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Common use of TELEPHONE & EMERGENCY PROCEDURES Clause in Contracts

TELEPHONE & EMERGENCY PROCEDURES. If you need to contact me between sessions, please text me or leave a message with my voice mail and your call will be returned as soon as possible. I check my messages several times a day, unless I am out of town. If an emergency situation arises, please indicate it clearly in your voice mail message. If you need to gain immediate assistance, please call 911. Clients are expected to pay the agreed-upon fee at the end of each session unless other arrangements have been made. Site visits, report writing, in-person consultation (as requested by you) with other professionals, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed otherwise. Please notify me if any problem arises during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that rendered professional services are charged to the clients and not to the insurance companies. Unless agreed upon differently, I can provide you with a copy of your receipt which you can then submit to your insurance company for reimbursement if you so choose. For any last-minute cancellations or no-show appointments, you responsible for the full payment of both the co-pay and what would normally be covered by the insurance company. As was indicated in the section, Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems, which are the focus of psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage prior to the initiation of services. You will be responsible for all services rendered in the event that you discover afterwards that your insurance coverage does not cover the costs of therapy services. All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement between us. The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Yolo County, CA in accordance with the rules of the American Arbitration Association that are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue and there is no agreement on a payment plan, I may use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitrator will determine that sum. Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. I will ask for your feedback and views on our work together, its progress, and other aspects of the therapy and will encourage you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During the initial phase of the evaluation or throughout the course of ongoing therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in your experiencing considerable discomfort including feelings of anger, sadness, worry, fear, anxiety, depression, etc. I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed negatively by another family member. Change will sometimes be easy and swift, but more often, it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, I am likely to draw on various psychological approaches to address the problem that is being treated and my assessment of what will best benefit you. These approaches may include those from the psychodynamic, cognitive-behavioral, system/family, developmental (adult, child, family), or psycho-educational perspectives. Your appointment will last 50 minutes. If I am providing services to your child, please do not drop him/her off in the waiting room without checking in with me first. I ask that you please be prompt in picking up your child after his/her appointment as I often have appointments scheduled each hour and would not want to risk leaving your child in the lobby unsupervised, unless specific arrangements are made with you. I routinely offer clients a lollipop and cup of tea or hot chocolate at the beginning of sessions. If you or your child has any dietary restrictions concerning any of these items, please let me know. By signing this form, you are agreeing to not hold me legally responsible for any incidental liquid xxxxx or unanticipated allergic reactions that may result from the consumption of these items.

Appears in 1 contract

Samples: Office Policies & General Information Agreement for Psychotherapy Services

TELEPHONE & EMERGENCY PROCEDURES. If you need to contact me Mimir Psychiatry LLC between sessions, please text me or leave a message with my voice mail at 000-000-0000 and your call will be returned as soon as possible. I check my Mimir Psychiatry LLC checks his/her messages several a few times a dayduring the week only, unless I am and less when the prescriber or therapist is out of town. If an emergency situation arises, please indicate it clearly in your voice mail message. If message and if you need to gain immediate assistancetalk to someone right away call Psychiatric Emergency Services, please call 911, 211 or 988. PAYMENTS & INSURANCE REIMBURSEMENT: Clients are expected to pay the agreedco-upon pay or standard fee of $200 for an intake or $120.00 per follow up session at the end of each session unless other arrangements have been madesession. Site Telephone conversations, site visits, report writingwriting and reading of reports, in-person consultation (as requested by you) with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed upon otherwise. Please notify me Mimir Psychiatry LLC if any problem arises problems arise during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that rendered professional services are charged Should you wish to the clients and not to the insurance companies. Unless agreed upon differentlyself pay, I can provide you with a copy of your receipt which you can then submit to your insurance company for reimbursement if you so choose. For any last-minute cancellations or no-show appointments, you responsible for the full payment of both the co-pay and what would normally be covered by the insurance company. As as was indicated in the section, Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems, which are the focus of psychotherapydealt with in psychiatry, are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage prior to the initiation of servicescoverage. You will be responsible for all services rendered in the event that you discover afterwards that your insurance coverage does not cover the costs of therapy services. All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement between us. The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Yolo County, CA in accordance with the rules of the American Arbitration Association that are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that If your account is overdue (unpaid) and there is no written agreement on a payment plan, I may Mimir Psychiatry LLC can use legal or other means (courtcourts, collection agencyagencies, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitrator will determine that sum. THE PROCESS OF THERAPY/EVALUATION AND SCOPE OF PRACTICE: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy Therapy, medications, and follow ups requires your very active involvement, honesty, and openness in order to change your thoughts, feelings feelings, and/or behavior. I Mimir Psychiatry LLC will ask for your feedback and views on our work togetheryour therapy, its progress, and other aspects of the therapy and will encourage expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During the initial phase of the evaluation or throughout the course of ongoing therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in your you experiencing considerable discomfort including or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. I Mimir Psychiatry LLC may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that situations, which can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to for therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy Therapy and medications may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often, often it will be slow and even sometimes frustrating. There is no guarantee that psychotherapy therapy will yield positive or intended results. During the course of therapy, I am Mimir Psychiatry LLC is likely to draw on various psychological approaches according, in part, to address the problem that is being treated and my his/her assessment of what will best benefit you. These approaches may include those from the psychodynamicinclude, but are not limited to, behavioral, cognitive-behavioral, cognitive, psychodynamic, existential, system/family, developmental (adult, child, family), humanistic or psycho-educational perspectives. Your appointment will last 50 minutes. If I am providing services to your child, please do not drop him/her off in the waiting room without checking in with me first. I ask that you please be prompt in picking up your child after his/her appointment as I often have appointments scheduled each hour and would not want to risk leaving your child in the lobby unsupervised, unless specific arrangements are made with you. I routinely offer clients a lollipop and cup of tea or hot chocolate at the beginning of sessions. If you or your child has any dietary restrictions concerning any of these items, please let me know. By signing this form, you are agreeing to not hold me legally responsible for any incidental liquid xxxxx or unanticipated allergic reactions that may result from the consumption of these itemseducational.

