Common use of Sessions Clause in Contracts

Sessions. Each individual session lasts 45-60 minutes and family sessions are 60-80 minutes. If you are late for a session, that time is lost from your session. If I am late for a session, we will extend the session if you are willing to do so or we will make other arrangements by mutual consent. MISSED APPOINTMENTS Since a time slot is reserved for you that cannot be offered to anyone else, you will be charged for all missed appointments not cancelled 24 hours in advance. Please note my snow policy: I do not follow Montgomery County’s snow policy. Unless you hear from me in the morning, I will assume that we will be meeting. If you cannot make it to the appointment for weather reasons, please call or email me by 8:00 a.m. (000-000-0000 or xxxxxx@xxxxxxxxxxxxxxxxxxxx.xxx) and I will waive the 24-hour cancellation fee. If you do not reschedule an appointment within one month of our last session, I will assume that you have decided to discontinue treatment with me. Please be assured that you are always welcome to return regardless of how much time has lapsed since our last session. Updated 10/2017 PROFESSIONAL FEES Fees are as specified on the signature page to be completed with me at our first session. You are responsible for payment for each therapy session at the time of the session by cash, check or credit card. During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. I do not participate in health insurance programs however I will provide you with an invoice with all the information needed should you wish to file a claim directly with the insurance company. It is your responsibility to contact your insurance company to determine if an authorization for treatment is required and to communicate that requirement to me. Please note, I am not a Medicare provider and therefore my services are not covered by Medicare. Should you want services from me and you are a Medicare recipient, this will serve as a separate private contract so that you may pay me out of pocket. Under this circumstance, you understand that you (or your beneficiaries or legal representatives) are waiving the right to submit claims or be reimbursed by Medicare for any services I provide that would otherwise be covered by Medicare if there was no private contract and a proper claim was submitted. You have every right to obtain similar services from a provider who has not opted out of Medicare. You understand that Medigap does not pay for services not covered by Medicare. The period of this agreement will be 2 years from the time of signature. This language is legalese required of me by Medicare guidelines! During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time and expenses, including preparation costs, transportation costs, and attorney’s fees, even if I am called to testify by another party. My professional time related to these activities is $350 per hour. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. It is very important to be aware that computers and email and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. If you communicate confidential or private information via email or text, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via email or text. Please do not use email or text for emergencies. Due to computer or network problems, emails and texts may not be deliverable, and I may not check my emails or faxes frequently.

Sessions. Each individual session lasts I normally conduct an evaluation that will last from 2 to 4 sessions. During that time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If psychotherapy is begun, I will usually schedule one 45-60 minute session (one appointment hour of 45 minutes and family duration) per week at a time we agree on, although some sessions are 60-80 minutesmay be longer or more frequent. PROFESSIONAL FEES The following information pertains to my financial policy. I hope this will answer any questions that you may have, but if you do have any questions or special concerns please do not hesitate to discuss them with me at the first session. Please acknowledge your understanding of this policy by signing at the end of this form. If you are late would like a copy of this form for a sessionyour records I will be happy to provide one for you. My fee is $175.00 for individual sessions and $185.00 for couples or family therapy sessions, that time is lost from your paid at the end of each session. If I am late The usual therapy hour consists of 45 minutes. The fee for a session, we will extend the initial diagnostic session if you are willing to do so or we will make other arrangements by mutual consentis $195.00. MISSED APPOINTMENTS Since a time slot is reserved Charges for you that cannot be offered to anyone else, you will be charged for all missed appointments not cancelled 24 hours in advance. Please note my snow policy: I do not follow Montgomery County’s snow policy. Unless you hear from me in services outside the morning, I will assume that we will be meeting. If you cannot make it to the appointment for weather reasons, please call or email me by 8:00 a.m. (000-000-0000 or xxxxxx@xxxxxxxxxxxxxxxxxxxx.xxx) and I will waive the 24-usual therapy hour cancellation fee. If you do not reschedule an appointment within one month of our last session, I will assume that you have decided to discontinue treatment with me. Please be assured that you are always welcome to return regardless of how much time has lapsed since our last session. Updated 10/2017 PROFESSIONAL FEES Fees are as specified on the signature page to be completed with me at our first session. You are responsible for payment for each therapy session at the time of the session by cash, check or credit card. During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. I do not participate in health insurance programs however I will provide you with an invoice with all the information needed should you wish to file a claim directly with the insurance company. It is your responsibility to contact your insurance company to determine if an authorization for treatment is required and to communicate that requirement to me. Please note, I am not a Medicare provider and therefore my services are not covered by Medicare. Should you want services from me and you are a Medicare recipient, this will serve as a separate private contract so that you may pay request of me out of pocket. Under this circumstance, you understand that you (or your beneficiaries or legal representatives) are waiving the right to submit claims or be reimbursed by Medicare for any services I provide that would otherwise be covered by Medicare if there was no private contract and a proper claim was submitted. You have every right to obtain similar services from a provider who has not opted out of Medicare. You understand that Medigap does not pay for services not covered by Medicare. The period of this agreement will be 2 years from determined on an individual basis. These services might include report writing, telephone conversations (lasting longer than 110 minutes), consulting with other professionals with your permission, and the time preparation of signature. This language is legalese required of me by Medicare guidelines! During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each yearrecords or treatment summaries. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time and expensestime, including preparation costspreparation, transportation coststransportation, and attorney’s feeswaiting costs, even if I am called to testify by another party. My professional Because of the difficulty of legal involvement, I charge $200.00 per hour for preparation and $350.00 per hour for attendance at any legal proceeding. BILLING AND PAYMENTS Payment isexpected at the end of each session. Please discuss any exceptional circumstances with me at the first session. Visa and MasterCard are accepted for your convenience. An insurance receipt is available should you wish to submit your insurance claims personally. If you are a member of a managed care company in which I participate, I am required to file insurance for you. After our office manager verifies your insurance eligibility and level of benefits, I will gladly accept only the co-payment. Until that time, please plan on paying the full contracted amount. I will fill out forms and provide you with whatever assistance I c a n in helping you to receive the benefits to which you are entitled; however, you, NOT your insurance company, are responsible for the full payment of my fees. For that reason, it is very important that you find out personally what mental health services your insurance policy specifically covers. *** NOTE: The amount we are required to collect is based on information we receive from your insurance company. However, we do not always receive accurate and reliable information from the company. Therefore, please be aware that you may receive a later bill for services after a session if your insurance company declines to pay for the service. • Since your appointment time related is reserved for you, please notify me as soon as possible if you find that you must cancel an appointment. Appointments not cancelled with at least 24 hours notice will be billed at the usual fee of $175.00 or $185.00. Missed appointments cannot be billed to these activities is $350 per hourthe insurance company. You may leave a message on my confidential voicemail after hours and on weekends if you need to cancel an appointment. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail that I monitor frequentlymy assistant or by my confidential voicemail. I will make every effort to return your call on the same day that you make it, with the exception of weekends and holidays. In the event of an emergency, a doctor is on call through Atlanta Psych Consultants 24 hours a day, 7 days a week. If you are unable difficult to reach reach, please inform me and feel that of some times when you can’t wait for me to return your call, will be available. You may contact your family physician or the nearest emergency room and ask for doctor on call through the psychologist or psychiatrist on callanswering service (770-928-5044). If I will be unavailable for an extended period of time, I will the answering service can provide you with the name of a colleague to contact, if necessary. It Statement of Confidentiality Under Georgia law communications between patients and psychologists are confidential, and under ordinary circumstances only the patient can waive this privilege. However, there are three clear exceptions in which a psychologist is very important legally and ethically bound to break confidentiality: (1) the patient is imminently dangerous to him or her self, (2) the patient is imminently dangerous to others and/or has made specific threats to harm an identifiable third person, (3) there may exist actual or suspected incidents of child abuse or elder abuse. Although legally and ethically bound to break confidentiality under the aforementioned circumstances, I generally will not do so without attempting to discuss it with you. MINORS & PARENTS Patients under 18 years of age (who are not emancipated), and their parents, should be aware that computers and email and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise the law allows parents to examine their child's treatment records, unless I believe that doing so would endanger the child, or the parents agree to suspend their right to examine the treatment record. Because privacy and confidentiality of such communicationin psychotherapy is often crucial to successful progress, particularly with teenagers, it is my policy to request an agreement from parents that they consent to give up access to their child's records. If you communicate confidential they agree, then during treatment I will provide them only with general information about the progress of their child's treatment, and his or private information via email her attendance at scheduled sessions. Any other communication will require the child's Authorization for Release of Information, unless I feel that the child is in danger or textis a danger to someone else, in which case, I will assume that you have made an informed decisionnotify the parents of my concern. Before giving parents any information, I will view it as your agreement to take discuss the risk that such communication may be interceptedmatter with the child, if possible, and do my best to handle any objections he or she may have. Consent to Pay for Treatment I acknowledge responsibility for all fees incurred and, if it is necessary, I consent to have my account collected through an attorney or collection agency. I also agree that I will honor be responsible for all costs of litigation, including attorney’s fees. I have read and understand the above policies. Patient Signature Date Parent (or Guardian of minor) Signature Date Patient Information: NAME: ADDRESS: PHONE Home: Cell: Work: Can a message be left at Home? Yes No Work? Yes No Cell? Yes No Email address: SOCIAL SECURITY#: SEX: Male Female MARITAL STATUS: DATE OF BIRTH: AGE: EMPLOYER: POSITION: REFERRED BY: May I contact this person? Yes No Have you been in therapy before? Yes No For your desire current issue? Yes No If yes, with Whom? Where? When? Next of Kin not living with you: Phone #: Address: Responsible Party/Spouse/Parent Information: Name: Date of Birth: SS #: PHONE Home: Cell: Work: Primary Insurance: Name of Carrier: Name of Insured: Phone #: ID#: Group #: Insurance Patients: Please read and sign the following assignment of benefits if you would like us to communicate on such matters via email or text. Please do not use email or text file your insurance for emergencies. Due to computer or network problems, emails and texts may not be deliverable, and I may not check my emails or faxes frequently.you

