelings like feelings, such as guilt, 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 treatmentetc. On the other hand, psychotherapy CBT in particular has also been shown consistently demonstrated to have benefits for people who go through it. Therapy often leads be helpful in the significant reduction of negative experiences such as distress and sadness, to better relationships, solutions enable people to specific problems, significant reductions in feelings of distress, improved sleepcontrol self-destructive behaviors, and less fatigue. But there are no guarantees as to what you will experienceoverall increase quality of life and one’s satisfaction in day to day living. Our first session few sessions will involve an evaluation of your needs. By the end of the this evaluation, I will be able to offer you some first impressions of what our your work will include and a treatment plan pertaining to follow, if the problems you decide to continue with me for therapydiscussed. 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 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. Psychotherapy Therapy is not easily described a relaHonship between people that works in general statementspart because of clearly defined rights and responsibiliHes held by each person. It varies depending on the personalities of the psychologist As a client in counseling, you have certain rights and patient, and the particular problems responsibiliHes that are important for you hope to addressunderstand. There are many different methods I also legal limitaHons to those rights that you should be aware of. I, as your counselor, have corresponding responsibiliHes to you. These rights and responsibiliHes are described in the following secHons. Counseling has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustraHon, loneliness and helplessness, because the process of counseling ▇▇▇▇ requires discussing the unpleasant aspects of your life. However, counseling has been shown to deal with those have benefits for individuals who undertake it. Counseling ▇▇▇▇ leads to a significant reducHon in feelings of distress, increased saHsfacHon in interpersonal relaHonships, greater personal awareness and insight, increased skills for managing stress and resoluHons to specific problems. Psychotherapy is not like a medical doctor visitBut, there are no guarantees about what will happen. Instead, it calls for Counseling requires a very active effort acHve 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 to 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 evaluation a comprehensive evaluaHon of your needs. By the end of the evaluationevaluaHon, I will be able to offer offer you some first iniHal impressions of what our work might include. At that point, we will include discuss your treatment goals and a create an iniHal treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with informaHon 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 quesHons 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 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 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. I provide psychotherapy for the treatment of mood and anxiety disorders, issues of adjustment, relationship problems, grief and loss, identity concerns, coping with trauma, and posttraumatic stress disorder. I also provide career counseling. I welcome clients who identify along the LGBTQ spectrum and I have previous experience working with clients on issues of gender and sexuality, including transgender identity. I respect and affirm all aspects of culture and identity which may be important or relevant for clients, such as race or ethnicity, nationality, gender, sexuality, spirituality or religion, and physical ability. All services are provided through my professional practice, ▇▇▇▇▇ ▇▇▇▇▇ Counseling, PLLC (“KMC”). Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patientclient, and the particular problems concerns you hope bring forward. My approach to addresspsychotherapy integrates cognitive and behavioral principles, interpersonal process approaches, feminist and multicultural theory, and mindfulness-based approaches. There are many different The methods I may use to deal with those problems. Psychotherapy is not like a medical doctor visit. Insteadutilize are informed by theory, it calls for a very active effort on your part. professional literature, research evidence (when available), and “best practices.” In order for to provide you with the therapy to be most successfulbest possible services, you will have to work on things we talk about both during our sessions I am engaged in ongoing professional development activities, such as reading professional publications, seeking consultation with colleagues, and at homeattending continuing education and training events. Psychotherapy can have benefits and risks. Because therapy often Therapy usually involves discussing unpleasant aspects a substantial commitment on your part in terms of your lifetime, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, lonelinessmoney, and helplessnessenergy. When treating insomnia specificallyIn my experience, 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 clients who put more effort into working on their goals between sessions tend to have greater benefits for people who go through itfrom counseling. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. You should know that sometimes people find that they feel worse before they feel better. Making changes in your life, improved sleepworking through emotional difficulties, shifting your ways of thinking, trying new behaviors, developing new patterns, and less fatiguegaining self-awareness or insight is often challenging. But there Although it is impossible to guarantee outcomes, if we decide to work together I will make every effort to help you succeed. Your sessions are no guarantees as your time to what discuss any topics that you will experiencefeel are appropriate. You may end our counseling relationship at any time. You also have the right to refuse any of the suggestions I make, and to initiate discussion about how the therapy is going for you. I invite you to provide [continued on following page] honest and direct feedback about the therapy process, and any concerns you may have about counseling or about me. Please talk with me about these things so that we may address them. I may also initiate discussions about your progress. If it seems that you are not making progress toward your goals or benefiting from therapy, I may recommend that we end counseling. Our first session (or sometimes 2 sessions) will involve be an evaluation of your needsinitial consultation. By the end of the evaluationDuring this time, I will be able to assess your needs and offer you some first impressions of what our work impressions. Together we will include set goals for therapy 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 make treatment recommendations to help you set up reach those goals. 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 recommend weekly sessions (typically 60 minutes per appointment) initially so that we can build a therapeutic relationship and establish some momentum in our work together. As we continue to meet we can re-evaluate whether 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 more or go to the nearest emergency roomless frequently would be appropriate. My hourly fee is $395 190 for an the initial evaluation lasting 90 minutesassessment. Individual sessions are $190 (55 min.). 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 my fee schedule for other professional services you may needneed is detailed on KMC’s Fee Agreement and Financial Policy, 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 which 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, given to you along with this Agreement and the time spent performing any other service you may request Notice 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:Privacy Practices.