Appears in 1 contract

Samples: Office Policies & General Information Agreement for Psychotherapy Services

TELEPHONE & EMERGENCY PROCEDURES. If you need to contact me Xx. Xxxxx between sessions, please text me or leave a message with my on his voice mail and your call will be returned as soon as possible. I check my Xx. Xxxxx checks his messages several times a day, unless I am out of town. throughout the day until 8 p.m. If an emergency urgent situation arises, please indicate it clearly in your voice mail message. You may also call Xx. Xxxxx on his cell phone at (000) 000-0000. If you need to gain immediate assistancedo not hear from Xx. Xxxxx in 10 minutes, please try calling him again on his cell phone. If you. are experiencing a medical emergency, call (911). Clients your physician or psychiatrist, or go the closest hospital emergency room. Payments & Insurance Reimbursement: Patients are expected to pay the agreedstandard fee of $100.00 per 50 minute session, deductibles and co-upon fee payments at the end of each session unless other arrangements have been made. Site Xx. Xxxxx will directly xxxx your insurance, EAP or other third party payor upon. , request fur no additional charge. Telephone conversations. site visits, report writing, in-person consultation (as requested by you) consultation. with other professionals, release of information, longer sessions, travel time, . etc. will be charged at the same rate, $100.00 per hour or at a minimum of $25.00 per each 15 minutes unless indicated and agreed otherwise. These services are not covered by insurance. Please notify me if Xx. Xxxxx .if any problem arises during the course of therapy regarding your ability to make timely payments. Clients Patients who carry insurance should remember that rendered professional services are rendered and charged to the clients patients and not to the insurance companies. Unless agreed upon differently, I can For insurances that Xx. Xxxxx is not contracted. Xx. Xxxxx will provide you with a copy of your receipt receipt, which you can then then. submit to your insurance company for reimbursement if you so choose. For any last-minute cancellations or no-show appointments, you responsible for the full payment of both the co-pay and what would normally be covered by the insurance company. As was indicated in the section, section Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a a. certain amount of risk. Not all issues/conditions/problems, problems which are the focus of psychotherapy, are reimbursed by insurance companies. You must be given a psychiatric diagnosis in order for medical insurance to reimburse for services rendered. In most cases, marital and couples therapy are not reimbursed by insurance. If you want your spouse or partner to participate in your treatment, they may do so. In that case. The medical insurance may be billed as individual or family therapy for your session. It is your responsibility to verify the specifics of your coverage prior to the initiation of servicescoverage. You will be responsible for all services rendered in the event that you discover afterwards that Any uncovered amount is your insurance coverage does not cover the costs of therapy services. All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement between us. The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Yolo County, CA in accordance with the rules of the American Arbitration Association that are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue and there is no agreement on a payment plan, I may use legal means (court, collection agency, etcresponsibility.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitrator will determine that sum. Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. I will ask for your feedback and views on our work together, its progress, and other aspects of the therapy and will encourage you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During the initial phase of the evaluation or throughout the course of ongoing therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in your experiencing considerable discomfort including feelings of anger, sadness, worry, fear, anxiety, depression, etc. I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed negatively by another family member. Change will sometimes be easy and swift, but more often, it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, I am likely to draw on various psychological approaches to address the problem that is being treated and my assessment of what will best benefit you. These approaches may include those from the psychodynamic, cognitive-behavioral, system/family, developmental (adult, child, family), or psycho-educational perspectives. Your appointment will last 50 minutes. If I am providing services to your child, please do not drop him/her off in the waiting room without checking in with me first. I ask that you please be prompt in picking up your child after his/her appointment as I often have appointments scheduled each hour and would not want to risk leaving your child in the lobby unsupervised, unless specific arrangements are made with you. I routinely offer clients a lollipop and cup of tea or hot chocolate at the beginning of sessions. If you or your child has any dietary restrictions concerning any of these items, please let me know. By signing this form, you are agreeing to not hold me legally responsible for any incidental liquid xxxxx or unanticipated allergic reactions that may result from the consumption of these items.

Appears in 1 contract

Samples: Office Policies & General Information Agreement for Psychotherapy Services