Sessions. Each individual session lasts 45-60 minutes and family sessions are 60-80 minutes. If you are late for a session, that time is lost from your session. If I am late for a session, we will extend the session if you are willing to do so or we will make other arrangements by mutual consent. MISSED APPOINTMENTS Since a time slot is reserved for you that cannot be offered to anyone else, you will be charged for all missed appointments not cancelled 24 hours in advance. Please note my snow policy: I do not follow Montgomery Xxxxxxxxxx County’s snow policy. Unless you hear from me in the morning, I will assume that we will be meeting. If you cannot make it to the appointment for weather reasons, please call or email me by 8:00 a.m. (000-000-0000 or xxxxxx@xxxxxxxxxxxxxxxxxxxx.xxx) and I will waive the 24-hour cancellation fee. If you do not reschedule an appointment within one month of our last session, I will assume that you have decided to discontinue treatment with me. Please be assured that you are always welcome to return regardless of how much time has lapsed since our last session. Updated 10/2017 PROFESSIONAL FEES Fees are as specified on the signature page to be completed with me at our first session. You are responsible for payment for each therapy session at the time of the session by cash, check or credit card. During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. I do not participate in health insurance programs however I will provide you with an invoice with all the information needed should you wish to file a claim directly with the insurance company. It is your responsibility to contact your insurance company to determine if an authorization for treatment is required and to communicate that requirement to me. Please note, I am not a Medicare provider and therefore my services are not covered by Medicare. Should you want services from me and you are a Medicare recipient, this will serve as a separate private contract so that you may pay me out of pocket. Under this circumstance, you understand that you (or your beneficiaries or legal representatives) are waiving the right to submit claims or be reimbursed by Medicare for any services I provide that would otherwise be covered by Medicare if there was no private contract and a proper claim was submitted. You have every right to obtain similar services from a provider who has not opted out of Medicare. You understand that Medigap does not pay for services not covered by Medicare. The period of this agreement will be 2 years from the time of signature. This language is legalese required of me by Medicare guidelines! During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time and expenses, including preparation costs, transportation costs, and attorney’s fees, even if I am called to testify by another party. My professional time related to these activities is $350 per hour. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. It is very important to be aware that computers and email and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. If you communicate confidential or private information via email or text, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via email or text. Please do not use email or text for emergencies. Due to computer or network problems, emails and texts may not be deliverable, and I may not check my emails or faxes frequently.

Sessions. Each individual session lasts 45-60 45 minutes and family sessions are 60-80 minutes. If you are late for a session, that time is lost from your session. If I am late for a session, we will extend the session if you are willing to do so or we will make other arrangements by mutual consent. MISSED APPOINTMENTS Since a time slot is reserved for you that cannot be offered to anyone else, you will be charged for all missed appointments not cancelled 24 hours in advance. Please note my snow policy: I do not follow Montgomery County’s snow policy. Unless you hear from me in the morning, I will assume that we will be meeting. If you cannot make it to the appointment for weather reasons, please call or email me by 8:00 a.m. (000-000-0000 or xxxxxx@xxxxxxxxxxxxxxxxxxxx.xxxxxxx@xxx-xxxxxxxxx-xxxxx.xxx) and I will waive the 24-hour cancellation fee. If you do not reschedule an appointment within one month of our last session, I will assume that you have decided to discontinue treatment with me. Please be assured that you are always welcome to return regardless of how much time has lapsed since our last session. Updated 10/2017 PROFESSIONAL FEES Fees Please confirm current fees with therapist: ____ for 45-minute sessions ____ for 60-minute sessions ____ for 75-minute sessions Additional time is billed at $ per quarter hour. These fees are also billed for services such as specified on the signature page telephone calls not related to be completed with me at our first sessionscheduling, special reports, and collateral consultation. You are responsible for payment for each therapy session at the time of the session by cash, check or credit card. During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. I do not participate in health insurance programs however I will provide you with an invoice with all the information needed should you wish to file a claim directly with the insurance company. It is your responsibility to contact your insurance company to determine if an authorization for treatment is required and to communicate that requirement to me. Please note, I am not a Medicare provider and therefore my services are not covered by Medicare. Should you want services from me and you are a Medicare recipient, this will serve as a separate private contract so that you may pay me out of pocket. Under this circumstance, you understand that you (or your beneficiaries or legal representatives) are waiving the right to submit claims or be reimbursed by Medicare for any services I provide that would otherwise be covered by Medicare if there was no private contract and a proper claim was submitted. You have every right to obtain similar services from a provider who has not opted out of Medicare. You understand that Medigap does not pay for services not covered by Medicare. The period of this agreement will be 2 years from the time of signature. This language is legalese required of me by Medicare guidelines! During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time and expensestime, including preparation costs, and transportation costs, and attorney’s fees, even if I am called to testify by another party. My professional time related to these activities is [Because of the difficulty of legal involvement, I charge $350 700 per hour. hour for preparation and attendance at any legal proceeding.] CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. It is very important to be aware that computers and email and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. If you communicate confidential or private information via email or text, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via email or text. Please do not use email or text for emergencies. Due to computer or network problems, emails and texts may not be deliverable, and I may not check my emails or faxes frequently.

Sessions. Each individual session lasts 45-45 or 60 minutes and family sessions are 60-80 60 minutes. If you are late for a session, that time is lost from your session. If I am late for a session, we will extend the session if you are willing to do so or we will make other arrangements by mutual consent. MISSED APPOINTMENTS Since a time slot is reserved for you that cannot be offered to anyone else, you will be charged for all missed appointments not cancelled 24 hours in advance. Please note my snow policy: I do not follow Montgomery Xxxxxxxxxx County’s snow policy. Unless you hear from me in the morning, I will assume that we will be meeting. If you cannot make it to the appointment for weather reasons, please call or email me by 8:00 a.m. (000301-000652-0000 1582 or xxxxxx@xxxxxxxxxxxxxxxxxxxx.xxxxxxxx@xxxxxxxxxxxxxxxxxxxx.xxx) and I will waive the 24-hour cancellation fee. If you do not reschedule an appointment within one month of our last session, I will assume that you have decided to discontinue treatment with me. Please be assured that you are always welcome to return regardless of how much time has lapsed since our last session. Updated 10/2017 PROFESSIONAL FEES AND INSURANCE Fees are as specified on the signature page to be completed with me at our first session. You are responsible for payment for each therapy session at the time of the session by cash, check or credit card. During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. Please note, I do not participate in health insurance programs however I will provide you with an invoice with all the information needed should you wish to file a claim directly with the insurance company. It is your responsibility to contact your insurance company to determine if an authorization for treatment is required and to communicate that requirement to me. Please note, I am not a Medicare provider and therefore my services are not covered by Medicare. Should you want services from me and you are a Medicare recipient, this will serve as a separate private contract so that you may pay me out of pocket. Under this circumstance, you understand that you (or your beneficiaries or legal representatives) are waiving the right to submit claims or be reimbursed by Medicare for any services I provide that would otherwise be covered by Medicare if there was no private contract and a proper claim was submitted. You have every right to obtain similar services from a provider who has not opted out of Medicare. You understand that Medigap does not pay for services not covered by Medicare. The period of this agreement will be 2 years from the time of signature. This language is legalese required of me by Medicare guidelines! During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time and expensestime, including preparation costs, and transportation costs, and attorney’s fees, even if I am called to testify by another party. My professional time related to these activities is [Because of the difficulty of legal involvement, I charge $350 400 per hour. hour for preparation and attendance at any legal proceeding.] CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. It is very important to be aware that computers and email and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. If you communicate confidential or private information via email or text, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via email or text. Please do not use email or text for emergencies. Due to computer or network problems, emails and texts may not be deliverable, and I may not check my emails or faxes frequently.