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 are 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 will involve an evaluation of your needs. By the end of the intake evaluation,, I we will be able to offer you some first discuss initial clinical impressions of what our work will include and a treatment plan to follow, if you decide to continue with me for therapytherapeutic goals. 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 youus. 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 doubts persist, I we will be happy to help you set up a meeting secure an appropriate consultation with another mental health professional professional. The following units of time and fees are set for these therapy sessions: Individual session—60 minutes One hour @ $220 Individual psychotherapy session—45 minutes 45 min @ $195 In addition to appointments, it is our practice to charge a second opinion. Please note that the psychological services I provide are not for emergency situations. For emergenciesfee, call 911 or go to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minuteson a prorated basis, 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 that you may needrequire such as report writing, though I will prorate the cost if I work for periods of less telephone conversations which last more than 45 minutes in increments of 15 10 minutes, rounded scoring tests you may take, attendance at meetings or consultations with other professionals which you have authorized, travel time to the nearest 15-minute increment (e.g.those meetings, 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 records or email responses lasting longer than 15 minutestreatment summaries, and or the time spent performing required to perform any other service which you may request of meus. If This fee is now $220.00 per 60 minutes and is prorated. Should you become involved in legal proceedings litigation that may require my our participation, you will be expected to pay for any of our professional time I spend that is required, unless the other party has agreed or is compelled to pay. You should also be aware that we charge a $1,000 retainer for preparation and testimony for court or a deposition. If you anticipate that you may be involved in litigation, please discuss this with us as soon as possible so that we may review any concerns you might have. WE DO NOT PARTICIPATE IN ANY MANAGED CARE OR INSURANCE AGREEMENTS, You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, we will provide you with whatever information we can based on your legal matterour experience. Due to the rising costs of health care, even if the request comes from another party, at the same $250 per 45insurance benefits have increasingly become more 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. These plans are often limited to short-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 term treatment approaches designed to time, I may institute fee increases and these will be discussed and agreed upon ahead of time work out specific problems that interfere with a new Treatment Contractperson’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. When we are unavailable, because we are in session or out of the office, our telephone is answered by a voice mail system that we monitor frequently. We will make every effort to return your call within 24 hours, with the exception of weekends and holidays. 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 us of some times when you will be scheduled for another initial evaluation (90 minutes) and charged accordinglyavailable. In emergencies, with subsequent 45-minute psychotherapy sessions thereafter. You are responsible for paying your full session fee. I am not in-network with any insurance companiesplease follow the instructions on our voicemail system. If you decide are unable to submit claims reach us and feel that you can’t wait for us 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 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 on call.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies specific terms, as it will vary depending on the personalities of the psychologist and patient, and the client as well as by the particular problems you hope to addressbring forward. There are many different Different treatment methods I may use to deal will fit best with those problemsyour problems or be a more comfortable fit with your personality. Psychotherapy is not like may have benefits such as a medical doctor visitsignificant reduction in distress, improved social relationships, resolution of specific problems, and clearer understanding of yourself, your values, and your goals. InsteadHowever, it calls for a very active effort on your partthere are no guarantees about what will happen in therapy. In order for the For therapy to be most successful, you will have to work be able to talk openly and honestly, be completely honest with your therapist, address any difficulties that arise, and attend regularly. To fully benefit from therapy, you will have to take an active role, both in session and outside of session. Working on things we talk about both during your problem must extend outside of our sessions and at homesession time to produce lasting changes. Psychotherapy can may also have benefits and risks. Because therapy Therapy often involves requires discussing unpleasant aspects of your history and current life. Therefore, you in the initial stages of treatment, psychotherapy may experience lead to uncomfortable levels of feelings like sadness, guilt, anxiety, anger, frustration, loneliness, and helplessnesshelplessness and could impact your relationship with others. When treating insomnia specificallyWhile unpleasant experiences are usually temporary, please let me know if they occur. Psychotherapy differs from medical doctor visits. With therapy, improvement is not usually completed in one or two sessions; psychological problems require much more treatment than curing a simple medical issue. Most problems people bring to therapy might cause you did not start overnight, so it is reasonable to experience increased sleepiness and fatigue, especially in the early phases of treatment. On the other hand, psychotherapy has expect that solutions may also been shown take longer 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 experienceachieve. Our first session few sessions will involve an evaluation of your problem, your situation, and your needs. By the end of the evaluation, I we will be able to offer go over you some first initial impressions of what our work will include and a discuss an initial treatment plan to follow, if you decide to continue with me for therapyplan. You should evaluate this information along with your own opinions assessment about whether you feel comfortable working with me. At the end of the evaluationDuring this time, I will notify you if I believe that we can both decide whether 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 you have any questions about my proceduresas our treatment progresses, we should please discuss them whenever with me as they arise. If your doubts persist, I will be happy can provide you with referrals to help you set up a meeting with another other mental health professional for a professionals if you would like second opinionopinion or wish to change therapists. 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 timeSometimes, I may institute fee increases and these will be discussed and agreed upon ahead of time with a new Treatment Contract. If feel that the fit between us 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 feenot right. I am not in-network with reserve the right to refer you to other mental health professionals at 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. time if 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:feel it is clinically indicated.

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. Once an appointment hour is scheduled, you will be happy expected to help pay for it unless you set up a meeting with another mental health professional for a second opinionprovide 24 hours advance notice of cancellation. Please 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 minutes125. 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 telephone conversations or email responses lasting longer than 15 minutes, 20 minutes and the time spent performing any other service you may request request. Due to my work schedule, I am often not immediately available by telephone. My telephone is answered by voice mail that I check periodically during my work day. I will make every effort to return your call on the same day you make it, with the exception of meweekends and holidays. If you become involved in legal proceedings that require my participationare difficult to reach, please inform me of some times when 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 companiesavailable. If you decide are in crisis and feel that you can’t wait for me to submit claims to return your insurance company for reimbursement for any outcall, contact your family physician or the nearest emergency room or the crisis hotline at 1-of800- 479-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 instances3339. 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. 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 state law and/or HIPAA. But, there are some situations where I am permitted or required to disclose information without either your consent or Authorization. If you are in danger of hurting yourself and/or someone else I am obligated to take protective action, including seeking hospitalization or contacting family members or others who can help provide protection. I will make every effort to discuss it with you before taking any action and I will limit my disclosure to what is necessary. If you inform me of any situations of child abuse, or abuse of elderly or legally dependent adults, I am obligated to make a report to the appropriate authorities. My duty to report also applies to situations that you will need tell me about that do not involve you directly. Confidentiality may also be broken due to submit a court order or other legal situations. Please refer to the Notice of Privacy Practices for a more detailed explanation. It is important to understand how psychotherapy is affected by legal proceedings. I believe that it is in your insurance company for reimbursement for any out-of-network benefits you might havebest interest to protect your psychotherapy from the intrusiveness of legal proceedings. Here are three reasons:

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. 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 1-2 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 note APPOINTMENTS Appointments will ordinarily be 50-55 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent, depending on your needs. Appointments will take place online, on a HIPAA compliant service so your information is secure. 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, you are responsible for paying the psychological services full rate of the session [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. 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 PROFESSIONAL FEES The fees work on a sliding scale; due to the nearest emergency roomcurrent COVID conditions, the fees range from $40-70 per hour. We will work together to arrange what is affordable for you. My fee is rates will eventually return to normal in December 2020, starting from $395 65-125. You are responsible for an initial evaluation lasting 90 minutespaying at the time of your session unless prior arrangements have been made. Payment must be made by check, and $250 for each subsequent psychotherapy session (either in-person cash, Zelle or over the telephone) lasting 45 minutesPayPal. I am also able to process credit card charges as payment through my website ▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. 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 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 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 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 50-60 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 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, 180.00 and $250 for each subsequent psychotherapy session (either in-person is $140.00. You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by check or over cash; I am not able to process credit card charges as payment. 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 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 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 whose services you may render for a second opinion. Please note 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 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 will usually 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 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 hour is scheduled, you will be expected to pay for any professional time I spend on it unless you provide 48 hours [2 days] advance notice of cancellation [unless we both agree that you were unable to attend due to circumstances beyond your legal matter, even if the request comes from another party, at the same $250 per 45-minutes ratecontrol]. I It is important to 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 youcancelled sessions. [If it is possible, I also do not charge for any time I may spend collaborating with your other providers. From will try to find another 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 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 may involve a variety of activities designed to support you in general statementssuccessfully resolving the difficulties or conditions, which have led you to seek therapy. It varies depending on the personalities of the psychologist is a learning process and patientour therapy will be most successful if you engage openly and honestly in it, and the particular problems apply what 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 discovering in how you live 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 homelife. Psychotherapy can have benefits and risksrisks as well as benefits. Because Since therapy often involves discussing exploring unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, These feelings (and others which you may dislike) are often an essential element in successful therapy; such 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 can lead to better relationships, solutions to specific problems, and significant reductions increases 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 therapyone's well being. You should evaluate consider this information along with your own opinions about in choosing whether you feel comfortable working to work 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 proceduresapproach or other relevant matter, we should discuss please bring them whenever up as they arise. If your doubts reservation or objections 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 situationsbetween us. For emergencies, call 911 or go to the nearest emergency room. My fee Once an appointment hour 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 participationscheduled, you will be expected to pay for any professional it unless you provide 24 hours advance notice of cancellation. My fee is $120 for individual therapy and $140 per hour for couples counseling. Much of the time I spend on your legal matteram not immediately available by telephone. When I am unavailable, even if the request comes from another party, at the same $250 per 45-minutes ratemy telephone is answered by voice mail that I monitor frequently. I do not charge for time spent writing reports will make every effort to return your call promptly, 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 leave in your message 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 feeavailable. I am not in-network with any insurance companiesmay also be reached by email at ▇▇▇▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. 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 outcall, contact your family physician or the University of Neuropsychiatric Institute at ▇▇▇-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 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 with a superbill after each session name of a colleague to contact if necessary. Professional ethics as well as the laws of the State of Utah protect the privacy of communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written authorization. I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are 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. Unless you specifically request otherwise, your signature on this Agreement provides consent for those activities. I am required to disclose confidential information if certain specific conditions exist. These are detailed in the accompanying Notice of Policies and Practices to Protect the Privacy of Your Health Information. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. HIPAA sets forth specific definitions and standards for Protected Health Information. These are detailed in the following information that you will need accompanying Notice of Policies and Practices to submit to your insurance company for reimbursement for any out-of-network benefits you might have:Protect the Privacy of Your Health Information.