TELEPHONE & EMERGENCY PROCEDURES. If you need to contact me Xx. Xxxxxx between sessions, please text me or leave a message with my voice mail the (000) 000-0000 number and your call will be returned as soon as possible. I check my Xx. Xxxxxx checks her messages several a few times a day, unless I am she is out of town. If an emergency urgent situation arises, please indicate it clearly in your voice mail messagemessage and for emergency situations, phone ‘911’ in the case of a medical or psychiatric emergency. If you need to gain immediate assistance, please call 911. PAYMENTS & INSURANCE REIMBURSEMENT: Clients are expected to pay the agreedstandard fee of $ 125.00 per 50-upon fee minute session at the end of each session or at the end of the month unless other arrangements have been made. Site Telephone conversations, site visits, report writingwriting and reading, in-person consultation (as requested by you) with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed otherwise. Please notify me Xx. Xxxxxx if any problem arises during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that rendered professional services are rendered and charged to the clients and not to the insurance companies. Unless agreed upon differently, I can Xx. Xxxxxx will provide you with a copy of your receipt on a monthly basis, which you can then submit to your insurance company for reimbursement if you so choose. For any last-minute cancellations or no-show appointments, you responsible for the full payment of both the co-pay and what would normally be covered by the insurance company. As was indicated in the section, Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problemsissues /conditions /problems, which are the focus of psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage prior to the initiation of servicescoverage. You will be responsible for all services rendered in the event that you discover afterwards that your insurance coverage does not cover the costs of therapy services. MEDIATION & ARBITRATION: All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement between usof Xx. Xxxxxx and client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Yolo Los Angeles County, CA in accordance with the rules of the American Arbitration Association that which are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, I may Xx. Xxxxxx can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitrator will determine that sum. THE PROCESS OF THERAPY/EVALUATION: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, ; however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. I Xx. Xxxxxx will ask for your feedback and views on our work togetheryour therapy, its progress, and other aspects of the therapy and will encourage expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During the initial phase of the evaluation or throughout the course of ongoing therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in your experiencing considerable discomfort including or strong feelings of anger, sadness, worry, fear, etc. or experiencing anxiety, depression, insomnia, etc. I Xx. Xxxxxx may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often, often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, I am Xx. Xxxxxx is likely to draw on various psychological approaches according, in part, to address the problem that is being treated and my his/her assessment of what will best benefit you. These approaches may include those from the psychodynamic, cognitive-behavioral, system/family, developmental (adult, child, family), or psycho-educational perspectives. Your appointment will last 50 minutes. If I am providing services to your child, please do not drop him/her off in the waiting room without checking in with me first. I ask that you please be prompt in picking up your child after his/her appointment as I often have appointments scheduled each hour and would not want to risk leaving your child in the lobby unsupervised, unless specific arrangements are made with you. I routinely offer clients a lollipop and cup of tea or hot chocolate at the beginning of sessions. If you or your child has any dietary restrictions concerning any of these items, please let me know. By signing this form, you are agreeing to not hold me legally responsible for any incidental liquid xxxxx or unanticipated allergic reactions that may result from the consumption of these items.,

Appears in 1 contract

Samples: Office Policies & General Information Agreement for Psychotherapy Services

TELEPHONE & EMERGENCY PROCEDURES. If you need to contact me Monarch Counseling between sessions, please text me or leave a message with my voice mail your therapist and your call will be returned as soon as possible. I Monarch Counseling therapists check my messages several a few times a day, unless I am out of townduring the daytime. If an emergency situation arises, please indicate it clearly in your voice mail message. If message and if you need to gain immediate assistance, please talk to someone right away call the 24-hour crisis line: (000) 000-0000 or call 911. Clients are expected to pay the agreed-upon fee at the end of each session unless other arrangements have been madePlease do not use email or faxes for emergencies. Site visits, report writing, in-person consultation (as requested by you) with other professionals, longer sessions, travel time, etc. PAYMENTS & INSURANCE REIMBURSEMENT: Monarch Counseling will be charged at the same rate, unless indicated and agreed otherwise. Please notify me if any problem arises during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that rendered professional services are charged to the clients and not to the insurance companies. Unless agreed upon differently, I can provide you with a copy of your receipt which you can then submit claims to your insurance company for reimbursement if on your behalf. The insurance company will process the claim and send an explanation of benefits to you so chooseand to Monarch Counseling. For any last-minute cancellations or no-show appointments, you responsible for the full payment The explanation of both the benefits will outline your financial responsibility such as; co-pay and what would normally be covered by the insurance company. As was indicated in the sectionpay, Health Insurance & Confidentiality of Recordsco-insurance, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems, which are the focus of psychotherapy, are reimbursed by insurance companiesor deductible. It is your YOUR responsibility to check with your insurance company to verify benefits and coverage. Questions you may want to ask your insurance company include the specifics amount of your coverage prior co-pay, co-insurance, and the amount that will be applied to the initiation of servicesyour deductible. You will be responsible are expected to make your payment at time of service. Monthly payment plans are also available for all services rendered in those who need assistance. Please speak with the event that you discover afterwards that office manager to set up a payment plan if necessary. If your insurance coverage does not cover the costs of therapy services. All disputes arising out of account is overdue and there is no payment plan on file, Monarch Counseling can use legal or in relation other means (courts, collection agencies, etc.) to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the obtain payment.( ) initial initiation of arbitration. The mediator shall be a neutral third party chosen by agreement between usof Monarch Counseling and the client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreedagreed upon. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Yolo County, CA Nebraska in accordance with the rules of the American Arbitration Association that which are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, I may Monarch Counseling can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum as and for attorneys’ attorney's fees. In the case of arbitration, the arbitrator will determine that sum. Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings feelings, and/or behavior. I will ask for your feedback and views on our work togetheryour therapy, its progress, and other aspects of the therapy and will encourage expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During the initial phase of the evaluation or throughout the course of ongoing therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in your you experiencing considerable discomfort including or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that situations, which can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often, often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, I am likely to draw on various psychological approaches according, in part, to address the problem that is being treated and my assessment of what will best benefit you. These approaches may include those from the include, but are not limited to, behavioral, cognitive- behavioral, cognitive, psychodynamic, cognitive-behavioralexistential, system/family, developmental (adult, child, family), humanistic or psycho-educational perspectiveseducational. Your appointment will last 50 minutes. If I am providing services to your childMonarch Counseling does not provide custody evaluation recommendations, please medication or prescription recommendations or legal advice, as these activities do not drop him/her off in the waiting room without checking in with me first. I ask that you please be prompt in picking up your child after his/her appointment as I often have appointments scheduled each hour and would not want to risk leaving your child in the lobby unsupervised, unless specific arrangements are made with you. I routinely offer clients a lollipop and cup fall within our scope of tea or hot chocolate at the beginning of sessions. If you or your child has any dietary restrictions concerning any of these items, please let me know. By signing this form, you are agreeing to not hold me legally responsible for any incidental liquid xxxxx or unanticipated allergic reactions that may result from the consumption of these itemspractice.