Sessions. Each individual session lasts 45-60 minutes and family sessions are 60-80 minutesNormally, a Diagnostic Evaluation is conducted that will last from 1 to 3 sessions. During this time, we can both decide if Premier PCC/TMS is the best office to provide the services you need in order to meet your treatment goals. If you are late for a session, that time psychotherapy is lost from your session. If I am late for a sessionbegun, we will extend the usually schedule one 45-55 minute session if you are willing to do so or we will make other arrangements by mutual consent. MISSED APPOINTMENTS Since (one hour appointment of 45-55 minutes duration) per week at a time slot we agree on, although some sessions may be longer or more frequent. Once an appointment hour is reserved for you that cannot be offered to anyone elsescheduled, you will be charged expected to pay for all missed appointments not cancelled it unless you provide 24 hours in advanceadvance notice of cancellation, unless we both agree that you were unable to attend due to circumstances beyond your control. Please note my snow policy: I do not follow Montgomery County’s snow policyYou recognize that your credit card on file will be automatically charged. Unless you hear from me in the morningIf it is possible, I will assume that we will try to find another time to reschedule the appointment. THERAPY CANCELATION POLICY I understand if I fail to appear for my scheduled therapy session, without providing 24 hour notice of cancellation, my credit card on file will be meetingcharged $135. If you cannot make it to the appointment for weather reasons, please call or email me by 8:00 a.m. (000-000-0000 or xxxxxx@xxxxxxxxxxxxxxxxxxxx.xxx) and I also understand if my credit card on file is declined there will waive the 24-hour cancellation be an additional $35 service fee. If you do not reschedule an appointment within one month of our last session, I will assume that you have decided understand all fees for missed sessions must be paid prior to discontinue treatment with me. Please be assured that you are always welcome to return regardless of how much time has lapsed since our last my next therapy session. Updated 10/2017 TMS CANCELATION POLICY I understand if I fail to appear for my scheduled TMS session without providing 24 hour notice of cancellation or calling ahead for a same-day reschedule, my credit card on file will be charged $100. I also understand if my credit card on file is declined there will be an additional $35 service fee. PROFESSIONAL FEES Fees The Initial Diagnostic Evaluations are as specified on the signature page to be completed with me at our $250.00 (first session. You are responsible for payment for each therapy session at the time of the session by cash, check or credit card. During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. I do not participate in health insurance programs however I will provide you with an invoice with all the information needed should you wish to file a claim directly with the insurance company1-3 appointments). It is your responsibility required that the $250.00 fee be paid upfront. If/When the insurance pays for the services provided, the patient/paying party will be reimbursed for the overpayment, or they may request to contact your insurance company have it applied to determine if an authorization for treatment future appointments. Our Counseling/Psychotherapy 45-55 minute session fee is required and $165.00. In addition to communicate that requirement to me. Please note, I am not a Medicare provider and therefore my services are not covered by Medicare. Should you want services from me and you are a Medicare recipientweekly appointments, this amount will serve as a separate private contract so that be charged for other professional services you may pay me out of pocket. Under this circumstanceneed, you understand that you (or your beneficiaries or legal representatives) are waiving though the right to submit claims or be reimbursed by Medicare for any services I provide that would otherwise be covered by Medicare if there was no private contract and a proper claim was submitted. You have every right to obtain similar services from a provider who has not opted out of Medicare. You understand that Medigap does not pay for services not covered by Medicare. The period of this agreement hourly cost will be 2 years from broken down if the work period is less than one hour. Other services include report writing, telephone conversations lasting longer than 10 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 signature. This language is legalese required of me by Medicare guidelines! During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each yearPremierPCC/TMS. If you become involved in legal proceedings that require my our participation, you will be expected to pay for all of my our professional time and expenses, including preparation costs, transportation costs, and attorney’s fees, even if I am we are called to testify by another party. My professional time related to these activities is Because of the difficulty of legal involvement, we charge $350 per hourhour for preparation and attendance at any legal proceeding. BILLING AND PAYMENTS 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 which requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, we 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, PremierPCC/TMS has the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. [If such legal action is necessary, its costs will be included in the claim. After 60 days all delinquent accounts will be charged an interest rate of 1.5% per month (18% per annum) . In the event any balance is not paid as agreed, the undersigned agrees to pay a collection fee not to exceed 40% of the unpaid balance. In the event of a lawsuit to collect the unpaid balance, the undersigned further agrees to pay court costs and reasonable attorney’s fees in addition to the collection fee. You authorize us to call you at any number you provide or at any number at which we reasonably believe we can contact you, including calls to mobile, cellular, or similar devices for any lawful purpose. You agree to any an fee(s) or charge(s) that you may incur for incoming calls from us, and /or outgoing calls to us, to or from any such number, without reimbursement from us.] In most collection situations, the only information we release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. INSURANCE REIMBURSEMENT 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. On your first visit, we MAY accept your insurance if you obtain approval from our office staff prior to the date of service. If we accept your insurance, you must pay at least 20% of the total charges at the time of service; some procedures may require a 50% payment. If your insurance company has not paid within 45 days, you have 15 days to pay the balance. Late payment charges are added to unpaid accounts after 60 days from the date of service. If, your insurance company pays more than the balance due, we will either credit your account or send a refund check to you. Insurance is a contract between you and your insurance company. In most cases, we are NOT a party to this contract. (We will inform you if we are a party to your insurance.) We file insurance claims AS A COURTESY to our patients. We will NOT become involved in disputes between you and your insurance company regarding deductibles, co-payments, covered charges, secondary insurance, “usual & customary” charges, etc., other than to supply factual information as necessary. YOU are responsible for the timely payment of your account. We will FILE forms and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) 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 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 our 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, we will be willing to call the company on your behalf. Due to the rising costs of health care, insurance 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-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. You should also be aware that most insurance companies require you to authorize Premier PCC/TMS to provide them with a clinical diagnosis. Sometimes, Premier PCC/TMS has to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, Premier PCC/TMS has no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. We will provide you with a copy of any report we submit, if you request it. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for our services yourself to avoid the problems described above (unless prohibited by contract). CONTACTING ME Due to my work schedulePremierPCC/TMS Please call PremierPCC/TMS at 000-000-0000 between 9:00 am and 5:00 pm Monday thru Thursday and between 9:00 am and 2:00 pm on Fridays. If you leave a message, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I we 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 us of some times when you will be available. If you are unable to reach me us and feel that you can’t wait for me to a return your call, contact your family physician or the nearest emergency room and ask for the psychologist Psychologist (Psychiatrist or psychiatrist Social Worker) on call. If I your practitioner will be unavailable for an extended time, I you will provide you be provided with the name of a colleague to contact, if necessary. It is very important PROFESSIONAL RECORDS The laws and standards of this profession require that we keep treatment records. You are entitled to receive a copy of the records unless we believe that seeing them would be emotionally damaging, in which case we will be happy to send them to a mental health professional of your choice. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. We recommend that you review them in your practitioner’s presence so that we can discuss the contents. Patients will be charged an appropriate fee for any time spent in preparing information requests. MINORS If you are under eighteen years of age, please be aware that computers the law may provide your parents the right to examine your treatment records. It is our policy to request an agreement from parents that they agree to give up access to your records. If they agree, we will provide them only with general information about our work together, unless PremierPCC/TMS feels there is a high risk that you will seriously harm yourself or someone else. In that case, they will be notified of that concern. PremierPCC/TMS will also provide them with a summary of your treatment when it is complete. Before giving them any information, this matter will be discussed with you, if possible, and email and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise PremierPCC/TMS will do it’s best to handle any objections you may have. CONFIDENTIALITY In general, the privacy of all communications between a patient and confidentiality a psychologist is protected by law, and information about our work can only be released to others with your written permission. But there are a few exceptions. In most legal proceedings, you have the right to prevent PremierPCC/TMS 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 testimony if he/she determines that the issues demand it. There are some situations in which the practitioner is legally obligated to take action to protect others from harm, even if the practitioner has to reveal some information about a patient’s treatment. For example, if the practitioner believes that a child (elderly or disabled person) is being abused, the practitioner must file a report with the appropriate state agency. If the practitioner believes that a patient is threatening serious bodily harm to another, he/she is 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, he/she may be obligated to seek hospitalization for the patient or to contact family members or others who can help provide protection. These situations have rarely occurred in this practice. If a similar situation occurs, the practitioner will make every effort to fully discuss it with you before taking any action. Your practitioner may occasionally find it helpful to consult other professionals about a case. During a consultation, your practitioner will make every effort to avoid revealing the identity of such communicationthe patient. The consult is also legally bound to keep the information confidential. If you communicate confidential don’t object, your practitioner will not tell you about these consultations unless he/she feels that it is important to your work together. 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 private information via email or text, I will assume concerns that you may have made an informed decisionat our next meeting. Premier PCC/TMS will be happy to discuss these issues with you if you need specific advice, will view it as your agreement to take the risk that such communication but formal legal advice may be intercepted, and will honor your desire to communicate on such matters via email or text. Please do not use email or text for emergencies. Due to computer or network problems, emails and texts may not be deliverableneeded because the laws governing confidentiality are quite complex, and I may am not check my emails or faxes frequentlyan attorney.

Sessions. Each individual session lasts 45-45 or 60 minutes and family sessions are 60-80 60 minutes. If you are late for a session, that time is lost from your session. If I am late for a session, we will extend the session if you are willing to do so or we will make other arrangements by mutual consent. MISSED APPOINTMENTS Since a time slot is reserved for you that cannot be offered to anyone else, you will be charged for all missed appointments not cancelled 24 hours in advance. Please note my snow policy: I do not follow Montgomery Xxxxxxxxxx County’s snow policy. Unless you hear from me in the morning, I will assume that we will be meeting. If you cannot make it to the appointment for weather reasons, please call or email me by 8:00 a.m. (000-000-0000 or xxxxxx@xxxxxxxxxxxxxxxxxxxx.xxxxxxxx@xxx-xxxxxxxxx-xxxxx.xxx) and I will waive the 24-hour cancellation fee. If you do not reschedule an appointment within one month of our last session, I will assume that you have decided to discontinue treatment with me. Please be assured that you are always welcome to return regardless of how much time has lapsed since our last session. Updated 10/2017 PROFESSIONAL FEES Fees Current fees are as specified on the signature page follows: $ for 45-minute sessions $ for 60-minute sessions $ for 75-minute sessions Additional time is billed at $45 per quarter hour. These fees are also billed for services such as telephone calls not related to be completed with me at our first sessionscheduling, special reports, and collateral consultation. You are responsible for payment for each therapy session at the time of the session by cash, check or credit card. During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. I do not participate in health insurance programs however I will provide you with an invoice with all the information needed should you wish to file a claim directly with the insurance company. It is your responsibility to contact your insurance company to determine if an authorization for treatment is required and to communicate that requirement to me. Please note, I am not a Medicare provider and therefore my services are not covered by Medicare. Should you want services from me and you are a Medicare recipient, this will serve as a separate private contract so that you may pay me out of pocket. Under this circumstance, you understand that you (or your beneficiaries or legal representatives) are waiving the right to submit claims or be reimbursed by Medicare for any services I provide that would otherwise be covered by Medicare if there was no private contract and a proper claim was submitted. You have every right to obtain similar services from a provider who has not opted out of Medicare. You understand that Medigap does not pay for services not covered by Medicare. The period of this agreement will be 2 years from the time of signature. This language is legalese required of me by Medicare guidelines! During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time and expensestime, including preparation costs, and transportation costs, and attorney’s fees, even if I am called to testify by another party. My professional time related to these activities is [Because of the difficulty of legal involvement, I charge $350 700 per hour. hour for preparation and attendance at any legal proceeding.] CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. It is very important to be aware that computers and email and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. If you communicate confidential or private information via email or text, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via email or text. Please do not use email or text for emergencies. Due to computer or network problems, emails and texts may not be deliverable, and I may not check my emails or faxes frequently.