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 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 ▇▇. ▇▇▇▇▇▇ 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 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. 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 typically 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 hours’ notice, my policy is to collect the psychological services amount of your session [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. 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, 180.00 and $250 for each subsequent psychotherapy session (either inis $150.00. The intake session may last longer than the typical 45-person 50 minute appointment. You are responsible for paying at the time of your session unless prior arrangements have been made. Payment may be made with cash, check, 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 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 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 or exploring 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, 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 and there are no guarantees as 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 yousuccess or outcome. 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 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 I often employ hypnosis, hypnotherapy and related strategies (e.g. imagery/visualization, using imagination) as part of psychotherapy. There are many commonly held misconceptions about hypnosis, and I will do my best to discuss pertinent issues about hypnosis with you. Feel free to ask me about this. Hypnosis can help memory, but it is very important for you to understand that hypnosis can distort memory. Memories, dreams, images and other experiences that you have in association with or through the psychological services I provide use of hypnosis, hypnotherapy or related strategies are not for emergency situations. For emergencies, call 911 necessarily truthful 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:valid.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist clinician 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 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 assessment of your needs. By the end of the evaluationassessment, 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 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 facilitate a referral to another treatment provider. If psychotherapy is begun, I will usually schedule one 50-55-minute session (one appointment hour of 50-55 minutes duration) per week at a time we agree on. Once an appointment is scheduled, you set up may be expected to pay a meeting with another mental health professional for a second opinion$50 charge unless you provide 24 hours advance notice of cancelation. Please The charge will be (It is important to note that the psychological services insurance companies do not provide reimbursement for missed sessions. Though I provide do offer reminder messages as a courtesy, your appointments are not for emergency situations. For emergencies, call 911 or go to the nearest emergency room. your responsibility.) My fee for the first session is $395 for an initial evaluation lasting 90 minutes145. Subsequent sessions are charged at $135 per 53-minute session. In addition to weekly appointments, and $250 for each subsequent psychotherapy session (either in-person or over the telephone) lasting 45 minutes. I may charge this same $250 per 45-minutes rate amount for other professional services you may might 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 letter or 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 me. If you become involved in legal proceedings that require my participationparticipation (whether or not you initiated these proceeding), you will be expected to pay for any all of my professional time I spend on your legal mattertime, including preparation and transportation time, even if the request comes from I am called to testify by another party. Because of the difficulty of legal involvement, I charge $200 per hour for preparation and attendance at the same $250 per 45-minutes rateany legal proceeding. Due to my work schedule, I am often not immediately available by telephone. My office hours are by appointment only. I do will not charge for time spent writing reports and progress notes as per answer the standard routine of my care of you. phone when 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 am with a new Treatment Contractclient. When I am unavailable (including during normal business hours), my telephone is answered by an answering machine that I monitor frequently. You can expect to hear a response from me 12-24 hours during weekdays, and by the next business day if on the weekend or holiday. 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 are unable to submit claims reach me and are in an emergency situation you should call Crisis Response Services at The law protects the privacy of all communications between a client and a clinician. In most situations, I can only release information about your treatment to your insurance company for reimbursement for any out-of-network benefits others if you might havesign a written Authorization (release) form that meets certain legal requirements imposed by HIPAA and/or Maine law, or in some cases, if you may do soprovide oral authorization. However, be aware that the services provided will still be charged to you, not your insurance company, and you are responsible for the full paymentin some situations no authorization is required. I have no role may use or disclose PHI without your consent or authorization 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 circumstances: • Child Abuse • Adult and Domestic Abuse • Health Oversight Activities • Judicial and Administrative Proceedings • Serious Threat to submit to your insurance company Health or Safety • Worker’s Compensation (See HIPAA Notice for reimbursement for any out-of-network benefits you might have:further explanation and details.)

PSYCHOLOGICAL SERVICES. Psychotherapy is Our first contact will consist of a free 15-minute phone consultation during which you and I will make an initial determination about whether or not easily described in general statementswe believe my services are a good fit for you. It varies depending on If we decide to proceed from there, the personalities following 1-2 sessions will be considered an initial assessment period, which may include one or more 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 following: an evaluation of existing current distress, a discussion of the factors that are contributing to your needscurrent concerns, and a complete psychological history. By At any time during these contacts, and no later than the end of the evaluationsecond session, I will discuss with you whether or not I believe that you could benefit from my services, or if other services/care providers would be able best suited to meet your needs. If we both determine that you could potentially benefit from my services, I will offer you some first initial impressions of what our work will together would include and recommend 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 meme to decide if you wish to continue the recommended course of treatment. At the end of the evaluationThroughout our work together, I will notify offer a variety of professional therapeutic techniques that will likely include facilitation of self- awareness, encouragement of new insights, experimentation with new behaviors, and new ways of looking at yourself and your life circumstances. Change usually involves letting go of things that are familiar in order to make room for new possibilities to emerge. Also, changes that you if make in one area of your life (e.g. your interpersonal style) may induce changes in other areas (e.g. your relationships with others). All in all, there are no guarantees of what you will experience, the results you will achieve, or how you will feel during and after working together. I believe that I am not the right therapist for you single most important factor in the success of therapy is the relationship between the client and if so, I will give you referrals to other practitioners who I believe are better suited to help youthe therapist. Therapy involves a large commitment If at any point during the course of time, money, and energy, so you should be very careful about therapy it is determined by either the therapist you select. If you have questions about my proceduresor the client that other treatment alternatives are a better fit, 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 with referrals for alternative treatment services. Also, I may determine that supplemental treatment recommendations (e.g. psychotropic medications, reduction or cessation of drug/alcohol use, 12-step programs, a superbill after each session with the following information that you medical evaluation, etc.) would strongly support or be required for your continued use of my services. In some situations, my willingness to provide services will need to submit to be dependent upon your insurance company for reimbursement for any out-of-network benefits you might have:participation in these additional treatment recommendations.