Appears in 1 contract

Samples: Office Policies and General Information Agreement for Psychotherapy Services and Informed Consent for Psychotherapy

TELEPHONE & EMERGENCY PROCEDURES. If you need to contact me Xx. Xxxxxxx between sessions, please text me or leave a message with my voice mail on his office cell phone (000) 000-0000 and your call will be returned as soon as possible. I check my Xx. Xxxxxxx checks his messages several a few times a dayduring the daytime only, unless I am he is out of town. If an emergency situation arises, please indicate it clearly in your voice mail message. If message and if you need to gain immediate assistance, please talk to someone right away call 911. Please do not use e-mail or Faxes for emergencies. Xx. Xxxxxxx does not always check his e-mail or Faxes daily. PAYMENTS & INSURANCE REIMBURSEMENT: Clients are expected to pay the agreed-upon standard fee of $150.00 per 45 minute or $200.00 per hour session at the end of each session unless other arrangements have been made. Site Telephone conversations, site visits, report writingwriting and reading, in-person consultation (as requested by you) with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed upon otherwise. Please notify me Xx. Xxxxxxx if any problem arises problems arise during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that rendered professional services are rendered and charged to the clients and not to the insurance companies. Unless agreed upon differently, I can Xx. Xxxxxxx will provide you you, upon request, with a copy of your receipt on a monthly basis, which you can then submit to your insurance company for reimbursement if you so choose. For any last-minute cancellations or no-show appointments, you responsible for the full payment of both the co-pay and what would normally be covered by the insurance company. As was indicated in the section, section Health Insurance & Confidentiality confidentiality of Recordsrecords, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems, which are the focus of dealt with in psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage prior to the initiation of servicescoverage. You will be responsible for all services rendered in the event that you discover afterwards that your insurance coverage does not cover the costs of therapy services. All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement between us. The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Yolo County, CA in accordance with the rules of the American Arbitration Association that are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that If your account is overdue (unpaid) and there is no written agreement on a payment plan, I may Xx. Xxxxxxx can use legal or other means (courtcourts, collection agencyagencies, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitrator will determine that sum. Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. I will ask for your feedback and views on our work together, its progress, and other aspects of the therapy and will encourage you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During the initial phase of the evaluation or throughout the course of ongoing therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in your experiencing considerable discomfort including feelings of anger, sadness, worry, fear, anxiety, depression, etc. I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed negatively by another family member. Change will sometimes be easy and swift, but more often, it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, I am likely to draw on various psychological approaches to address the problem that is being treated and my assessment of what will best benefit you. These approaches may include those from the psychodynamic, cognitive-behavioral, system/family, developmental (adult, child, family), or psycho-educational perspectives. Your appointment will last 50 minutes. If I am providing services to your child, please do not drop him/her off in the waiting room without checking in with me first. I ask that you please be prompt in picking up your child after his/her appointment as I often have appointments scheduled each hour and would not want to risk leaving your child in the lobby unsupervised, unless specific arrangements are made with you. I routinely offer clients a lollipop and cup of tea or hot chocolate at the beginning of sessions. If you or your child has any dietary restrictions concerning any of these items, please let me know. By signing this form, you are agreeing to not hold me legally responsible for any incidental liquid xxxxx or unanticipated allergic reactions that may result from the consumption of these items.

Appears in 1 contract

Samples: Office Policies & General Information Agreement for Psychotherapy Services

TELEPHONE & EMERGENCY PROCEDURES. If you need to contact me Xxxxx between sessions, please text me or leave a message with my voice mail or text at (000)000-0000 and your call will be returned as soon as possible. I check my Xxxxx checks her messages several a few times a dayduring the daytime only, unless I am she is out of town. If an emergency situation arises, please indicate it clearly in your voice mail message. If message and if you need to gain immediate assistance, please talk to someone right away call Psychiatric Emergency Services. Prescott: 000-000-0000 for 24-hour crisis line or the Police: 911. Please do not use email or faxes for emergencies. Xxxxx does not always check her email daily. PAYMENTS & INSURANCE REIMBURSEMENT: Clients are expected to pay the agreed-upon standard fee of $100 per 50 minute at the end of each session or at the end of the month unless other arrangements have been made. Site Telephone conversations, site visits, report writingwriting and reading of reports, in-person consultation (as requested by you) with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed upon otherwise. Please notify me Xxxxx if any problem arises problems arise during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that rendered professional services are rendered and charged to the clients and not to the insurance companies. Unless agreed upon differently, I can Xxxxx will provide you with a copy of your receipt on a monthly basis, which you can then submit to your insurance company for reimbursement reimbursement, if you so choose. For any last-minute cancellations or no-show appointments, you responsible for the full payment of both the co-pay and what would normally be covered by the insurance company. As was indicated in the section, Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems, which are the focus of dealt with in psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage prior to the initiation of servicescoverage. You will be responsible for all services rendered in the event that you discover afterwards that your insurance coverage does not cover the costs of therapy services. All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement between us. The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Yolo County, CA in accordance with the rules of the American Arbitration Association that are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that If your account is overdue (unpaid) and there is no written agreement on a payment plan, I may Xxxxx Xxxxxxx can use legal or other means (courtcourts, collection agencyagencies, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitrator will determine that sum. THE PROCESS OF THERAPY/EVALUATION AND SCOPE OF PRACTICE: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings feelings, and/or behavior. I Xxxxx will ask for your feedback and views on our work togetheryour therapy, its progress, and other aspects of the therapy and will encourage expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During the initial phase of the evaluation or throughout the course of ongoing therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in your you experiencing considerable discomfort including or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. I may Xxxxx xxx challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that situations, which can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often, often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, I am Xxxxx is likely to draw on various psychological approaches according, in part, to address the problem that is being treated and my her assessment of what will best benefit you. These approaches may include those from the psychodynamicinclude, but are not limited to, behavioral, cognitive-behavioral, system/familycognitive, psychodynamic, Somatic Experiencing, developmental (adult, child, family), Internal Family Systems or psycho-educational perspectiveseducational. Your appointment will last 50 minutes. If I am providing services to your childXxxxx provides neither custody evaluation recommendation nor medication or prescription recommendation nor legal advice, please as these activities do not drop him/fall within her off in the waiting room without checking in with me first. I ask that you please be prompt in picking up your child after his/her appointment as I often have appointments scheduled each hour and would not want to risk leaving your child in the lobby unsupervised, unless specific arrangements are made with you. I routinely offer clients a lollipop and cup scope of tea or hot chocolate at the beginning of sessions. If you or your child has any dietary restrictions concerning any of these items, please let me know. By signing this form, you are agreeing to not hold me legally responsible for any incidental liquid xxxxx or unanticipated allergic reactions that may result from the consumption of these itemspractice.