Sessions. Each individual session lasts 45-60 minutes Our first few sessions will involve an evaluation of your (or your child’s) needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you (and family sessions are 60-80 minutesyour child when applicable) feel comfortable working with me. Psychotherapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you are late have any questions, please feel free to ask them as they arise. Once psychotherapy has begun, I will usually schedule one 50-minute session (one appointment hour of 50 minutes duration – 40 minutes when doing play therapy) per week at a time we agree on although this may vary. To ensure that all clients have an equal opportunity to schedule an appointment, all appointments require a 24 hour cancellation notice except for a session, that time is lost from your sessionthose rare occasions such as significant illness or unforeseeable emergencies. If a significant illness or emergency does arise, I am late for a sessionask that you notify me as soon as possible so that I can plan accordingly. If an appointment is not cancelled 24 hours prior, we will extend the session or if you are willing fail to do so or we will make other arrangements by mutual consent. MISSED APPOINTMENTS Since a time slot is reserved arrive for you that cannot be offered to anyone elseyour appointment, you will be charged for all missed appointments not cancelled 24 hours in advance. Please note my snow policy: I do not follow Montgomery County’s snow policy. Unless you hear from me in the morning, I will assume that we will be meeting. If you cannot make it to the appointment for weather reasons, please call or email me by 8:00 a.m. (000-000-0000 or xxxxxx@xxxxxxxxxxxxxxxxxxxx.xxx) and I will waive the 24-hour a $125.00 cancellation fee. If you do not reschedule an appointment have booked your session within one month of our last session, I will assume that you have decided to discontinue treatment with me. Please be assured that you are always welcome to return regardless of how much time has lapsed since our last session. Updated 10/2017 PROFESSIONAL FEES Fees are as specified on the signature page to be completed with me at our first session. You are responsible for payment for each therapy session at the time 24 hours of the session by cashappointment, check but fail to arrive or credit card. During the course cancel within a reasonable amount of treatmenttime, it may become necessary to increase fees. Fees are reviewed in January and June of each year. I do not participate in health insurance programs however I will provide you with an invoice with all the information needed should you wish to file a claim directly with the insurance company. It is your responsibility to contact your insurance company to determine if an authorization for treatment is required and to communicate that requirement to me. Please note, I am not a Medicare provider and therefore my services are not covered by Medicare. Should you want services from me and you are a Medicare recipient, this will serve as a separate private contract so that you may pay me out of pocket. Under this circumstance, you understand that you (or your beneficiaries or legal representatives) are waiving the right to submit claims or be reimbursed by Medicare for any services I provide that would otherwise be covered by Medicare if there was but no private contract and a proper claim was submitted. You have every right to obtain similar services from a provider who has not opted out of Medicare. You understand that Medigap does not pay for services not covered by Medicare. The period of this agreement will be less than 2 years from the time of signature. This language is legalese required of me by Medicare guidelines! During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. If you become involved in legal proceedings that require my participationhours, you will be charged a $75.00 cancellation fee. Please understand that every “no show” appointment occupies a block of time that could have been dedicated to another client seeking care. Please also note that 3rd party payers do not provide reimbursement for unused sessions. This payment will be expected before you can schedule another appointment with me. Contacting Me: My telephone number is (000) 000-0000. Due to pay for all the nature of my professional time and expenses, including preparation costs, transportation costs, and attorney’s fees, even if I am called to testify by another party. My professional time related to these activities is $350 per hour. CONTACTING ME Due to my work schedulework, I am most often not immediately available by telephone. While I strive to be available during business hours, I will not answer the phone when I am in an appointment or am otherwise unavailable. When I am unavailable, my telephone is answered by confidential voice mail that I monitor frequentlyregularly. I will make every effort to return your call on the same day you make itwithin 24 hours, with the exception of weekends weekends, holidays, and holidaysvacations. Nighttime and weekend calls will usually be returned the next business day. If you are unable to reach me and feel that you can’t wait find yourself in an urgent situation, make a judgment about the prudence of waiting for me to return my call versus calling your callprimary care physician, contact your family physician 911, or the nearest emergency room and ask for the psychologist or psychiatrist on callAnchorage Community Mental Health Center’s 24-hour crisis line (907-563-3200). If I am away for extended periods, my voice mail message will be unavailable for an extended time, indicate that and state when I will provide you with the name return. My email address is xxxxxxxxxxxxxxxxxx@xxxx.xxx. Email is a convenient method of a colleague to contactcommunication, if necessary. It though it is very important to be aware that computers best used for administrative matters such as scheduling and email and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. If you communicate confidential or private information via email or text, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via email or textpayment issues. Please do note that information transmitted by email is not entirely secure. Please use email or text for emergencies. Due to computer or network problems, emails your judgment and texts may not be deliverable, and I may not check my emails or faxes frequentlyyour own level of comfort when transmitting personal information using this medium.

Sessions. Each individual session lasts 45-60 minutes and family sessions are 6075-80 90 minutes. If you are late for a session, that time is lost from your session. If I am late for a session, we will extend the session if you are willing to do so or we will make other arrangements by mutual consent. MISSED APPOINTMENTS Since a time slot is reserved for you that cannot be offered to anyone else, you will be charged for all missed appointments not cancelled 24 hours in advance. Please note my snow policy: I do not follow Montgomery County’s snow policy. Unless you hear from me in the morning, I will assume that we will be meeting. If you cannot make it to the appointment for weather reasons, please call or email me by 8:00 a.m. (000-000-0000 or xxxxxx@xxxxxxxxxxxxxxxxxxxx.xxxXxx@xxxxxxxxxxxxxxxxxxxx.xxx) and I will waive the 24-hour cancellation fee. If you do not reschedule an appointment within one month of our last session, I will assume that you have decided to discontinue treatment with me. Please be assured that you are always welcome to return regardless of how much time has lapsed since our last session. Updated 10/2017 PROFESSIONAL FEES Fees are as specified on the signature page to be completed with me at our first session. You are responsible for payment for each therapy session at the time of the session by cash, check or credit card. During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. I do not participate in health insurance programs however I will provide you with an invoice with all the information needed should you wish to file a claim directly with the insurance company. It is your responsibility to contact your insurance company to determine if an authorization for treatment is required and to communicate that requirement to me. Please note, I am not a Medicare provider and therefore Medicare does not cover my services are not covered by Medicareservices. Should you want services from me and you are a Medicare recipient, this will serve as a separate private contract so that you may pay me out of pocket. Under this circumstance, you understand that you (or your beneficiaries or legal representatives) are waiving the right to submit claims or be reimbursed by Medicare for any services I provide that would otherwise be covered by Medicare if there was no private contract and a proper claim was submitted. You have every right to obtain similar services from a provider who has not opted out of Medicare. You understand that Medigap does not pay for services not covered by Medicare. The period of this agreement will be 2 years from the time of signature. This language A fee of $60 per quarter hour is legalese required of me by Medicare guidelines! billed for services such as telephone calls not related to scheduling, special reports, and collateral consultation. During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time and expenses, including preparation costs, transportation costs, and attorney’s fees, even if I am called to testify by another party. My professional time related to these activities is $350 425 per hour. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail that I monitor frequentlymonitor. I 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 unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. It is very important to be aware that computers and email and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. If you communicate confidential or private information via email or text, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via email or text. Please do not use email or text for emergencies. Due to computer or network problems, emails and texts may not be deliverable, and I may not check my emails or faxes frequently.

Sessions. Each individual session lasts 45-60 minutes and family sessions are 6075-80 90 minutes. If you are late for a session, that time is lost from your session. If I am late for a session, we will extend the session if you are willing to do so or we will make other arrangements by mutual consent. MISSED APPOINTMENTS Since a time slot is reserved for you that cannot be offered to anyone else, you will be charged for all missed appointments not cancelled 24 hours in advance. Please note my snow policy: I do not follow Montgomery Xxxxxxxxxx County’s snow policy. Unless you hear from me in the morning, I will assume that we will be meeting. If you cannot make it to the appointment for weather reasons, please call or email me by 8:00 a.m. (000-000-0000 or xxxxxx@xxxxxxxxxxxxxxxxxxxx.xxxXxx@xxxxxxxxxxxxxxxxxxxx.xxx) and I will waive the 24-hour cancellation fee. If you do not reschedule an appointment within one month of our last session, I will assume that you have decided to discontinue treatment with me. Please be assured that you are always welcome to return regardless of how much time has lapsed since our last session. Updated 10/2017 PROFESSIONAL FEES Fees are as specified on the signature page to be completed with me at our first session. You are responsible for payment for each therapy session at the time of the session by cash, check or credit card. During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. I do not participate in health insurance programs however I will provide you with an invoice with all the information needed should you wish to file a claim directly with the insurance company. It is your responsibility to contact your insurance company to determine if an authorization for treatment is required and to communicate that requirement to me. Please note, I am not a Medicare provider and therefore Medicare does not cover my services are not covered by Medicareservices. Should you want services from me and you are a Medicare recipient, this will serve as a separate private contract so that you may pay me out of pocket. Under this circumstance, you understand that you (or your beneficiaries or legal representatives) are waiving the right to submit claims or be reimbursed by Medicare for any services I provide that would otherwise be covered by Medicare if there was no private contract and a proper claim was submitted. You have every right to obtain similar services from a provider who has not opted out of Medicare. You understand that Medigap does not pay for services not covered by Medicare. The period of this agreement will be 2 years from the time of signature. This language A fee of $60 per quarter hour is legalese required of me by Medicare guidelines! billed for services such as telephone calls not related to scheduling, special reports, and collateral consultation. During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time and expenses, including preparation costs, transportation costs, and attorney’s fees, even if I am called to testify by another party. My professional time related to these activities is $350 425 per hour. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail that I monitor frequentlymonitor. I 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 unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. It is very important to be aware that computers and email and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. If you communicate confidential or private information via email or text, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via email or text. Please do not use email or text for emergencies. Due to computer or network problems, emails and texts may not be deliverable, and I may not check my emails or faxes frequently.

Sessions. Each individual session lasts 45-60 minutes and family sessions are 60-80 minutesI 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 you or your child’s treatment goals. If you are late for a sessionpsychotherapy is begun, that time is lost from your session. If I am late for a sessionwill usually schedule one, we will extend the 50-minute session if you are willing to do so per week or we will make every other arrangements by mutual consent. MISSED APPOINTMENTS Since week at a time slot we agree on, although some sessions may be longer or more frequent. Once an appointment session is reserved for you that cannot be offered to anyone elsescheduled, you will be charged expected to pay for all missed appointments not cancelled it unless you provide 24 hours in advanceadvance notice of cancellation or unless we both agree that you were unable to attend due to circumstances beyond your control. Please note my snow policy: I do not follow Montgomery County’s snow policyPROFESSIONAL FEES The per session fee for Xx. Unless you hear from me in Xxxxxxxxxx is $000.00.Xxx will be expected to pay for each session at the morningtime it is held by credit card, check, or cash. Clients are expected to pay the session fee at the end of each session unless other arrangements have been made. Each appointment lasts approximately 50 minutes. In addition to regular appointments, I will assume that we will be meeting. If charge this amount for other professional services you cannot make it to the appointment for weather reasonsmay need, please call or email me by 8:00 a.m. (000-000-0000 or xxxxxx@xxxxxxxxxxxxxxxxxxxx.xxx) and though I will waive break down the 24hourly cost if I work for periods less than one hour. Other services include report-hour cancellation fee. If writing, assessment, telephone conversations lasting longer than 10 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you do not reschedule an appointment within one month may request of our last session, I will assume that you have decided to discontinue treatment with me. Please be assured aware that you are always welcome to return regardless some of how much time has lapsed since our last session. Updated 10/2017 PROFESSIONAL FEES Fees are as specified on the signature page to be completed with me at our first session. You are responsible for payment for each therapy session at the time of the session by cash, check or credit card. During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. I do these services will not participate in health insurance programs however I will provide you with an invoice with all the information needed should you wish to file a claim directly with the insurance company. It is your responsibility to contact your insurance company to determine if an authorization for treatment is required and to communicate that requirement to me. Please note, I am not a Medicare provider and therefore my services are not covered by Medicare. Should you want services from me and you are a Medicare recipient, this will serve as a separate private contract so that you may pay me out of pocket. Under this circumstance, you understand that you (or your beneficiaries or legal representatives) are waiving the right to submit claims or be reimbursed by Medicare for any services I provide that would otherwise be covered by Medicare if there was no private contract your insurance and a proper claim was submitted. You have every right to obtain similar services from a provider who has not opted out of Medicare. You understand that Medigap does not pay for services not covered by Medicare. The period of this agreement you will be 2 years from responsible for the time of signature. This language is legalese required of me by Medicare guidelines! During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time and expensestime, including preparation costs, and transportation costs. Because of the difficulty of legal involvement, we will charge more per hour for preparation and attorney’s fees, even if I am called to testify by another party. My professional time related to these activities is $350 per hourattendance at any legal proceeding. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail that I monitor frequentlymail. I will make every effort to return your non-emergency call on the same day you make itwithin 48 hours, with the exception of weekends and holidays. If you are unable to reach me and feel that believe you can’t cannot wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call, or dial 911. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. Please do not use email or faxes for emergencies. I do not always check my e-mail daily. E–MAILS, CELL PHONES, COMPUTERS, AND FAXES It is very important to be aware that computers and email unencrypted e-mail, texts, and cell phone e- faxes communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. E-mails, texts, and e- faxes, in particular, are vulnerable to such unauthorized access due to the fact that servers or communication companies may have unlimited and direct access to all e-mails, texts and e- faxes that go through them. While my computers are password protected, e-mails and e-fax are not encrypted. It is always a possibility that e-faxes, texts, and email can be sent erroneously to the wrong address and computers. Voicemail messages are kept confidential as well, and accessed only by myself or another licensed psychologist that covers my practice in my absence. Please notify me if you decide to avoid or limit, in any way, the use of e-mail, texts, cell phones calls, phone messages, or e-faxes. If you communicate confidential or private information via email unencrypted e-mail, texts or texte-fax or via phone messages, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via email or text. Please do not use email texts, e- mail, or text faxes for emergencies. Due LIMITS OF CONFIDENTIALITY The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can release only information about your treatment to computer 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 my patient. The other professionals are also legally bound to keep the information confidential. If you do not object, I will not tell you about these consultations unless I believe 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). ● If a patient seriously threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or network 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 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. 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 a patient files worker’s compensation claim, I must, upon appropriate request, provide records relating to treatment or hospitalization for which compensation is being sought. 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 cause to believe that a child who I am evaluating may be abused or neglected (including physical injury, substantial threat of harm, mental or emotional injury, or any kind of sexual contact or conduct), the law requires that I make a report to the appropriate governmental 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 be requires 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 discus 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, emails and texts it is important that we discuss any questions or concerns that you may not have now or in the future. The laws governing confidentiality can be deliverablequite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. PROFESSIONAL RECORDS The law and standards of my profession require that I keep 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 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. Except in unusual circumstances that involve danger to yourself and/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. If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon your request. In addition, I may or may not check also keep a set of Psychotherapy Notes. These Notes are for my emails 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 content of our conversations, my analysis of those conversations, and how they impact you in therapy. These Psychotherapy Notes are kept separate from your Clinical Record. Your 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 companies without your written, signed Authorization. PATIENT RIGHTS HIPAA provides you with several new or faxes frequentlyexpanded 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, or any of my privacy policies and procedures. I am happy to discuss any of these rights with you. MINORS & PARENTS Patients under 18 years of age who are not 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 my policy to request an agreement from the patient and his/her parents that the parents 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 communications 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. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment.