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 of which you should be aware. As your psychologist, I may use have corresponding responsibilities to deal with those problemsyou. These rights and responsibilities are described below. Therapy is a way of talking through your problems in order to begin resolving them. Psychotherapy is not like a medical doctor visit. Instead, it calls for you will need to play a very active effort role in deciding on treatment goals, discussing how to pursue those goals, and practicing new skills outside of session. Depending on the particular problems you bring forward, there are many different methods I may use to help, and a number of new skills I will teach you so that you can begin to better manage your problems on your partown. In order for the therapy to be most successfuleffective, you will have to work on think about and practice the things we talk about discuss both during our sessions and at homehome in between 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 Therapy has also been shown to have benefits for people who go through itmany benefits. You will likely learn to cope better with difficult emotions and situations, and communicate better with others. Therapy often leads to better relationships, solutions to specific problemsproblems you are facing, 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, and at times a therapy session may cause you to experience uncomfortable feelings, such as sadness, anger, anxiety, frustration, or loneliness. While I cannot prevent the experience of these emotions, I will help you to develop tools to cope with these feelings. Our first session will involve an be a formal evaluation of your needsneeds and, depending on the complexity of your problems, this evaluation may take a few sessions. By the end of the evaluation, I will be able to offer you some first impressions of what you are experiencing, and what our work together will include and a treatment plan to follow, if you decide to continue with me for therapy. You should evaluate consider this information very carefully, 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 it is critical that you should be very careful about the feel comfortable working with any therapist you select. If you have questions about my proceduresor concerns at any point, we you should feel free to discuss them whenever they arisewith me. With every new client, I conduct a thorough psychological evaluation that takes approximately an hour and a half. Thus, for your first session, you should plan to be at my office for at least two hours. This time will involve the review and completion of forms and questionnaires, as well as a clinical interview where I will ask about your history, thoughts, emotions, behaviors, and experiences you have had. If your doubts persistexperiences are complex or you need more time to tell your story, this evaluation may take longer than one session. By the time the evaluation is complete, we can both decide if I am the best person to provide the services you need to meet your treatment goals. If psychotherapy is begun, we will collaboratively decide on treatment goals and which problems to focus. We will typically meet once per week for 50 minutes at an agreed upon time, although sometimes sessions may be happy longer or more frequent if you need them to help you set up be. To schedule a meeting session, please call or text (▇▇▇) ▇▇▇-▇▇▇▇ with another mental health professional for a second opinion. Please your name and requested appointment date and time; however, please note that the psychological services I provide are your appointment is not for emergency situationsofficially scheduled unless you speak to me directly or you have received a confirmation email or text. For emergencies, call 911 or go to the nearest emergency room. My fee Once an appointment 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 participationscheduled, you will be expected to pay for any professional time I spend on the session in full, unless you provide 24 hours advance notice of cancellation (or we agree that you were unable to attend due to circumstances beyond 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 Contractcontrol). If it has been more than one year since our last is possible, I will try to find another time to reschedule your 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 also responsible for paying your full session fee. I am not in-network with any insurance companies. If you decide to submit claims coming to your insurance company for reimbursement for any out-of-network benefits sessions at the agreed- upon time; if you might haveare late, your appointment will still need to end on time so as not to inconvenience other clients. Therapy is conducted at one of my offices. My primary office is located in the Upper West Side neighborhood of Manhattan at ▇▇▇ ▇. ▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇ ▇▇, ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇. My secondary office is located on the Columbia University Medical Center campus at ▇▇▇ ▇. ▇▇▇▇▇ ▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇▇ ▇▇▇ ▇▇▇▇, ▇▇ ▇▇▇▇▇. Appointments at the Upper West Side location are available on Tuesdays, while appointments at the CUMC location at available on Thursdays. Other days may also be available upon request. On certain occasions, you may do so. Howeverwish to conduct a session at a different location, such as your home or school; this can also 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 arranged if advance notice 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:week is given.

PSYCHOLOGICAL SERVICES. Psychotherapy is not easily described in general statements. It varies depending on Cognitive-behavioral psychotherapy involves jointly setting treatment goals and weekly agendas, and discussing the personalities techniques to be used as part of the psychologist treatment. There are many different cognitive and patient, and behavioral techniques that may be helpful in dealing with the particular problems that you hope to address. There are many different methods I may use to deal with those problemsIf you have any questions about my procedures, we should discuss them whenever they arise. Psychotherapy is not like a medical doctor visit. Instead, it calls will call for a very an active effort on your partthe part of the child/adolescent patient, and often include the parent(s) as well. In order for the therapy to be most successful, you the patient and sometimes parent(s) will have to work on things we talk spoken about both during our in therapy sessions and at home. Psychotherapy can have benefits and risks. Because Since therapy often involves discussing unpleasant difficult aspects of your or your child’s life, you may experience uncomfortable feelings like sadness, guilt, or 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 I normally conduct an initial evaluation that will involve last approximately 2 sessions. A parent must be present during this intake period. Parents’ inclusion in subsequent sessions will be determined on an evaluation individual basis. During the intake period, the patient, parent and I will decide if I am the best person to provide the services needed in order to meet treatment goals. Also, it is highly recommended for you to provide me with information of your needscollateral contacts (e.g., physicians, psychiatrists, educators, previous treatment providers), for which a signed authorization form will allow us to exchange information. By Once the end of the evaluationintake process is completed, we will discuss my treatment recommendations. If psychotherapy begins, I will usually schedule one 45-minute session per week at a time we agree on. The session time includes any parent contact, individual psychotherapy provided to the child/adolescent, and joint sessions with parents or other family members. If there is a clinical issue that the parent wants to discuss, it should 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 noted at the end outset of the evaluationsession rather than at the end, so I will notify you if I believe that can allot ample time to discuss the matter. I am not the right therapist for you supervised by a licensed psychologist, ▇▇. ▇▇▇▇▇ ▇▇▇▇▇, Dr. ▇. ▇▇▇▇ ▇▇▇▇▇▇, or another New York Behavioral Health supervisor. My supervisor and if so, I will give you referrals meet regularly to other practitioners who discuss cases 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 selectmanage. If you have any questions about my procedureshow this supervision works, we should discuss them whenever they ariseplease let me know and I can provide further details. If your doubts persist, I The fees are $____ for the initial intake session and $ per session thereafter. You will be happy expected to help you set up a meeting with another mental health professional pay for a second opinioneach session at the time it is held. You may pay by check or cash. Please note in the case of a returned check you will be charged a check nonsufficient funds fee of $40.00. Bills 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 minutes60 days past due may be placed in collections. I will inform you before I take this measure so that you will have the opportunity to pay promptly. Once an appointment is scheduled you will be expected to pay for it unless you provide 24 hours advance notice of cancellation. If payment is not received for the canceled session your credit card will be billed. Please provide your credit card information below: Name on credit card: __________________________ Type of card: Visa Master Card American Express Discover Card Number: ____________________________________________ Billing Address: ___________________________________________ Expiration date: Security code: _______________ Please arrive to sessions on time. If you arrive late, that time will be deducted from your 45- minute session time. In addition to weekly appointments, I may charge this the 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 may include telephone conversations phone contact with you, report and letter writing, attendance at meetings or email responses lasting longer than 15 minutesphone consultation with other professionals you have authorized, and the time spent performing any other service preparation of records or treatment summaries. Any phone conversation with you may request of meor another professional in reference to your treatment that exceeds 10 minutes will be billed at a prorated hourly rate. If full phone sessions are conducted, the same rates will apply as psychotherapy in the office. If you become involved in legal proceedings that require my participation, you will be expected to pay for any her professional time I spend on your legal matter, even if the request comes from another partytime, 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 , even if she is called 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 testify by 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:party.

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 for a second opinion. Please note I will 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 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 will usually 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 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 hour is scheduled, you will be expected to pay for any professional time I spend on it unless you provide 48 business hours advance notice of cancellation [unless we both agree that you were unable to attend due to circumstances beyond your legal matter, even if the request comes from another party, at the same $250 per 45-minutes ratecontrol]. I It is important to 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 youcancelled sessions. I also do not charge for any time I may spend collaborating with Please note, if you cancel your other providers. From time to timeappointment within 48 business hours, I may institute fee increases and these you will be discussed and agreed upon ahead of time with charged a new Treatment Contract$50 late cancellation fee, unless I am able to rebook the appointment. 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 cancel the fee you were previously paying. In addition, if it has been more than one year since our last day of your 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:$125 charge.