Appears in 1 contract

Samples: Office Policies & General Information Agreement for Psychotherapy Services

TELEPHONE & EMERGENCY PROCEDURES. If you need to contact me Xxx Xxxxxxxxxx between sessions, please text me or leave a message with my voice mail at (000) 000-0000 and your call will be returned as soon as possible. I check my She checks her messages several a few times a dayday (but never during the night time), unless I am she is out of town. She checks the messages less frequently on weekends and holidays. If an emergency situation arises, please indicate it clearly in your voice mail message. If you need to gain immediate assistancetalk to someone right away, please you can call 911the 24-hour crisis line (000) 000-0000 or the Police at: 9-1-1. PAYMENTS & INSURANCE REIMBURSEMENT: Clients are expected to pay the agreed-upon fee standard Fee of $160 per 50 minutes session at the end beginning of each session unless other arrangements have been made. Site Telephone conversations, site visits, report writingwriting and reading, in-person consultation (as requested by you) with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed otherwise. Please notify me your therapist if any problem arises during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that rendered professional services are rendered and charged to the clients and not to the insurance companies. Unless agreed upon differently, I can your therapist will provide you with a copy of your receipt on a monthly basis, which you can then submit to your insurance company for reimbursement if you so choose. For any last-minute cancellations or no-show appointments, you responsible for the full payment of both the co-pay and what would normally be covered by the insurance company. As was indicated in the section, Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problemsproblem, which are the focus of psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage prior to the initiation of servicescoverage. You will be responsible for all services rendered in the event that you discover afterwards that your insurance coverage does not cover the costs of therapy services. All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement between us. The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Yolo County, CA in accordance with the rules of the American Arbitration Association that are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue and there is no agreement on a payment plan, I may use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitrator will determine that sum. THE PROCESS OF THERAPY/EVALUATION: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships relationship and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, ; however, requires effort on your part. Psychotherapy requires your a very active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. I Your therapist will ask for your feedback and views on our work togetherDiscussion of Treatment Plan: Within a reasonable period of time after the initiation of treatment, its progressyour therapist will discuss with you (client) her working understanding of the problem, treatment plan, therapeutic objectives, and other aspects her view of the therapy and will encourage possible outcomes of treatment. IF you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During the initial phase have any unanswered questions about any of the evaluation or throughout the course of ongoing therapy, remembering or talking about unpleasant events, feelings, or thoughts can result procedures to be used in your experiencing considerable discomfort including feelings of anger, sadness, worry, fear, anxiety, depression, etc. I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed negatively by another family member. Change will sometimes be easy and swift, but more often, it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, I am likely to draw on various psychological approaches to address the problem that is being treated and my assessment of what will best benefit you. These approaches may include those from the psychodynamictheir possible risks, cognitive-behavioral, system/family, developmental (adult, child, family)your therapist’s expertise in employing them, or psycho-educational perspectives. Your appointment will last 50 minutes. If I am providing services to your childabout the treatment plan, please do not drop him/her off in and you will be answered fully. You also have the waiting room without checking in with me first. I right to ask that you please be prompt in picking up about other treatments for your child after his/her appointment as I often have appointments scheduled each hour condition and would not want to risk leaving your child in the lobby unsupervised, unless specific arrangements are made with you. I routinely offer clients a lollipop their risks and cup of tea or hot chocolate at the beginning of sessionsbenefits. If you or could benefit from any treatment that your child therapist does not provide, she has any dietary restrictions concerning any of these items, please let me know. By signing this form, an ethical obligation to assist you are agreeing to not hold me legally responsible for any incidental liquid xxxxx or unanticipated allergic reactions that may result from the consumption of these itemsobtaining those treatments.

Appears in 1 contract

Samples: Office Policies & General Information Agreement for Psychotherapy Services