Sessions. Each individual session lasts 45-60 minutes and family sessions are 60-80 minutesDuring the time of initial assessment, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If you are late for counseling is begun, I will schedule one appointment hour of 50 minutes duration at a sessionfrequency and time we agree on, that time although some sessions may be longer, or frequency may change. Once an appointment hour is lost from your session. If I am late for a session, we will extend the session if you are willing to do so or we will make other arrangements by mutual consent. MISSED APPOINTMENTS Since a time slot is reserved for you that cannot be offered to anyone elsescheduled, you will be charged for all missed appointments not cancelled expected to attend unless you provide 24 hours advance notice of cancellation, or unless we both agree that you were unable to attend due to circumstances beyond your control. You will be expected to pay half the fee if you cancel less than 24 hours in advance. Please note my snow policy: I advance and the full fee if you provide no notice of cancellation since insurance providers do not follow Montgomery County’s snow policy. Unless you hear from me in the morning, I will assume that we will be meeting. If you cannot make it to the appointment pay for weather reasons, please call or email me by 8:00 a.m. (000-000-0000 or xxxxxx@xxxxxxxxxxxxxxxxxxxx.xxx) and I will waive the 24-hour cancellation fee. If you do not reschedule an appointment within one month of our last session, I will assume that you have decided to discontinue treatment with me. Please be assured that you are always welcome to return regardless of how much time has lapsed since our last session. Updated 10/2017 PROFESSIONAL FEES Fees are as specified on the signature page to be completed with me at our first session. You are responsible for payment for each therapy session at the time of the session by cash, check or credit card. During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. I do not participate in health insurance programs however I will provide you with an invoice with all the information needed should you wish to file a claim directly with the insurance companymissed sessions. It is your my ethical responsibility to contact your insurance company end the counseling relationship when it becomes reasonably clear you are not benefiting from treatment. PROFESSIONAL FEES My fee for the initial assessment is $185.00 and the hourly fee for individual counseling is $135.00. In addition to determine if an authorization for treatment is required and to communicate that requirement to me. Please noteindividual counseling appointments, I am not a Medicare provider and therefore my charge an hourly fee of $60.00 for other consultation services are not covered by Medicare. Should (includes report writing, phone conversations over 10 minutes, attendance at meetings you want request me to attend, or other services from me and you are a Medicare recipient, this will serve as a separate private contract so that you may pay me out request), though I will break down the hourly cost in 15-minute blocks for periods of pocketless than one hour. Under this circumstanceAs an established client, you understand that you (or your beneficiaries or legal representatives) are waiving the right to submit claims or be reimbursed by Medicare for any may also take advantage of online support services I provide that would otherwise be covered by Medicare if there was no private contract and a proper claim was submitted. You have every right to obtain similar services from a provider who has not opted out of Medicare. You understand that Medigap does not pay for services not covered by Medicare. The period of this agreement will be 2 years from the time of signature. This language is legalese required of me by Medicare guidelines! During the course of treatmentas outlined on my website, it may become necessary to increase fees. Fees are reviewed in January and June of each yearxxxxxxxxxxx.xxx. If you become involved in legal proceedings that and require my participation, you will be expected to pay for all my professional time. Because of the difficulty of legal involvement, I charge $175.00 per hour for preparation and attendance at any legal proceeding. The payment schedule for additional services is included in the intake packet. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held unless you have insurance coverage. If you have insurance coverage, I will accept the insurance reimbursement for covered services and will only expect co-pay fees, if any, to be paid at the time of service unless we agree otherwise. In circumstances of unusual financial hardship, I may be willing to negotiate a payment installment plan. However, if more than 90 days have passed without payment and there have been no attempts to make arrangements to the pay the bill, or I have been unable to reach you to discuss your bill during that timefrme, I reserve the right to seek payment through formal collection services. 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 going through small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information I release regarding a client's treatment is his or her name, the nature of services provided, and the amount due. INSURANCE REIMBURSEMENT 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) are responsible for full payment of my professional time fees. For example, certain insurance providers may not allow some services and expensesyou will be expected to pay for all services not covered by your insurance plan. It is very important that you find out exactly what mental health services your insurance policy covers. You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information such as treatment plans or summaries, including preparation costsor copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, transportation costsI have no control over what they do with it once it is in their hands. In some cases, and attorney’s feesthey may share the information with a national medical information databank. I will provide you with a copy of any report I submit, even if I am called to testify by another party. My professional time related to these activities is $350 per houryou request it. CONTACTING ME Due to my work schedule, I am often sometimes not immediately available by telephone. I probably will not answer the phone when I am with a client. When I am unavailable, my telephone is answered by voice mail that I monitor frequentlycontinually monitor. I will make every effort to return your call on the same day day. If you make itare difficult to reach, with the exception please inform me of weekends and holidaysseveral times when you will be available. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or call Rescue Mental Health Services at 419.255.2801. If it is an emergency, call 911 or go to the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. It is very important PROFESSIONAL RECORDS The laws and standards of my profession require that I keep treatment records. These records are considered Protected Health Information. You are entitled to receive a copy of the records unless I believe that seeing them would be aware that computers and email and cell phone communication emotionally damaging, in which case I will be happy to send them to a mental health professional of your choice. Because these are professional records, they can be relatively easily accessed by unauthorized people and hence misinterpreted or may be upsetting to untrained readers. I recommend that you review them in my presence so that we can compromise discuss the contents. Additional information regarding your Protected Health Information is included in the intake packet. Clients will be charged an appropriate fee for any time spent in preparing information requests. CONFIDENTIALITY In general, the law protects the privacy of all communications between a client and confidentiality a counselor, and I can only release information about our work to others with your written permission. But there are a few exceptions. In most legal proceedings, you have the right to prevent me from providing any information about your treatment unless you use your state of mental health as a defense. 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 or 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 client’s treatment. For example, if I believe that a child, elderly person, or disabled person is being abused, I am required to file a report with the appropriate state agency. If I believe that a client is threatening serious bodily harm to an identifiable person or persons, including an identifiable structure, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for a client. If a client threatens to harm himself or herself, I am obligated to seek hospitalization for him or 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. At times, I will be under supervision with Xxxxx X. Xxxxx, Ph.D. or his designee because of insurance purposes as required by Ohio law. You have the right to ask for an appointment with the supervisor at any time. I may occasionally find it helpful to consult other professionals about a case. During such communicationa consultation, I make every effort to avoid revealing the identity of my client. Any consultant or supervisor is also legally bound to keep the information confidential. If you communicate confidential or private information via email or textdon’t object, I will assume not tell you about these consultations or supervision sessions unless I feel that it is important to our work together. 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 made an informed decisionat our next meeting. I will be happy to discuss these issues with you if you need specific advice, will view it as your agreement to take the risk that such communication but formal legal advice may be intercepted, and will honor your desire to communicate on such matters via email or text. Please do not use email or text for emergencies. Due to computer or network problems, emails and texts may not be deliverableneeded because the laws governing confidentiality are quite complex, and I am not an attorney. CHILD AND ADOLESCENT CONFIDENTALITY Before treatment, it's important for you to understand my approach to child and adolescent counseling and agree to some rules about your child’s confidentiality while in treatment. One risk of child counseling involves disagreements among parents or disagreements between parents and the counselor regarding the best interests of the child. If such disagreements occur, I will strive to listen carefully so that I can understand your perspectives and fully explain mine. We can either resolve such disagreements or we can agree to disagree, so long as this enables your child’s therapeutic progress. Ultimately, you will decide whether counseling will continue. If either of you decides that counseling should end, I will honor that decision, however I ask that you allow me the option of having a few closing sessions to appropriately end the treatment relationship. Counseling is most effective when a trusting relationship exists between the counselor and the client. Privacy is especially important in securing and maintaining that trust. One goal of treatment is to promote a stronger and better relationship between children and their parents. However, it is often necessary for children to develop a “zone of privacy” so that they feel free to discuss personal matters with greater freedom. This is particularly true for adolescents who are naturally developing a greater sense of independence. However, it's my policy to provide you with general information about treatment status. I will raise issues that may impact your child either inside or outside the home. If it is necessary to refer your child to another mental health professional with more specialized skills, I will share that information with you. I will not share with you what your child has disclosed to me without your child’s consent. I will tell you if your child does not attend sessions. At the end of your child’s treatment, I will provide you with a treatment summary that will describe what issues were discussed, what progress was made, and what areas are likely to require intervention in the future. If your child is an adolescent, it is possible that he or she will reveal sensitive information regarding sexual contact, alcohol and drug use, or other potentially problematic behaviors. Sometimes these behaviors are within the range of normal adolescent experimentation, but at other times they may require parental intervention. We must carefully and directly discuss your feelings and opinions regarding acceptable behavior. If I ever believe that your child is at serious risk of harming himself or herself or another, I will inform you. Although my responsibility to your child may require my involvement in conflicts between the two of you, I need your agreement that my involvement will be strictly limited to that which will benefit your child. This means, among other things, that you will treat anything that is said in session with me as confidential. Neither of you will attempt to gain advantage in any legal proceeding between the two of you from my involvement with your children. In particular, I need your agreement that in any such proceedings, neither of you will ask me to testify in court, whether in person, or by affidavit. You also agree to instruct your attorneys not to subpoena me or to refer in any court filing to anything I have said or done. Note that such agreement may not check prevent a judge from requiring my emails testimony, even though I will work to prevent such an event. If I am required to testify, I am ethically bound not to give my opinion about either parent’s custody or faxes frequentlyvisitation suitability. If the court appoints a custody evaluator, guardian ad litem, or parenting coordinator, I will provide information as needed (if appropriate releases are signed or a court order is provided), but I will not make any recommendation about the final decision. Xxxxx X Xxxxx, Ph.D. & Associates Client Information and Consent for Treatment Form Client Name: Address: (Street) (City) (State & Zip Code) Home Phone: Cell: Work: Client SSN: Client Date of Birth: Martial Status: Married [ ] Single [ ] Xxxxxx's Name: Gender: Male [ ] Female [ ] Xxxxxx's Work Phone: Client's Employer: Who is Financially Responsible for this Bill? Name: Address: If different from clients (Street) (City) (State & Zip Code) Home Phone: Cell: Work: Insured SSN: Insured Date of Birth: Insured's Employer Insurance Carrier: Primary Care Physician: Address: (Street) (City) (State & Zip Code) Current Medications: Past Mental Health Outpatient Treatment: Past Substance Abuse Outpatient Treatment: Past Mental Health / Substance Abuse Inpatient Treatment: Current Medical Conditions: Emergency Contact Person: Referral Source: Copy of Insurance Card(s) Attached: Yes [ ] No [ ] I hereby give permission to Xxxxxx X. Xxxx, M.Ed., LPCC-S or designee to provide counseling for me on an outpatient basis and by signing this form, I am acknowledging the following:

Sessions. Each individual session lasts 45-60 minutes and family sessions are 60-80 minutesDuring the time of initial assessment, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If you are late for counseling is begun, I will schedule one appointment hour of 50 minutes-duration at a sessionfrequency and time we agree on, that time although some sessions (couples) may be longer or frequency can change. Once an appointment hour is lost from your session. If I am late for a session, we will extend the session if you are willing to do so or we will make other arrangements by mutual consent. MISSED APPOINTMENTS Since a time slot is reserved for you that cannot be offered to anyone elsescheduled, you will be charged for all missed appointments not cancelled expected to attend unless you provide 24 hours in advanceadvance notice of cancellation, or unless we both agree that you were unable to attend due to circumstances beyond your control. Please note my snow policy: I do not follow Montgomery County’s snow policy. Unless you hear from me in the morning, I will assume that we You will be meetingexpected to pay half the fee if you cancel less than 24 hours in advance and the full fee if you provide no notice of cancellation. If you cannot make it to PROFESSIONAL FEES My fee for the appointment for weather reasons, please call or email me by 8:00 a.m. initial assessment is $250.00 (000-000-0000 or xxxxxx@xxxxxxxxxxxxxxxxxxxx.xxxcouples- 90 minutes) and I will waive the 24-hour cancellation fee$160 (individual- 50/60 minutes). If you do not reschedule an appointment within one month of our last session, I will assume that you have decided to discontinue treatment with me. Please be assured that you are always welcome to return regardless of how much time has lapsed since our last session. Updated 10/2017 PROFESSIONAL FEES Fees are as specified on the signature page to be completed with me at our first session. You are responsible The hourly fee for payment for each therapy session at the time of the session by cash, check or credit card. During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each yearindividual counseling is $120.00 (50 minutes). I do not participate in health have a student rate (active and current students) of $130 initial session and $95 for the regular 50- minute session. The regular session fee for couples is $220 for the 90-minute session. I DO NOT accept insurance programs however at this time. In addition to individual counseling appointments, I charge an hourly fee of $100.00 for other consultation services (includes report writing, phone conversations over 10 minutes, attendance at meetings you request me to attend, or other services you may request), though I will provide you with an invoice with all break down the information needed should you wish to file a claim directly with the insurance company. It is your responsibility to contact your insurance company to determine if an authorization hourly cost in 15-minute-blocks for treatment is required and to communicate that requirement to me. Please note, I am not a Medicare provider and therefore my services are not covered by Medicare. Should you want services from me and you are a Medicare recipient, this will serve as a separate private contract so that you may pay me out periods of pocket. Under this circumstance, you understand that you (or your beneficiaries or legal representatives) are waiving the right to submit claims or be reimbursed by Medicare for any services I provide that would otherwise be covered by Medicare if there was no private contract and a proper claim was submitted. You have every right to obtain similar services from a provider who has not opted out of Medicare. You understand that Medigap does not pay for services not covered by Medicare. The period of this agreement will be 2 years from the time of signature. This language is legalese required of me by Medicare guidelines! During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each yearless than one hour. If you become involved in legal proceedings that and require my participation, you will be expected to pay for all of my professional time. Because of the difficulty of legal involvement, I charge $200 per hour for preparation and attendance at any legal proceeding. The payment schedule for additional services is included in the intake packet. BILLING AND PAYMENTS You will be expected to pay for each session at the time and expensesit is held. At this time, including preparation costsI accept cash, transportation costsVenmo, and attorney’s fees, even if I am called to testify by another party. My professional time related to these activities is $350 per hourPayPal only. CONTACTING ME Due to my work schedule, I am often sometimes not immediately available by telephone. I will not be able to answer the phone when I am with a client. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. you are welcome to leave me a message and I will make every effort to return your call within 24 hours as able. I try to return calls on the same day when possible and when it is a reasonable time. If you make itare difficult to reach, with the exception please inform me of weekends and holidayssome times when you will be available. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or call the crisis line at 988 or 0-000-000-0000. If it is an emergency, call 911 or go to the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. It is very important PROFESSIONAL RECORDS The laws and standards of my profession require that I keep treatment records. These records are considered Protected Health Information. You are entitled to receive a copy of the records unless I believe that seeing them would be aware that computers and email and cell phone communication emotionally damaging, in which case, I will be happy to send them to a mental health professional of your choice. Because these are professional records, they can be relatively easily accessed by unauthorized people and hence misinterpreted or may be upsetting to untrained readers. I recommend that you review them in my presence so that we can compromise discuss the contents. Additional information regarding your Protected Health Information is included in the intake packet. Clients will be charged an appropriate fee for any time spent in preparing information requests. CONFIDENTIALITY In general, the law protects the privacy of all communications between a client and confidentiality a counselor, and I can only release information about our work to others with your written permission. But there are a few exceptions. In most legal proceedings, you have the right to prevent me from providing any information about your treatments unless you use your state of such communicationmental health as a defense. In some proceedings involving child custody and those in which your emotional condition is an importance issue, a judge may order my testimony if he or 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 client’s treatment. For example, if I believe that a child, elderly person, or disabled person is being abused, I am required to file a report with the appropriate state agency. If I believe that a client is threatening serious bodily harm to an identifiable person or persons, including an identifiable structure, I am required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for a client. If a client threatens to harm himself or herself, I am obligated to seek hospitalization for him or her; or 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 with other professionals about a case. During this consultation, I make every effort to avoid revealing the identity of my client. The consulting professional is also legally bound to keep the information confidential. If you communicate confidential or private information via email or textdon’t object, I will assume not tell you about these consultations unless I feel that it is important to our work together. In addition, when engaging in family, group, or couples counseling I cannot guarantee that all participants shall honor the confidentiality agreement. 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 made an informed decisionwhen we meet. I will be happy to discuss these issues with you if you need specific advice, will view it as your agreement to take the risk that such communication but formal legal advice may be intercepted, and will honor your desire to communicate on such matters via email or text. Please do not use email or text for emergencies. Due to computer or network problems, emails and texts may not be deliverableneeded because of the laws governing confidentiality are quite complex, and I am not an attorney. CHILD AND ADOLESCENT CONFIDENTIALITY Before treatment, it’s important for you to understand my approach to child and adolescent counseling and agree to some rules about your child’s confidentiality while in treatment. One risk of child counseling involves disagreements among parents or disagreements between parents and the counselor regarding the best interests of the child. If such disagreements occur, I will strive to listen carefully so that I can understand your perspective and fully explain mine. We can either resolve such disagreements or we can agree to disagree, so long as this enables your child’s therapeutic progress. Ultimately, you will decide whether counseling will continue. If either of you decides that counseling should end, I will honor that decision, however I ask that you allow me the option of having a few closing sessions to appropriately end the treatment relationship. Counseling is most effective when a trusting relationship exists between the counselor and the client. Privacy is especially important in securing and maintaining the trust. One goal of treatment is to promote a stronger and better relationship between children and their parents. However, it is often necessary for children to develop a “zone of privacy” so that they feel free to discuss personal matters with greater freedom. This is particularly true for adolescents who are naturally developing a greater sense of independence. However, it’s my policy to provide you with general information about treatment status. I will raise issues that may impact your child either inside or outside the home. If it is necessary to refer your child to another mental health professional with more specialized skills, I will share that information with you. I will not check share with you what your child has disclosed to me without your child’s consent. I will tell you if your child does not attend sessions. At the end of your child’s treatment, I will provide you with a treatment summary that will describe what issues were discussed, what progress was made, and what areas are likely to require interventions in the future. If your child, is an adolescent, it is possible that he or she will reveal sensitive information regarding sexual contact, alcohol and drug use, or other potentially problematic behaviors. Sometimes these behaviors are within the range of normal adolescent experimentation, but at other times they may require parental intervention. We must carefully and directly discuss your feelings and opinions regarding acceptable behavior. If I ever believe that your child is at serious risk or harming himself or herself or another, I will inform you. Although my emails responsibility to your child may require my involvement in conflicts between the two of you, I need your agreement that my involvement will be strictly limited to that which will benefit your child. This means, among other things, that you will treat anything that I said in session with me as confidential. Neither of you will attempt to gain advantage in any legal proceeding between the two of you from my involvement with your children. In particular, I need your agreement that in any such proceedings, neither of you will ask me to testify in court, whether in person, or faxes frequentlyby affidavit. You also agree to instruct your attorneys not to subpoena me or to refer in any court filling to anything I have said or done.