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 ▇▇▇▇▇ ▇▇▇▇▇▇▇ 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 clinician and patient, and the particular problems you hope to addressare experiencing. There are many different methods I which may use be used to deal with those problemsthe problems that you hope to address. Psychotherapy is not like visits to a medical doctor visitdoctor. Instead, it calls for a very an active effort on your part. In order for the For therapy to be most successful, you will have to must work on things we talk about both during our sessions 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 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 our procedures, we should discuss them whenever they arise. If your doubts persist, 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 You must provide are not for emergency situations. For emergenciesus with accurate information about your insurance coverage, 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 including any other service you may request of mechanges. If and/or when you become involved in legal proceedings that require my participationare covered by more than one policy, we must know this right away. Otherwise, you will be expected to pay responsible 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 fees 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 payment is denied by any insurance companiescarrier. If you decide Your insurance policy does not guarantee coverage for mental health services! You should know the limits of your benefits. It’s your responsibility to submit claims to know your insurance company for reimbursement for any outco-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 coveragepayment fees, deductibles, payment ratesand maximum coverage limits. You will be billed directly, pre-authorization procedures, etcafter you have reached your maximum coverage. Missed appointments, late cancellations (i.e., cancellations within 24 hours Your insurance carrier will pay for mental health services that are medically necessary – those that focus on alleviating symptoms of service), and telephone session a specific mental illness or disorder. Your insurance carrier will not pay for mental health services that are not typically covered by insurance companies and therefore you medically necessary; such as focusing solely on interpersonal problems, phase of life difficulties, personal growth, enrichment, or enhancement. You will likely be financially responsible for the full session fee in these instancescharges. If your Your insurance company doesn’t reimburse you, I am carrier will not pay for failed appointments or for sessions cancelled with less than 24 hours’ notice. You will be financially 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:these charges.

PSYCHOLOGICAL SERVICES. I am a clinical psychologist licensed in Oregon to provide services to individuals, families, and couples in need of help for life problems. I received a doctorate from the University of Connecticut in 1987, and completed an internship and two year post-doctoral residency in Medical Psychology at Oregon Health Sciences University. I have been in private practice since 1989. Psychotherapy is not easily described in general statements. It a process that 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 It is not like a medical doctor visit. Instead, it calls important for a very active effort on you to know that psychotherapy requires an investment of your part. In order for time and energy to make the therapy to be process most successful, you . 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 sadnessperiods of emotional discomfort, guiltchanges in relationships, anger, frustration, loneliness, and helplessnessor temporary worsening of symptoms. When treating insomnia specifically, therapy might cause you to experience increased sleepiness and fatigue, especially in the early phases of treatmentThis should subside as treatment progresses. 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, 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 evaluationFollowing this, 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. Therapy typically involves an initial evaluation and follow-up treatment sessions. He first session lasts one hour after which sessions typically last for 45 minutes. The fee for the first session is $250. This covers the costs of the evaluation and generating the chart with treatment plan. The fee for a 45 minute session is $150. If a therapy session is extended to an hour, the fee is $180. I ask that you avoid missing appointments. If you must cancel, you will not be charged for the appointment if you give 24 hour notice. Cancellations can be phoned into my office at any time day or night (503-466-2846). If you do not show up for your appointment, you may be charged full fee and this will be noted on your billing statement. If you cancel with less than 24 hour notice, you may be charged one-half the session fee. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. Please note that the fees may be charged for any additional time that I may need to spend on your behalf, such as prolonged phone calls (over 15 minutes), preparing letters, conferring with other professionals, evaluation of psychological services data, preparing psychological reports, etc. If I provide are not for emergency situations. For emergenciesam required to be in court on your behalf, call 911 or go to the nearest emergency room. My a 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 of $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 hour will be charged for 15 minutes whereas 23 minutes preparation and review, meetings and conversations with your attorney, any time I am required to be out of service will be charged for 30 minutes). Other professional services include telephone conversations or email responses lasting longer than 15 minutesmy office, and the time spent performing testimony. I will negotiate a retainer and contract with your attorney and you prior to any other service legal work I do on your behalf. These fees apply even if I am called by another party to be involved in your behalf. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you may request of mehave available to pay for your treatment. If you become involved 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 legal proceedings that require my participationhelping you receive the benefits to which you are entitled; however, 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 full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. Some plans may require authorization before they provide reimbursement for mental health services. It is your responsibility to make sure sessions are preauthorized. It may be necessary to seek approval for additional sessions after the full paymentpreauthorization, which is typically my responsibility. 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. If you have an Oregon insurance policy, by state law when you accept policy benefits, you are deemed to have consented to examination of your Clinical Record for purposes of utilization review, quality assurance and peer review by the insurance company. I have no role in deciding what may provide clinical information to your insurance coversinsurer for such purposes. You are responsible for checking Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your insurance coverageentire Clinical Record. In such situations, 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 I will make every effort to release only the minimum information about you will likely be responsible that is necessary 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 otherwisepurpose requested. 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 will need always have the right to submit pay for my services yourself to your insurance company for reimbursement for any out-of-network benefits you might have:avoid the problems described above [unless prohibited by contract].

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. Therapy 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 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 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 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. 80 minute session can be useful in Couples and Family Therapy. However, insurance only pays for 45-50 min session therefore if you choose to utilize 80 min sessions you will be required to pay for the additional time out of pocket. 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 the psychological services I you provide are not for emergency situationsme with 24 hours notice. For emergencies, call 911 or go to the nearest emergency room. My If you miss a session without canceling you will be charged PROFESSIONAL FEES The standard fee is $395 150.00 for an 45-50 min sessions. For Couple/Family 80 min session my initial evaluation lasting 90 minutesfee is $250 and $200 thereafter. You are responsible for paying at the time of your session unless prior arrangements have been made. Our billing company will ▇▇▇▇ your insurance however you are responsible to pay any copayments, coinsurance, and deductibles. You are also responsible for any fees not covered by your insurance. A credit card will be placed on file and my billing agency will charge these to your card. If you do not have a card on file, you must pay by check or cash at each visit. Any checks returned to my office are subject to an additional fee of up to $250 for each subsequent psychotherapy session (either in-person 50.00 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 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 You can make the best decisions for yourself if you have an understanding of how psychological treatment works. The cornerstone of psychotherapy is a collaborative relationship of mutual trust and respect between therapist and client, and that is my goal for our relationship as well. Therapy is not easily described like visiting a medical doctor, in general statementsthat it requires active involvement on your part to change and to find ways to cope more effectively with your life. It varies depending If you are coming to work on issues around recent or past losses in you life, the personalities process is also bound to involve some emotional pain as we work together to understand and integrate your loss. We will spend time exploring the nature of the psychologist problems you wish to work on, what your feelings and patientwishes are about those problems, and possible courses of action. I can offer guidance and support into this process of self-discovery, and sometimes I will make direct suggestions for change. But in general, I believe that clients are best served by supporting their capacities to take responsibility for their own life choices. Also, though it is sometimes a short encounter, therapy can also be a rather slow process of “two steps forward and one step back”. As we go along, it will be important to review our progress and your current goals for the particular problems therapy. If we are not making progress, then we will review the possible reasons for this, and consider what options you hope may wish to addresstake, including getting a second opinion, referral to another therapist, or additional services (such as medication or group therapy). There are many different methods both benefits and risks to being in psychotherapy, and I am obligated to inform you of some of these possibilities. Risks might include such things as an increase in distressing feelings, less certainty for a period of time about what direction to take, making poor decisions, delaying actions; and difficulties with other people. Some changes may lead to worsening of symptoms or even further losses (for example, therapy may lead to an increase in marital tensions). For a variety of reasons, therapy may not end up being helpful, and we may not be able to know this until after you have spent some time and money on the process. Not everyone is able to make use to deal with those problems. Psychotherapy of psychotherapy, and a given therapist is not like a medical doctor visit. Instead, it calls for a very active effort on your partnecessarily able to help every client. In order short, there can be no guarantees about the success of psychotherapy. However, psychotherapy can also be of great benefit to most people who put a sincere effort into it, and who work with a competent therapist. Benefits might include the lifting of a depression or no longer feeling as afraid, angry, or anxious. If you are coming 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 lifegrief counseling, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, lonelinessfeel more resolved and settled about your loss, and helplessnessbetter able to move on in your life. When treating insomnia specificallyYou may be better able to cope with social or family relationships, and so receive more satisfaction from them. You may better understand your personal goals and values, as well as your reactions to yourself and others. And hopefully, therapy might cause can help you to experience increased sleepiness grow 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 sleepmature as a person, and less fatigueto function better in whatever roles you play in your life. 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 evaluationGiven these various risks and benefits, I will be able do my best to offer you some first impressions of what our work will include and a treatment plan to follow, if help 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 you, and if so, I will give our work together is helping to resolve the problems you referrals bring to other practitioners who I believe are better suited treatment. You should feel free 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 these issues 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, me 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:during therapy.