TELEPHONE & EMERGENCY PROCEDURES. If you need to contact me Xxxxxx Xxxxxxx between sessions, please text me or leave a message with my voice mail at (000) 000-0000 and your call will be returned as soon as possible. I check my She checks her messages several a few times a dayday (but never during the night time), unless I am she is out of town. She checks the messages less frequently on weekends and holidays. If an emergency situation arises, please indicate it clearly in your voice mail message. If you need to gain immediate assistancetalk to someone right away, please you can call 911the 24-hour crisis line (000) 000-0000 or the Police at: 9-1-1. PAYMENTS & INSURANCE REIMBURSEMENT: Clients are expected to pay the agreed-upon fee standard Fee of $165 per 60 minute session or $185 per 90 minute session at the end beginning of each session unless other arrangements have been made. Site Telephone conversations, site visits, report writingwriting and reading, in-person consultation (as requested by you) with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed otherwise. Please notify me your therapist if any problem arises during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that rendered professional services are rendered and charged to the clients and not to the insurance companies. Unless agreed upon differently, I can your therapist will provide you with a copy of your receipt on a monthly basis, which you can then submit to your insurance company for reimbursement if you so choose. For any last-minute cancellations or no-show appointments, you responsible for the full payment of both the co-pay and what would normally be covered by the insurance company. As was indicated in the section, Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problemsproblem, which are the focus of psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage prior to the initiation of servicescoverage. You will be responsible for all services rendered in the event that you discover afterwards that your insurance coverage does not cover the costs of therapy services. All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement between us. The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Yolo County, CA in accordance with the rules of the American Arbitration Association that are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue and there is no agreement on a payment plan, I may use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitrator will determine that sum. THE PROCESS OF THERAPY/EVALUATION: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships relationship and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, ; however, requires effort on your part. Psychotherapy requires your a very active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. I Your therapist will ask for your feedback and views on our work togetheryour therapy, its progress, and other aspects of the therapy and will encourage expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing Discussion of Treatment Plan: Within a reasonable period of time after the initiation of treatment, your therapist will discuss with a certain situation. During the initial phase you (client) her working understanding of the evaluation or throughout problem, treatment plan, therapeutic objectives, and her view of the course possible outcomes of ongoing therapy, remembering or talking treatment. IF you have any unanswered questions about unpleasant events, feelings, or thoughts can result any of the procedures to be used in your experiencing considerable discomfort including feelings of anger, sadness, worry, fear, anxiety, depression, etc. I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed negatively by another family member. Change will sometimes be easy and swift, but more often, it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, I am likely to draw on various psychological approaches to address the problem that is being treated and my assessment of what will best benefit you. These approaches may include those from the psychodynamictheir possible risks, cognitive-behavioral, system/family, developmental (adult, child, family)your therapist’s expertise in employing them, or psycho-educational perspectives. Your appointment will last 50 minutes. If I am providing services to your childabout the treatment plan, please do not drop him/her off in and you will be answered fully. You also have the waiting room without checking in with me first. I right to ask that you please be prompt in picking up about other treatments for your child after his/her appointment as I often have appointments scheduled each hour condition and would not want to risk leaving your child in the lobby unsupervised, unless specific arrangements are made with you. I routinely offer clients a lollipop their risks and cup of tea or hot chocolate at the beginning of sessionsbenefits. If you or could benefit from any treatment that your child therapist does not provide, she has any dietary restrictions concerning any of these items, please let me know. By signing this form, an ethical obligation to assist you are agreeing to not hold me legally responsible for any incidental liquid xxxxx or unanticipated allergic reactions that may result from the consumption of these itemsobtaining those treatments.

Appears in 1 contract

Samples: Office Policies & General Information Agreement for Psychotherapy Services

TELEPHONE & EMERGENCY PROCEDURES. If you need to contact me your therapist between sessions, please text me or leave a message with my voice mail at the office 000-000-0000 or call the number your therapist has indicated as the best way to be reached and your call will be returned as soon as possible. I check my Your therapist checks his/her messages several a few times a dayduring the daytime only, unless I am s/he is out of town. If an emergency situation arises, please indicate it clearly in your voice mail message. If message and if you need to gain immediate assistancetalk to someone right away call Infoline 2-1-1, please call or the Police: 911. Please do not use text, email or faxes for emergencies. Your therapist does not always check his/her texts, email or faxes daily. PAYMENTS & INSURANCE REIMBURSEMENT: Clients are expected to pay the agreed-upon standard fee of $150.00 per 45 minute or $175.00 per hour session at the end of each session unless other arrangements have been madeagreed upon otherwise. Site Telephone conversations, site visits, report writingwriting and reading of reports, in-person consultation (as requested by you) with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed upon otherwise. Please notify me your therapist if any problem arises problems arise during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that rendered professional services are rendered and charged to the clients and not to the insurance companies. Unless agreed upon differently, I can provide you with a copy of your receipt which you can then submit to your insurance company for reimbursement if you so choose. For any last-minute cancellations or no-show appointments, you responsible for the full payment of both the co-pay and what would normally be covered by the insurance company. As was indicated in the section, Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems, which are the focus of dealt with in psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage prior to the initiation of servicescoverage. You will be responsible for all services rendered in the event that you discover afterwards that your insurance coverage does not cover the costs of therapy services. All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement between us. The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Yolo County, CA in accordance with the rules of the American Arbitration Association that are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that If your account is overdue (unpaid) and there is no written agreement on a payment plan, I may your therapist can use legal or other means (courtcourts, collection agencyagencies, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitrator will determine that sum. Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. I will ask for your feedback and views on our work together, its progress, and other aspects of the therapy and will encourage you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During the initial phase of the evaluation or throughout the course of ongoing therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in your experiencing considerable discomfort including feelings of anger, sadness, worry, fear, anxiety, depression, etc. I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed negatively by another family member. Change will sometimes be easy and swift, but more often, it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, I am likely to draw on various psychological approaches to address the problem that is being treated and my assessment of what will best benefit you. These approaches may include those from the psychodynamic, cognitive-behavioral, system/family, developmental (adult, child, family), or psycho-educational perspectives. Your appointment will last 50 minutes. If I am providing services to your child, please do not drop him/her off in the waiting room without checking in with me first. I ask that you please be prompt in picking up your child after his/her appointment as I often have appointments scheduled each hour and would not want to risk leaving your child in the lobby unsupervised, unless specific arrangements are made with you. I routinely offer clients a lollipop and cup of tea or hot chocolate at the beginning of sessions. If you or your child has any dietary restrictions concerning any of these items, please let me know. By signing this form, you are agreeing to not hold me legally responsible for any incidental liquid xxxxx or unanticipated allergic reactions that may result from the consumption of these items.