Sessions. Each individual session lasts 45-45 or 60 minutes and family sessions are 60-80 60 minutes. If you are late for a session, that time is lost from your session. If I am late for a session, we will extend the session if you are willing to do so or we will make other arrangements by mutual consent. MISSED APPOINTMENTS Since a time slot is reserved for you that cannot be offered to anyone else, you will be charged for all missed appointments not cancelled 24 hours in advance. Please note my snow policy: I do not follow Montgomery Xxxxxxxxxx County’s snow policy. Unless you hear from me in the morning, I will assume that we will be meeting. If you cannot make it to the appointment for weather reasons, please call or email me by 8:00 a.m. (000301-000652-0000 1582 or xxxxxx@xxxxxxxxxxxxxxxxxxxx.xxxxxxxx@xxx-xxxxxxxxx-xxxxx.xxx) and I will waive the 24-hour cancellation fee. If you do not reschedule an appointment within one month of our last session, I will assume that you have decided to discontinue treatment with me. Please be assured that you are always welcome to return regardless of how much time has lapsed since our last session. Updated 10/2017 PROFESSIONAL FEES Fees Current fees are as specified on the signature page follows: $ for 45-minute sessions $ for 60-minute sessions $ for 75-minute sessions Additional time is billed at $45 per quarter hour. These fees are also billed for services such as telephone calls not related to be completed with me at our first sessionscheduling, special reports, and collateral consultation. You are responsible for payment for each therapy session at the time of the session by cash, check or credit card. During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. I do not participate in health insurance programs however I will provide you with an invoice with all the information needed should you wish to file a claim directly with the insurance company. It is your responsibility to contact your insurance company to determine if an authorization for treatment is required and to communicate that requirement to me. Please note, I am not a Medicare provider and therefore my services are not covered by Medicare. Should you want services from me and you are a Medicare recipient, this will serve as a separate private contract so that you may pay me out of pocket. Under this circumstance, you understand that you (or your beneficiaries or legal representatives) are waiving the right to submit claims or be reimbursed by Medicare for any services I provide that would otherwise be covered by Medicare if there was no private contract and a proper claim was submitted. You have every right to obtain similar services from a provider who has not opted out of Medicare. You understand that Medigap does not pay for services not covered by Medicare. The period of this agreement will be 2 years from the time of signature. This language is legalese required of me by Medicare guidelines! During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time and expensestime, including preparation costs, and transportation costs, and attorney’s fees, even if I am called to testify by another party. My professional time related to these activities is [Because of the difficulty of legal involvement, I charge $350 700 per hour. hour for preparation and attendance at any legal proceeding.] CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. It is very important to be aware that computers and email and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. If you communicate confidential or private information via email or text, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via email or text. Please do not use email or text for emergencies. Due to computer or network problems, emails and texts may not be deliverable, and I may not check my emails or faxes frequently.

Sessions. Each individual session lasts 45-60 minutes and family sessions are 60-80 minutesI 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 you are late for a session, that time psychotherapy is lost from your session. If I am late for a session, we will extend the session if you are willing to do so or we will make other arrangements by mutual consent. MISSED APPOINTMENTS Since a time slot is reserved for you that cannot be offered to anyone else, you will be charged for all missed appointments not cancelled 24 hours in advance. Please note my snow policy: I do not follow Montgomery County’s snow policy. Unless you hear from me in the morningbegun, I will assume that usually schedule one 50-minute session (one appointment hour of 50 minutes duration) per week at a time we will agree on, although some sessions may be meetinglonger or more frequent if special circumstances arise. If you cannot make it to the appointment for weather reasons, please call or email me by 8:00 a.m. (000-000-0000 or xxxxxx@xxxxxxxxxxxxxxxxxxxx.xxx) and I will waive the 24-hour cancellation fee. If you do not reschedule CANCELLATIONS Once an appointment within one month of our last session, I will assume that you have decided to discontinue treatment with me. Please be assured that you are always welcome to return regardless of how much time has lapsed since our last session. Updated 10/2017 PROFESSIONAL FEES Fees are as specified on the signature page to be completed with me at our first session. You are responsible for payment for each therapy session at the time of the session by cash, check or credit card. During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. I do not participate in health insurance programs however I will provide you with an invoice with all the information needed should you wish to file a claim directly with the insurance company. It hour is your responsibility to contact your insurance company to determine if an authorization for treatment is required and to communicate that requirement to me. Please note, I am not a Medicare provider and therefore my services are not covered by Medicare. Should you want services from me and you are a Medicare recipient, this will serve as a separate private contract so that you may pay me out of pocket. Under this circumstance, you understand that you (or your beneficiaries or legal representatives) are waiving the right to submit claims or be reimbursed by Medicare for any services I provide that would otherwise be covered by Medicare if there was no private contract and a proper claim was submitted. You have every right to obtain similar services from a provider who has not opted out of Medicare. You understand that Medigap does not pay for services not covered by Medicare. The period of this agreement will be 2 years from the time of signature. This language is legalese required of me by Medicare guidelines! During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. If you become involved in legal proceedings that require my participationscheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation. If it is possible, I will always try to find another time to reschedule the appointment for another that same week, thus avoiding the cancellation fee. Since we live in a climate with frequent snow and inclement weather my policy is to follow BVSD’s school closure recommendation. Specifically, if BVSD cancels school due to snow or weather, then I waive my 24-hour cancellation policy for that day. If clients feel uncomfortable coming to session due to weather on a non BVSD closure day, I will try to reschedule you for another day that week, however, it may not always be possible. If you choose to discontinue therapy for more than sixty (60) days without communicating with me, your therapy will be considered terminated. If you want to resume therapy after termination, please discuss this with me. The ability to resume treatment will depend on availability and will be at my sole discretion. PROFESSIONAL FEES My hourly (50 min. session) fee is $ 120.00 unless a different fee is agreed upon. (Insert different amount here $ and your Initials , my initials: ). I may raise this fee in the future to offset increased costs related to doing business. Of course, all changes in fees will be discussed before an adjustment is made. I charge this amount for other professional services you may need, though I will pro-rate the hourly cost if I work for periods of my less than one hour. Other services include report writing, telephone conversations of a clinical nature (consultation, collateral information gathering, responding to emergencies or crisis), 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 me. If you become involved in legal proceedings, I charge $250 per hour for services related to your legal matter. You will be responsible for paying for any professional time and expenses, including preparation costs, transportation costs, and attorney’s feesI spend on your legal matter, even if I am called to testify by the request comes from another party. My professional Professional time related to these activities spent on your legal matter includes but is $350 per hour. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail limited to: attorney fees that I monitor frequently. I will make every effort to return your call on the same day you make it, may incur in preparing for or complying with the exception of weekends and holidays. If you are unable to reach me and feel that you can’t wait for me to return your callrequested legal services; testimony related matters such as case research, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended timereport writing, I will provide you with the name of a colleague to contacttravel, if necessary. It is very important to be aware that computers and email and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. If you communicate confidential or private information via email or textdepositions, I will assume that you have made an informed decisionactual testimony, will view it as your agreement to take the risk that such communication may be interceptedcross examination, and will honor your desire to communicate on such matters via email or text. Please do not use email or text for emergencies. Due to computer or network problems, emails and texts may not be deliverable, and I may not check my emails or faxes frequentlycourtroom waiting time.

Sessions. Each individual session lasts 45-60 minutes and family sessions are 60-80 minutes. If you are late for a session, that time is lost from your session. If I am late for a session, we will extend the session if you are willing to do so or we will make other arrangements by mutual consent. MISSED APPOINTMENTS Since a time slot is reserved for you that cannot be offered to anyone else, you will be charged for all missed appointments not cancelled 24 hours in advance. Please note my snow policy: I do not follow Montgomery Xxxxxxxxxx County’s snow policy. Unless you hear from me in the morning, I will assume that we will be meeting. If you cannot make it to the appointment for weather reasons, please call or email me by 8:00 a.m. (000-000-0000 or xxxxxx@xxxxxxxxxxxxxxxxxxxx.xxx) and I will waive the 24-hour cancellation fee. If you do not reschedule an appointment within one month of our last session, I will assume that you have decided to discontinue treatment with me. Please be assured that you are always welcome to return regardless of how much time has lapsed since our last session. Updated 10/2017 PROFESSIONAL FEES Fees Please confirm current fees with therapist: $170 for 45-minute sessions $200 for 60-minute sessions $230 for 75-minute sessions $ 75 for 60-minute group $100 for 90-minute group Additional time is billed at $50 per quarter hour. These fees are also billed for services such as specified on the signature page telephone calls not related to be completed with me at our first sessionscheduling, special reports, and collateral consultation. You are responsible for payment for each therapy session at the time of the session by cash, check or credit card. During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. I do not participate in health insurance programs however I will provide you with an invoice with all the information needed should you wish to file a claim directly with the insurance company. It is your responsibility to contact your insurance company to determine if an authorization for treatment is required and to communicate that requirement to me. Please note, I am not a Medicare provider and therefore my services are not covered by Medicare. Should you want services from me and you are a Medicare recipient, this will serve as a separate private contract so that you may pay me out of pocket. Under this circumstance, you understand that you (or your beneficiaries or legal representatives) are waiving the right to submit claims or be reimbursed by Medicare for any services I provide that would otherwise be covered by Medicare if there was no private contract and a proper claim was submitted. You have every right to obtain similar services from a provider who has not opted out of Medicare. You understand that Medigap does not pay for services not covered by Medicare. The period of this agreement will be 2 years from the time of signature. This language is legalese required of me by Medicare guidelines! During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time and expenses, including preparation costs, transportation costs, and attorney’s fees, even if I am called to testify by another party. My professional time related to these activities is $350 per hour. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. It is very important to be aware that computers and email and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. If you communicate confidential or private information via email or text, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via email or text. Please do not use email or text for emergencies. Due to computer or network problems, emails and texts may not be deliverable, and I may not check my emails or faxes frequently.