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 may involve a variety of activities designed to support you in general statementssuccessfully resolving the difficulties or conditions, which have led you to seek therapy. It varies depending on the personalities of the psychologist is a learning process: Your therapy will be most successful if you engage openly and patienthonestly in it, and the particular problems apply what 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 discovering in how you live 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 homelife. Psychotherapy can have benefits and risksrisks as well as benefits. Because Since therapy often involves discussing exploring unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, These feelings (and others which you may dislike) are often an essential element in successful therapy; such 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 can lead to better relationships, solutions to specific problems, and significant reductions increases 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 therapyone's well being. You should evaluate consider this information along with your own opinions about in choosing whether you feel comfortable working to work 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 proceduresapproach or other relevant matter, we should discuss please bring them whenever up as they arise. If your doubts reservation or objections 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 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 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)usually schedule appointments as agreed upon between us. 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 hour is scheduled, you will be expected to pay for any professional 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]. My fee is $110 for Individual Therapy and $130 per hour for Couples Counseling Much of the time I spend on your legal matteram not immediately available by telephone. When I am unavailable, even if the request comes from another party, at the same $250 per 45-minutes ratemy telephone is answered by voice mail that I monitor frequently. I do not charge for time spent writing reports will make every effort to return your call promptly, 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 leave in your message 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 feeavailable. I am not in-network with any insurance companiesmay also be reached by email at: ▇▇▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇.▇▇▇. 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, 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 University 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 instancesNeuropsychiatric Institute. 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 with a superbill after each session name of a colleague to contact if necessary. Professional ethics as well as the laws of the State of Utah protect the privacy of communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written authorization. I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are 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. Unless you specifically request otherwise, your signature on this Agreement provides consent for those activities. I am required to disclose confidential information if certain specific conditions exist. These are detailed in the accompanying Notice of Policies and Practices to Protect the Privacy of Your Health Information. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. HIPAA sets forth specific definitions and standards for Protected Health Information. These are detailed in the following information that you will need accompanying Notice of Policies and Practices to submit to your insurance company for reimbursement for any out-of-network benefits you might have:Protect the Privacy of Your Health Information.

PSYCHOLOGICAL SERVICES. Psychotherapy Counseling (also termed therapy or psychotherapy) is not easily described in general statements. It varies depending on the personalities of the psychologist counselor and patient, client and the particular problems you hope to addressare experiencing. There are many different methods I may use utilize to deal with those problemsthe problems that you come to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for Your participation in therapy also requires a very active effort on your part. In order for to maximize the therapy to be most successfultherapy, you will have to make a commitment to work on things we talk about problems or concerns both during our sessions and at homebetween sessions. Psychotherapy can All forms of therapy (individual, couple, family and group) have potential benefits and risks. Because therapy In the initial stage of counseling, it may actually feel as though things are getting worse rather than better. Since counseling often involves requires 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 it. Therapy often leads to better many benefits: improved relationships, solutions to specific problems, and significant reductions in feelings of distress, improved sleep, and less fatigue. But there There are no guarantees as to about 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 . Clients should be select their therapist very careful about the therapist you selectcarefully. If you have questions about my procedures, we should discuss please ask them whenever as they arise. If your doubts persistdoubt persists, ask, and I will be happy to help provide you set up with referral names. In this packet you will find a meeting form entitled “Statement of Professional Disclosure.” By state law, every Licensed Professional Counselor is required to provide this information to their clients. My appointments are scheduled for 50 minutes: usually beginning on the hour and ending at ten minutes before the following hour. Out of respect for my clients’ and my own time, and working to model good time management, I make every effort to stay on schedule throughout the day. If you arrive late, your appointment will end at the regular designated time. I encourage my clients to work with another me in ending sessions on time. If there are questions you want to ask, or points you want to introduce, please let me know early enough in the session so that we can address them before the session ends. One of the main reasons that I decided to switch to TherapyAppointment is to take every available measure to keep our communication confidential. Emails and texts are non-secure communications, and therefore not appropriate for confidential messages. These types of electronic communications should only be used to schedule appointments, to briefly address administrative matters (such as insurance issues), or to receive on-line materials, resources, and recommendations of therapeutic value. (For instance, there are times in which I may e-mail you with specific instructions or Internet resources regarding mindfulness, stress reduction, etc.) Let me know if you do not wish to receive these messages. There are times that I do not check e-mail on a daily basis, so you understand that e-mail is not the appropriate form of communication in case of a crisis or for last-minute cancellation of an appointment. Text messages pertaining to therapy issues will not be responded to. As part of standard practice, all electronic correspondence becomes part of my official clinical record. TherapyAppointment will allow you to send me confidential messages having to do with your therapeutic work, and you can still call and leave a voice message on my phone. Due to my work schedule, I am often not immediately available by phone, as I generally will not answer the phone when I am with a client. When I am unavailable, my telephone is answered by voicemail, which I monitor daily. If you leave a voicemail on a weekday, I will make an effort to return your call within 24 hours. If you are difficult to reach, please inform me of some times when you will be available. If you feel you are having a mental health professional for a second opinion. Please note that the psychological services I provide emergency or if you feel unsafe and are not for emergency situations. For emergenciesunable to contact or speak with me, call please dial 911 or go to the nearest hospital emergency room, where psychiatric emergencies services should be available. My fee I have a 24-hour cancellation policy. ▇▇▇▇▇▇▇▇▇ appointments as early as possible is greatly appreciated. When appointments are cancelled with 24 hours notice I am usually able to re-book the appointment. If you fail to/or are unable to cancel at least 24 hours in advance, you will be charged 50% of your full session fee. If you do not show for your appointment you will be charged the full session fee. This is not a punitive measure, but a business policy that assures my time will be covered. (For those using insurance: insurance companies will not cover missed appointments. Therefore, you, and not your insurance company, will be responsible for fail to show/late cancellation fee.) Appointment reminders (voice message, email, or text) are available through ▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Whether a reminder is received or not, you are still held responsible for remembering your appointment time and day. Appointment information is considered to be “Protected Health Information” under HIPAA. By your signature below, you are authorizing that this information be transmitted through the format you have indicated on ▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Please describe any restrictions regarding messages or reminders about your therapy services.______________________________________________________________________________________________________________________________ You acknowledge and, by signing this information and consent form below, agree that neither you or your therapist will record any part of your sessions unless you and the therapist mutually agree in writing that the session may be recorded. You further acknowledge that your therapist objects to you recording any portion of your sessions without the therapist’s written consent. I charge $395 150 for an initial evaluation lasting 90 minutesappointment/assessment; on-going 50-minute appointments are $120. I ask that you pay those amounts in full at the beginning of each appointment, or your co-pay, unless other arrangements have been agreed upon. Having your payment ready as the session starts helps us to end on time. My billing policy requires payment for each session at the time it is held. If you are paying privately and you would like to receive a statement that you can submit to your insurance company, please let me know. You, and $250 not your insurance company, are responsible for each subsequent psychotherapy session the full payment of my fees (either in-person or over the telephoneincluding returned check fees and failing to cancel an appointment 24 hours in advance.) lasting 45 minutesIf you are planning to use your insurance it is your responsibility to contact your company to verify your benefits. I charge recommend that you clarify the following questions: Does my insurance policy cover mental health benefits? Is my mental health deductible separate/combined with my medical deductible? How much is my mental health (or combined) deductible per year? How much of mental health (or combined) deductible has been met this same $250 year? What is the outpatient session limit per 45year? Can I convert inpatient treatment days to outpatient sessions to extend my limit? What services are included under my policy: individual? couple? family? group? After my deductible is met, what is my co-minutes rate for other professional pay/co-insurance? I am using the credit card services associated with ▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. Unless you may needchoose to pay by check or cash, though I will prorate keep your credit card information on file in this confidential, on-line management service. Your signature on the cost final agreement page below indicates your consent: 1) to have your credit card information stored, and 2) to charge your card $60 for a late cancellation and $120 if I work you do not show up 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 your appointment. Other services will be charged for 15 minutes whereas 23 minutes of service will be charged for 30 minutes). Other professional services include a pro-rated amount including 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. 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 . Because of the same $250 per 45-minutes rate. I do not charge for time spent writing reports and progress notes as per the standard routine complexity of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to timelegal involvement, I charge $200 per hour for preparation and attendance at any legal proceeding. (If your account has not been 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 institute fee increases 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 client’s treatment is his/her name, the nature of services provided, and these the amount due. 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 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 serviceclaim.), 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 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 ▇▇▇▇ ▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇, ▇▇▇▇▇ ▇ Telephone (▇▇▇) ▇▇▇-▇▇▇▇ San Diego, California 92129 ▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ I normally conduct an evaluation that will last 1 to 1.5 hours. During this time, we can both decide if I am the psychological best person to provide the services that you need in order to meet your treatment goals. If psychotherapy is begun, I provide are not for emergency situations. For emergencies, call 911 or go will usually schedule one 45 to the nearest emergency room. My fee is $395 for an initial evaluation lasting 90 minutes, and $250 for each subsequent psychotherapy 50-minute session (either in-person one appointment) 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 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 hour is scheduled, you will be expected to pay for any professional time I spend on the appointment ($300) unless you provide one business day advance notice of (usually 24 hours, excepting Monday appointments), unless we both agree that you were unable to attend due to critical circumstances beyond your legal matter, even if the request comes from another party, at the same $250 per 45-minutes ratecontrol. I It is important to 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 Contractcancelled sessions. 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 youis possible, I am not responsible for refunding you any payment you expected will try to be reimbursed or otherwise. I will provide you a superbill after each session with find another time to reschedule 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 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 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 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 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 may involve a variety of activities designed to support you in general statementssuccessfully resolving the difficulties or conditions, which have led you to seek therapy. It varies depending on the personalities of the psychologist is a learning process and patientour therapy will be most successful if you engage openly and honestly in it, and the particular problems apply what 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 discovering in how you live 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 homelife. Psychotherapy can have benefits and risksrisks as well as benefits. Because Since therapy often involves discussing exploring unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. When treating insomnia specifically, These feelings (and others which you may dislike) are often an essential element in successful therapy; such 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 can lead to better relationships, solutions to specific problems, and significant reductions increases 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 therapyone's well being. You should evaluate consider this information along with your own opinions about in choosing whether you feel comfortable working to work 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 proceduresapproach or other relevant matter, we should discuss please bring them whenever up as they arise. If your doubts reservation or objections 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 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 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)usually schedule appointments as agreed upon between us. 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 hour is scheduled, you will be expected to pay for any professional it unless you provide 24 hours advance notice of cancellation. My fee is $125 for individual therapy and $145 per hour for couples counseling. Much of the time I spend on your legal matteram not immediately available by telephone. When I am unavailable, even if the request comes from another party, at the same $250 per 45-minutes ratemy telephone is answered by voice mail that I monitor frequently. I do not charge for time spent writing reports will make every effort to return your call promptly, 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 leave in your message 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 feeavailable. I am not in-network with any insurance companiesmay also be reached by email at ▇▇▇▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇. 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 outcall, contact your family physician or the University of Neuropsychiatric Institute at ▇▇▇-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 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 with a superbill after each session name of a colleague to contact if necessary. Professional ethics as well as the laws of the State of Utah protect the privacy of communications between a client and a therapist. In most situations, I can only release information about your treatment to others if you sign a written authorization. I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are 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. Unless you specifically request otherwise, your signature on this Agreement provides consent for those activities. I am required to disclose confidential information if certain specific conditions exist. These are detailed in the accompanying Notice of Policies and Practices to Protect the Privacy of Your Health Information. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. HIPAA sets forth specific definitions and standards for Protected Health Information. These are detailed in the following information that you will need accompanying Notice of Policies and Practices to submit to your insurance company for reimbursement for any out-of-network benefits you might have:Protect the Privacy of Your Health Information.