Appears in 1 contract

Samples: Office Policies & General Information Agreement for Psychotherapy Services

TELEPHONE & EMERGENCY PROCEDURES. If you need to contact me between sessions, please text me or leave a message with my voice mail and your call will be returned as soon as possible. I check my messages several a few times a day, unless I am out of town. If an emergency situation arises, please indicate it clearly in your voice mail message. If you need to gain immediate assistance, please call 911. Clients are expected to pay the agreed-upon fee at the end of each session unless other arrangements have been made. Site visits, report writing, in-person consultation (as requested by you) with other professionals, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed otherwise. Please notify me if any problem arises during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that rendered professional services are charged to the clients and not to the insurance companies. Unless agreed upon differently, I can provide you with a copy of your receipt receipt, which you can then submit to your insurance company for reimbursement if you so choose. For any last-minute cancellations or no-show appointments, you responsible for the full payment of both the co-pay and what would normally be covered by the insurance company. As was indicated in the section, Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems, which are the focus of psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage prior to the initiation of services. You will be responsible for all services rendered in the event that you discover afterwards that your insurance coverage does not cover the costs of therapy servicescoverage. All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement between us. The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Yolo County, CA in accordance with the rules of the American Arbitration Association that are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue and there is no agreement on a payment plan, I may use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitrator will determine that sum. Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. I will ask for your feedback and views on our work togetheryour therapy, its progress, and other aspects of the therapy and will encourage you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During the initial phase of the evaluation or throughout the course of ongoing therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in your experiencing considerable discomfort including feelings of anger, sadness, worry, fear, etc. or anxiety, depression, insomnia, etc. I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed negatively by another family member. Change will sometimes be easy and swift, but more often, it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, I am likely to draw on various psychological approaches according, in part, to address the problem that is being treated and my assessment of what will best benefit you. These approaches may include those from the psychodynamic, cognitive-behavioral, system/acceptance commitment therapy, solutions focused, psychodynamic, system/ family, developmental (adult, child, family), or psycho-educational perspectives. Your appointment will last 50 minutes. If I am providing services to your child, please do not drop him/her off in the waiting room without checking in with me first. I ask that you please be prompt in picking up your child after his/her appointment as I often have appointments scheduled each hour and would not want to risk leaving your child in the lobby unsupervised, unless specific arrangements are made with you. to terminate treatment. In such a case, I routinely offer clients would give you a lollipop and cup number of tea or hot chocolate at the beginning referrals that may be of sessionshelp to you. If you request it and authorize it in writing, I would be happy to talk to the psychotherapist of your choice in order to help with the transition. If at any time you want another professional’s opinion or wish to consult with another therapist, I will assist you in finding someone qualified, and, if I have your written consent, I will provide the therapist with the essential information needed. You have the right to terminate therapy at any time. If you choose to do so, I will offer to provide you with names of other qualified professionals whose services might be of benefit to you. I ask that you please inform me if you are thinking about reducing or ending therapy so that I will have the time to bring closure to the therapeutic relationship and process. Consequently, you may bump into someone you know in the waiting room or into me out in the community. I will never acknowledge working therapeutically with anyone without your permission. Dual or multiple relationships can enhance therapeutic effectiveness but can also detract from it in a manner that is difficult to predict. I ask that you please communicate with me if a non-exploitative and non-sexual dual relationship develops between us in a manner that becomes uncomfortable for you in any way. I will always listen carefully and respond accordingly to your feedback. I will discontinue the dual relationship if I find it interfering with the effectiveness of the therapeutic process or your child has any dietary restrictions concerning any welfare and, of these items, please let me know. By signing this formcourse, you are agreeing to not hold me legally responsible for can do the same at any incidental liquid xxxxx or unanticipated allergic reactions that may result from the consumption of these itemstime.