Sessions. Each individual The first few sessions will involve an evaluation of your needs. During this time, we can both decide if I am the best person to provide these services in order to meet your treatment goals. By the end of this period of time, if I have not already done so, I will be able to offer you some impressions of what the work will include if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working in this way. You always maintain the right to ask about other treatments for and about their risks and benefits. Once psychotherapy has begun, I usually schedule one 50-minute session lasts 45-60 (one appointment hour of 50 minutes duration) per week at a time we agree upon. Based on your needs, some sessions may be longer or more frequent. Missed sessions present a special problem in therapy because the given hour is specifically blocked out for you and family sessions are 60-80 minutesoften can not be filled on short notice. If you are late for a must miss an appointment, please notify me as soon as possible at (000) 000-0000. I will try to find another time to reschedule the appointment. Unless you give 48 hours notice of your intention to miss the session, that time is lost from your session. If I am late for a session, we will extend the session if you are willing to do so or we will make other arrangements by mutual consent. MISSED APPOINTMENTS Since a time slot is reserved for you that cannot be offered to anyone else, you will be charged billed for all the session. Insurance will not reimburse you for missed appointments not cancelled 24 hours in advancesessions. Please note my snow policy: I do not follow Montgomery County’s snow policyPROFESSIONAL FEES Sessions are 50 minutes long and are billed at the rate of $ . Unless If this rate should change, you hear from me in the morning, I will assume that we will be meetinggiven at least 2 months notice. If you cannot make it to the appointment for weather reasons, please call Longer or email me shorter sessions are pro-rated by 8:00 a.m. (000-000-0000 or xxxxxx@xxxxxxxxxxxxxxxxxxxx.xxx) and I will waive the 24-hour cancellation fee. If you do not reschedule an appointment within one month of our last session, I will assume that you have decided to discontinue treatment with me. Please be assured that you are always welcome to return regardless of how much time has lapsed since our last session. Updated 10/2017 PROFESSIONAL FEES Fees are as specified on the signature page to be completed with me at our first sessionprior mutual agreement. You are responsible for payment will be expected to pay for each therapy session at the time it is held unless we arrange for monthly xxxxxxxx. If for any reason you should become involved in legal action that requires your therapist or other counseling clinical staff to protect your privilege of confidentiality or testify on your behalf, you must agree to cover legal expenses and the session by cash, check or credit card. During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each yeartherapist's time. I do not participate agree to take on any cases where there is an established legal case or where you would expect me to testify in health insurance programs however I will provide you with an invoice with all the information needed should you wish to file a claim directly with the insurance companyany such case. It Our contract is your responsibility to contact your insurance company to determine if an authorization for treatment is required and to communicate that requirement to mepurposes only. Please note, I am not a Medicare provider and therefore my services are not covered In the rare case of your records being subpoenaed by Medicare. Should you want services from me and you are a Medicare recipient, this will serve as a separate private contract so that you may pay me out of pocket. Under this circumstance, you understand that you (or your beneficiaries or legal representatives) are waiving the right to submit claims or be reimbursed by Medicare for any services I provide that would otherwise be covered by Medicare if there was no private contract and a proper claim was submitted. You have every right to obtain similar services from a provider who has not opted out of Medicare. You understand that Medigap does not pay for services not covered by Medicare. The period of this agreement will be 2 years from the time of signature. This language is legalese required of me by Medicare guidelines! During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. If you become involved in legal proceedings that require my participationcourts, you will be expected to pay for all of my professional time and expenses, including preparation costs, transportation costs, and attorney’s fees, even if I am called to testify cover the cost incurred by another party. My professional time related to these activities is $350 per hour. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with processing of the name of a colleague to contact, if necessary. It is very important to be aware that computers and email and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. If you communicate confidential or private information via email or text, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via email or text. Please do not use email or text for emergencies. Due to computer or network problems, emails and texts may not be deliverable, and I may not check my emails or faxes frequentlyrecords.

Sessions. Each individual The first few sessions will involve an evaluation of your needs. During this time, we can both decide if I am the best person to provide these services in order to meet your treatment goals. By the end of this period of time, if I have not already done so, I will be able to offer you some impressions of what the work will include if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working in this way. You always maintain the right to ask about other treatments for and about their risks and benefits. Once psychotherapy has begun, I usually schedule one 50-minute session lasts 45-60 (one appointment hour of 50 minutes duration) per week at a time we agree upon. Based on your needs, some sessions may be longer or more frequent. Missed sessions present a special problem in therapy because the given hour is specifically blocked out for you and family sessions are 60-80 minutesoften can not be filled on short notice. If you are late for a must miss an appointment, please notify me as soon as possible at (000) 000-0000. I will try to find another time to reschedule the appointment. Unless you give 48 hours notice of your intention to miss the session, that time is lost from your session. If I am late for a session, we will extend the session if you are willing to do so or we will make other arrangements by mutual consent. MISSED APPOINTMENTS Since a time slot is reserved for you that cannot be offered to anyone else, you will be charged billed for all the session. Insurance will not reimburse you for missed appointments not cancelled 24 hours in advancesessions. Please note my snow policy: I do not follow Montgomery County’s snow policyPROFESSIONAL FEES Sessions are 50 minutes long and are billed at the rate of $225 for individuals and $250 for couples and families. Unless If this rate should change, you hear from me in the morning, I will assume that we will be meetinggiven at least 2 months notice. If you cannot make it to the appointment for weather reasons, please call Longer or email me shorter sessions are pro-rated by 8:00 a.m. (000-000-0000 or xxxxxx@xxxxxxxxxxxxxxxxxxxx.xxx) and I will waive the 24-hour cancellation fee. If you do not reschedule an appointment within one month of our last session, I will assume that you have decided to discontinue treatment with me. Please be assured that you are always welcome to return regardless of how much time has lapsed since our last session. Updated 10/2017 PROFESSIONAL FEES Fees are as specified on the signature page to be completed with me at our first sessionprior mutual agreement. You are responsible for payment will be expected to pay for each therapy session at the time it is held unless we arrange for monthly xxxxxxxx. If for any reason you should become involved in legal action that requires your therapist or other counseling clinical staff to protect your privilege of confidentiality or testify on your behalf, you must agree to cover legal expenses and the session by cash, check or credit card. During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each yeartherapist's time. I do not participate agree to take on any cases where there is an established legal case or where you would expect me to testify in health insurance programs however I will provide you with an invoice with all the information needed should you wish to file a claim directly with the insurance companyany such case. It Our contract is your responsibility to contact your insurance company to determine if an authorization for treatment is required and to communicate that requirement to mepurposes only. Please note, I am not a Medicare provider and therefore my services are not covered In the rare case of your records being subpoenaed by Medicare. Should you want services from me and you are a Medicare recipient, this will serve as a separate private contract so that you may pay me out of pocket. Under this circumstance, you understand that you (or your beneficiaries or legal representatives) are waiving the right to submit claims or be reimbursed by Medicare for any services I provide that would otherwise be covered by Medicare if there was no private contract and a proper claim was submitted. You have every right to obtain similar services from a provider who has not opted out of Medicare. You understand that Medigap does not pay for services not covered by Medicare. The period of this agreement will be 2 years from the time of signature. This language is legalese required of me by Medicare guidelines! During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. If you become involved in legal proceedings that require my participationcourts, you will be expected to pay for all of my professional time and expenses, including preparation costs, transportation costs, and attorney’s fees, even if I am called to testify cover the cost incurred by another party. My professional time related to these activities is $350 per hour. CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with processing of the name of a colleague to contact, if necessary. It is very important to be aware that computers and email and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. If you communicate confidential or private information via email or text, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via email or text. Please do not use email or text for emergencies. Due to computer or network problems, emails and texts may not be deliverable, and I may not check my emails or faxes frequentlyrecords.

Sessions. Each individual session lasts 45-60 45 minutes and family sessions are 60-80 minutes. If you are late for a session, that time is lost from your session. If I am late for a session, we will extend the session if you are willing to do so or we will make other arrangements by mutual consent. MISSED APPOINTMENTS Since a time slot is reserved for you that cannot be offered to anyone else, you will be charged for all missed appointments not cancelled 24 hours in advance. Please note my snow policy: I do not follow Montgomery Xxxxxxxxxx County’s snow policy. Unless you hear from me in the morning, I will assume that we will be meeting. If you cannot make it to the appointment for weather reasons, please call or email me by 8:00 a.m. (000301-000652-0000 1582 or xxxxxx@xxxxxxxxxxxxxxxxxxxx.xxxxxxx@xxx-xxxxxxxxx-xxxxx.xxx) and I will waive the 24-hour cancellation fee. If you do not reschedule an appointment within one month of our last session, I will assume that you have decided to discontinue treatment with me. Please be assured that you are always welcome to return regardless of how much time has lapsed since our last session. Updated 10/2017 PROFESSIONAL FEES Fees Please confirm current fees with therapist: ____ for 45-minute sessions ____ for 60-minute sessions ____ for 75-minute sessions Additional time is billed at $ per quarter hour. These fees are also billed for services such as specified on the signature page telephone calls not related to be completed with me at our first sessionscheduling, special reports, and collateral consultation. You are responsible for payment for each therapy session at the time of the session by cash, check or credit card. During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. I do not participate in health insurance programs however I will provide you with an invoice with all the information needed should you wish to file a claim directly with the insurance company. It is your responsibility to contact your insurance company to determine if an authorization for treatment is required and to communicate that requirement to me. Please note, I am not a Medicare provider and therefore my services are not covered by Medicare. Should you want services from me and you are a Medicare recipient, this will serve as a separate private contract so that you may pay me out of pocket. Under this circumstance, you understand that you (or your beneficiaries or legal representatives) are waiving the right to submit claims or be reimbursed by Medicare for any services I provide that would otherwise be covered by Medicare if there was no private contract and a proper claim was submitted. You have every right to obtain similar services from a provider who has not opted out of Medicare. You understand that Medigap does not pay for services not covered by Medicare. The period of this agreement will be 2 years from the time of signature. This language is legalese required of me by Medicare guidelines! During the course of treatment, it may become necessary to increase fees. Fees are reviewed in January and June of each year. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time and expensestime, including preparation costs, and transportation costs, and attorney’s fees, even if I am called to testify by another party. My professional time related to these activities is [Because of the difficulty of legal involvement, I charge $350 700 per hour. hour for preparation and attendance at any legal proceeding.] CONTACTING ME Due to my work schedule, I am often not immediately available by telephone. When I am unavailable, my telephone is answered by voice mail that I monitor frequently. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. It is very important to be aware that computers and email and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. If you communicate confidential or private information via email or text, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate on such matters via email or text. Please do not use email or text for emergencies. Due to computer or network problems, emails and texts may not be deliverable, and I may not check my emails or faxes frequently.