PSYCHOLOGICAL SERVICES. The psychological services that are provided at ▇▇▇▇▇ 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, 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 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 meprofessional. If you become involved are unable to keep appointments and I do not hear back from you for one month, this will constitute a formal ending of our work together. I do not serve as an advocate for clients obtaining or keeping disability or in legal matters such as lawsuits, custody evaluations, divorce proceedings that require my participation, you or criminal cases. Information will be released with your written permission and direction as determined appropriate for a situation. You will be expected to pay for any 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 time and my fees for legal services will be greater than customary fees. For psychotherapy, I spend on 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 your legal matterchild need in order to meet your treatment goals. Each session lasts from 45 to 60 minutes. Sessions are typically scheduled once per week, even if although in some situations we may meet more or less frequently. My practice provides outpatient services and is set up to accommodate individuals who are reasonably safe and resourceful. My practice, therefore, may not always be appropriate for clients who need more intensive and frequent contact. If this is found to be the request comes from another partycase, at I will provide recommendations and referrals for a better fit to meet your needs. Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office regular hours, I probably will not answer the same $250 per 45-minutes ratephone when I am with a client. When I am unavailable, my 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 ▇▇▇-▇▇▇-▇▇▇▇, Peachford Hospital at ▇▇▇-▇▇▇-▇▇▇▇, or SummitRidge Center for reimbursement for any outPsychiatry and Addictions at ▇▇▇-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 concerns you hope wish us to addressaddress together. There are many different methods I may use to deal with those problemsthe issues 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 You will make the therapy to be most successful, best progress if you will have to work actively on things we talk about address, both during in 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 There can be no guarantees as to guarantee 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. I usually schedule one 50-minute session (one appointment hour of 50 minutes duration) per week or every other week at a time we agree upon, although some sessions may be longer or more or less frequent. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation, or unless I can fill the open slot with another patient. An appointment scheduled for Monday must be cancelled by 5 PM the preceding Thursday to avoid having to pay for the session. Please 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 roommissed appointments. My fee for a standard 50-minute session is $395 for an initial evaluation lasting 90 minutes195.00. In addition to 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 although I will prorate break down the cost into tenths of an hour if I work for periods of less than 45 minutes in increments of 15 50 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 might include report writing, telephone conversations or email responses lasting longer than 15 five minutes, email exchanges, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you or your representative may request of me. At the time of scheduling your first appointment, you will be asked to pay for the first session to hold your spot, using a secure, HIPAA-compliant credit card processing service called Ivy Pay. With your consent, you will receive a text message from ▇▇▇, asking you to enter your credit card information and make your first payment. This is a one-time set up. Thereafter, each time a fee is generated, it will be charged to this credit card using Ivy. (If you prefer, you may pay for in-person services with cash or check.) If your card is charged for a session or for one of the other services described above, you will receive a text message notifying you that a fee has been processed. More detailed information about Ivy Pay is included later in this Agreement. If you become involved in legal proceedings that require my participation, you will be expected to pay for any my professional time, including preparation and transportation time I spend on your legal mattercosts, even if the request comes from I am called to testify by another party, at . Because of the same $250 per 45-minutes rate. I do not charge for time spent writing reports complexity and progress notes as per the standard routine liability of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to timelegal involvement, I may institute fee increases charge $225 per hour for preparation for 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 thereafterparticipation in any legal proceeding. 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 will find more information about court involvement below in 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:section entitled Limits on Confidentiality.