Appears in 1 contract

Samples: Office Policies & General Information Agreement

TELEPHONE & EMERGENCY PROCEDURES. If you need to contact me the practice between sessions, please text me or leave a message with my voice mail at (000) 000-0000 and your call will be returned as soon as possible. I check my The practice checks messages several a few times a during the business day, unless I am out of townthe practice is closed. If an emergency situation arises, please indicate it clearly in your voice mail message. If message and if you need to gain immediate assistancetalk to someone right away call the National Suicide Prevention Lifeline 0-000-000-0000 or the Police: 911. Please do not use email, please call 911text messaging, or faxes for emergencies. The practice does not always check email or faxes daily. PAYMENTS & INSURANCE REIMBURSEMENT: The same fee rates will apply for telemental health as they apply for in-person psychotherapy. However, insurance or other managed care providers may not cover sessions that are conducted via telecommunication. If your insurance, HMO, third-party payor, or other managed care provider does not cover electronic psychotherapy sessions, you will be solely responsible for the entire fee of the session. Please contact your insurance company prior to our engaging in telemental health sessions in order to determine whether these sessions will be covered. Clients are expected to pay the agreed-upon fee at the end of $145 for an intake and $85 for an individual session, prior to each session unless other arrangements have been madesession. Site Telephone conversations, site visits, report writingwriting and reading of reports, in-person consultation (as requested by you) with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed upon otherwise. Please notify me the practice if any problem arises problems arise during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that rendered professional services are rendered and charged to the clients and not to the insurance companies. Unless agreed upon differently, I can the practice will provide you with a copy of your receipt on a monthly basis, which you can then submit to your insurance company for reimbursement reimbursement, if you so choose. For any last-minute cancellations or no-show appointments, you responsible for the full payment of both the co-pay and what would normally be covered by the insurance company. As was indicated in the section, Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems, which are the focus of dealt with in psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage prior to the initiation of servicescoverage. You will be responsible for all services rendered in the event that you discover afterwards that your insurance coverage does not cover the costs of therapy services. All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement between us. The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Yolo County, CA in accordance with the rules of the American Arbitration Association that are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that If your account is overdue (unpaid) and there is no written agreement on a payment plan, I may the practice can use legal or other means (courtcourts, collection agencyagencies, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitrator will determine that sum. THE PROCESS OF THERAPY/EVALUATION AND SCOPE OF PRACTICE: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings feelings, and/or behavior. I The practice will ask for your feedback and views on our work togetheryour therapy, its progress, and other aspects of the therapy and will encourage expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During the initial phase of the an evaluation or throughout the course of ongoing therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in your you experiencing considerable discomfort including or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. I the practice may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that situations, which can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often, often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, I am the practice is likely to draw on various psychological approaches according, in part, to address the problem that is being treated and my the assessment of what will best benefit you. These approaches may include those from the psychodynamicinclude, but are not limited to, behavioral, cognitive-behavioral, cognitive, psychodynamic, person-centered, existential, system/family, developmental (adult, child, family), humanistic, or psycho-educational perspectiveseducational. Your appointment will last 50 minutes. If I am providing services to your childThe practice provides neither custody evaluation recommendation nor medication or prescription recommendation nor legal advice, please as these activities do not drop himfall within its scope of practice. TELEMENTAL HEALTH BENEFITS/her off RISKS: Telemental health refers to providing psychotherapy services remotely using telecommunications technologies, such as video conferencing or telephone. One of the benefits of telemental health is that the client and the practice can engage in services without being in the waiting room without checking same physical location. This can be helpful in with me firstensuring continuity of care if the client or the practice moves to a different location, takes an extended vacation, or is otherwise unable to continue to meet in person. I ask that you please It is also more convenient. Telemental health, however, requires technical competence for both the client and the practice in order to be prompt in picking up your child after his/her appointment helpful. Although there are benefits of telemental health, there are some differences between in-person psychotherapy and telemental health, as I often have appointments scheduled each hour and would not want well as some risks. There are risks to risk leaving your child in confidentiality since telemental health sessions take place outside of the lobby unsupervisedpractice’s private office, unless specific arrangements are made with you. I routinely offer clients a lollipop and cup of tea or hot chocolate at the beginning of sessions. If you or your child has any dietary restrictions concerning any of these items, please let me know. By signing this form, there is potential for other people to overhear sessions if you are agreeing not in a private place during the session. The practice will take reasonable steps to ensure your privacy; however, it is important for you to make sure you find a private place for sessions where you will not hold me legally responsible be interrupted. It is also important for any incidental liquid xxxxx you to protect the privacy of sessions on your cell phone or unanticipated allergic reactions other device. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation. There could possibly be issues related to technology, which may impact telemental health. For example, technology may stop working during a session, other people might be able to get access to private conversations between you and the practice, or stored data could be accessed by unauthorized people or companies. Since sessions take place remotely, there are limitations on how the practice can handle crisis situations. Therefore, usually, the practice will not engage in telemental health with clients, who are currently in a crisis situation requiring high levels of support and intervention. Before engaging in telemental health, we will develop an emergency response plan to address potential crisis situations that may result from arise during the consumption course of these itemsour telemental health work. (See also relevant section above: “EMERGENCY”). Most research shows that telemental health is about as effective as in-person psychotherapy. However, some clinicians disagree with this. For example, there is debate about a clinician’s ability to fully understand non-verbal information when working remotely. Telemental health-based services may not yield the same results, nor be as complete as face-to-face services.

Appears in 1 contract

Samples: Office Policies & General Information Agreement for Psychotherapy

TELEPHONE & EMERGENCY PROCEDURES. If you need to contact me the therapist between sessions, please text me or leave a voicemail message with my voice mail and your call will be returned as soon as possible. I check my The therapist checks his/her messages several a few times a dayduring the daytime only, unless I am s/he is out of town. If an emergency situation arises, please indicate it clearly in your voice mail message. If message and if you need to gain immediate assistancetalk to someone right away call Psychiatric Emergency Services, please call 24-­‐hour crisis line or the Police: 911. Please do not use email, text messages or faxes for emergencies. The therapist does not always check his/her email or faxes daily. PAYMENTS & INSURANCE REIMBURSEMENT: Clients are expected to pay the agreed-agreed upon fee per session at the end beginning of each session unless other arrangements have been madesession. Site visitsTelephone conversations, report writing, in-person consultation (as requested by you) with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed upon otherwise. Please notify me the therapist if any problem arises problems arise during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that rendered professional services are rendered and charged to the clients and not to the insurance companies. Unless agreed upon differently, I can the therapist will provide you with a copy of your receipt on a monthly basis, which you can then submit to your insurance company for reimbursement reimbursement, if you so choose. For any last-minute cancellations or no-show appointments, you responsible for the full payment of both the co-pay and what would normally be covered by the insurance company. As was indicated in the section, Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems, which are the focus of dealt with in psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage prior to the initiation of servicescoverage. You will be responsible for all services rendered in the event that you discover afterwards that your insurance coverage does not cover the costs of therapy services. All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement between us. The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Yolo County, CA in accordance with the rules of the American Arbitration Association that are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that If your account is overdue (unpaid) and there is no written agreement on a payment plan, I may the therapist can use legal or other means (courtcourts, collection agencyagencies, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitrator will determine that sum. Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. I will ask for your feedback and views on our work together, its progress, and other aspects of the therapy and will encourage you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During the initial phase of the evaluation or throughout the course of ongoing therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in your experiencing considerable discomfort including feelings of anger, sadness, worry, fear, anxiety, depression, etc. I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed negatively by another family member. Change will sometimes be easy and swift, but more often, it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, I am likely to draw on various psychological approaches to address the problem that is being treated and my assessment of what will best benefit you. These approaches may include those from the psychodynamic, cognitive-behavioral, system/family, developmental (adult, child, family), or psycho-educational perspectives. Your appointment will last 50 minutes. If I am providing services to your child, please do not drop him/her off in the waiting room without checking in with me first. I ask that you please be prompt in picking up your child after his/her appointment as I often have appointments scheduled each hour and would not want to risk leaving your child in the lobby unsupervised, unless specific arrangements are made with you. I routinely offer clients a lollipop and cup of tea or hot chocolate at the beginning of sessions. If you or your child has any dietary restrictions concerning any of these items, please let me know. By signing this form, you are agreeing to not hold me legally responsible for any incidental liquid xxxxx or unanticipated allergic reactions that may result from the consumption of these items.

Appears in 1 contract

Samples: Office Policies & General Information Agreement for Psychotherapy Services