PSYCHOLOGICAL SERVICES. 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 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 me getting to know and your needs. By the end of the evaluation, Over time 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 therapy. Because I am here to serve you, I would like you to be open and honest with me for therapyabout what I have said. Please let me know if I have misunderstood something or you have different ideas. You should evaluate this information I provide 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 provide you set up a meeting with another names of other mental health professional providers to see if they might be a better match for a second opinionyou. Please note Our first session is usually one full hour, with the goal of me getting you know and your needs. At the end of that session, I will let you know my thoughts regarding what I understood and how I believe it would be best to proceed. 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, we can decide upon session frequency that we believe would be most beneficial for all of your needs. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours [1 day] advance notice of cancellation. I provide may make an exception for significant illness, emergency, and inclement weather. However, I reserve the right to charge my full fee if appointments are not for emergency situations. For emergenciesmissed or canceled less than 24 hours in advance or on an ongoing basis, call 911 or go to the nearest emergency roomregardless of reason. My fee is schedule for therapy sessions follows: Initial 60-minute Evaluation $395 for an initial evaluation lasting 90 minutes, and 200 60-minute Therapy Session $250 for each subsequent psychotherapy session (either in175 75-person or over the telephone) lasting 45 minutes. I charge this same minute Therapy Session $250 per 45-minutes rate 205 Missed Session $75 Fees for other professional services you may needwill vary, though I will prorate break down the hourly cost into 15 minute increments 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 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 $350 per hour for preparation and attendance at any legal proceeding and $175 per hour for travel time. If this occurs, the full estimated fee will be due five business days prior to the date of testimony. If the fees accrued are different from the estimate, the amount will be adjusted accordingly after the legal proceeding. If a balance accrues for any reason, it is due within 14 days of the invoice date. I will inform you of your balance and charge your credit card on file. If for some reason there is an outstanding balance after 14 days, a finance charge of 5% will be added for each two weeks of outstanding balance. A collection agency may be notified if the bill has not been paid within 60 days. If an attorney must be hired to collect the past due balance, all fees for this service will be charged to you as well. Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office between 9 AM and 5 PM, I will not answer the phone when I am with a client. When I am unavailable, my telephone is answered by voicemail that I monitor frequently. I will make every effort to return your call on the same $250 per 45-minutes rateday you make it, with the exception of evenings, weekends, vacations, and holidays. Please inform me of some times when you will be available. You may email me if you wish. However, email is not a secure form of communication and I cannot guarantee confidentiality. If you wish, you may email me regarding non- clinical issues such as appointment schedule or billing. However, I do not discuss clinical issues via email. Ethical guidelines regarding dual relationships prevent me from having any form of relationship with you outside of the agreed upon professional services. Thus, I will not respond to requests to be connected through any form of social media, nor will I initiate contact or converse with you outside of the office. I believe that these boundaries are in your best interest, allow us to work together more effectively, and better protect your confidentiality. Additionally, if you choose to follow me on any form of social media, there is a possibility that you would then be identified as a client with whom I work. Consequently, I would discourage you from doing so in order to maintain your confidentiality. Finally, if you wish, it is your option to review my services as you see fit. I will not respond to that in any way, either online or in person. Please be aware that this also could result in a breach your confidentiality as you may then be identified as receiving mental health services from me. With that said, any time you are interested in recommending my services, you are my best referral source. Please ask any questions you have about this policy. I do not charge provide emergency services and am not available for time spent writing reports and progress notes as per the standard routine contact outside 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 payingbusiness hours. In additionthe case of an emergency, if it has been more than one year since our last appointmentplease contact your primary care provider, you will be scheduled for another initial evaluation call 911, call ▇▇▇▇▇ ▇▇▇▇ Hospital at (90 minutes▇▇▇) ▇▇▇-▇▇▇▇, or go to the nearest hospital emergency room and charged accordinglyask to speak with the psychiatrist on call, 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 and/or follow 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 carrier’s emergency 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 statementsdescribed. It varies depending on the personalities of the psychologist therapist and patient, client 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 however, my theoretical orientation, or how I approach therapy, is cognitive-behavioral. Psychotherapy This theory states that a large majority of an individual’s emotional problems stem from their thoughts or beliefs about themselves and the world. These beliefs shape how an individual will perceive a given event. These thoughts drive a person’s feelings and their behaviors. Once one is not like aware of their beliefs work can be done to help them challenge and modify the beliefs that are keeping them “stuck”. Consequently, a medical doctor visitperson’s feelings and behavior will also be modified. Instead, it calls It is at this point where real change in a person’s life occurs. In order for your therapy to be successful a very active effort on your partpart is required. In order for Not only will we work together to determine the therapy to be most successful, goals and course of treatment but you will have to work on things we talk about both during our out sessions and at home. Psychotherapy Therapy 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 therapy 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. Included in the treatment plan are diagnoses that will guide our work together. These diagnoses of a client’s current mental state will become a part of the client’s permanent record. Please note that it is my policy that I focus on treatment of the individual and I do not make recommendations or give opinions regarding custody or visitation. 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 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 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, ▇▇▇▇▇▇▇'▇ 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 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 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 ▇▇▇ ▇▇▇-▇▇▇▇. 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 concerns you hope wish us to addressaddress together. There are many different methods I may use to deal with those problemsthe issues 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 You will make the therapy to be most successful, best progress if you will have to work actively on things we talk about address, both during in 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 There can be no guarantees as to guarantee 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. I usually schedule one 50-minute session (one appointment hour of 50 minutes duration) per week or every other week at a time we agree upon, although some sessions may be longer or more or less frequent. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation, or unless I can fill the open slot with another patient. An appointment scheduled for Monday must be cancelled by 5 PM the preceding Thursday to avoid having to pay for the session. Please 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 roommissed appointments. My fee for a standard 50-minute session is $395 for an initial evaluation lasting 90 minutes180.00. In addition to 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 although I will prorate break down the cost into tenths of an hour if I work for periods of less than 45 minutes in increments of 15 50 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 might include report writing, telephone conversations or email responses lasting longer than 15 five minutes, email exchanges, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you or your representative may request of me. At the time of scheduling your first appointment, you will be asked to pay for the first session to hold your spot, using a secure, HIPAA-compliant credit card processing service called Ivy Pay. With your consent, you will receive a text message from ▇▇▇, asking you to enter your credit card information and make your first payment. This is a one-time set up. Thereafter, each time a fee is generated, it will be charged to this credit card using Ivy. (If you prefer, you may pay for in-person services with cash or check.) If your card is charged for a session or for one of the other services described above, you will receive a text message notifying you that a fee has been processed. More detailed information about Ivy Pay is included later in this Agreement. If you become involved in legal proceedings that require my participation, you will be expected to pay for any my professional time, including preparation and transportation time I spend on your legal mattercosts, even if the request comes from I am called to testify by another party, at . Because of the same $250 per 45-minutes rate. I do not charge for time spent writing reports complexity and progress notes as per the standard routine liability of my care of you. I also do not charge for any time I may spend collaborating with your other providers. From time to timelegal involvement, I may institute fee increases charge $225 per hour for preparation for 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 thereafterparticipation in any legal proceeding. 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 will find more information about court involvement below in 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:section entitled Limits on Confidentiality.