Common use of TERMINATION OF TREATMENT Clause in Contracts

TERMINATION OF TREATMENT. If at any point during psychotherapy I assess that I am not effective in helping you reach the therapeutic goals, I am obliged to discuss it with you and, if appropriate, to terminate treatment. In such a case, I will give a number of referrals that may be of help to you. If you request it and authorize it in writing, I will 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 you provide a written consent, I will provide 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 the names of other qualified professionals whose services you might prefer. PROFESSIONAL FEES My hourly fee is $150. In addition to weekly appointments, I charge this amount for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services are generally not reimbursed by your insurance plan. These other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $300 per hour for preparation and attendance at any legal proceeding. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above, unless prohibited by contract. CONTACTING ME I am often not immediately available by telephone. While I am usually in my office between 10 AM and 7 PM Monday throughThursday and between 9 AM and 4 PM on Friday, I probably will not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by an answering machine when I am in the office which I monitor frequently and voice mail when I am away from the office . I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available for me to return your call. If you have a life threatening emergency, please call 911 or go to the nearest emergency room. For other types of crises, my pager (cell phone) number is 000-000-0000. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of your records, or I can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or may be upsetting to untrained readers. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents. There may be a fee charged to conduct a review meeting. Patients will be charged an appropriate fee for any professional time spent in responding to information requests. MINORS If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from parents that they agree to give up access to your records. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. I will also provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss. At the end of your treatment, I will prepare a summary of our work together for your parents, and we will discuss it before I send it to them.

TERMINATION OF TREATMENT. If at any point during psychotherapy I assess that I am not effective in helping you reach the therapeutic goals, I am obliged to discuss it with you and, if appropriate, to terminate Length of treatment. In such a case, I : The length of time required for therapy will give a number of referrals that may be of help to you. If you request it and authorize it in writing, I will 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 you provide a written consent, I will provide 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 the names of other qualified professionals whose services you might prefer. PROFESSIONAL FEES My hourly fee is $150. In addition to weekly appointments, I charge this amount for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services are generally not reimbursed determined by your insurance planpersonal situation. These other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $300 per hour for preparation and attendance at any legal proceeding. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find fulfill your therapeutic needs and provide you with the best therapeutic care. For your part, you agree to participate in the process to the best of your ability. It is intended that when your needs are met, to the extent they can be, we will terminate our relationship. Client Termination: You may terminate services at any time. This may be done in several ways. These include, but are not limited to, putting it in writing or informing me verbally. If you choose to terminate therapy with me, it will be my decision as to whether we can re-establish our therapeutic relationship if you request to do so in the future. In such circumstances, referrals to other therapists or agencies will be provided if requested. Therapist Termination: A pattern of frequently canceled or missed appointments will result in termination. Non-payment for services may result in termination. If I feel that the services I can offer are not or will not be appropriate for you, I may, after discussing reasons with you, refer you to another provider who or agency. Furthermore, I reserve the right to terminate service if dangerous/risky behaviors are continued or if sessions are attended after consuming drugs or alcohol. Regardless of the reason for ending treatment, I ask that you allow yourself/your child to have 1-3 closure sessions. HIPAA The information about HIPAA included in this agreement, along with the Texas Notice Form describes your rights with regards to your Clinical Record and disclosures of protected health information. Your signature below serves as an acknowledgement that you have received the HIPAA notice. X Client/Guardian Printed Name X X Client/Guardian Signature Date Complaint Procedure: If you are dissatisfied with any aspect of the counseling process, please inform my office so I can determine if our work together can be more efficient and effective or whether a referral would be appropriate. If you believe you have been treated unfairly or unethically, and I cannot resolve the problem, contact: Texas State Board of Examiners of Professional Counselor Complaint Process Complaints Management and Investigative Section P.O. Box 141369 Austin, Texas 00000-0000 Or call 0-000-000-0000 Session and Fees: Schedule of Fees Type of Service Fee Initial Consultation $250.00 45 Minute (Individual) Session $170.00 25 minute (Individual) Session $90.00 90 Minute Session $250.00 Additional Services- 1-30 minutes: $75.00 dollars 31-60 minutes: $150.00 Time therapist works outside of session on behalf of the client: 1. Talking to teachers/administration on behalf of your child 2. Consulting with a medical doctor, another psychologist or psychiatrist with whom you have given me permission to speak 3. Report writing 4. Scoring tests/reports 5. Contact between sessions via phone or text lasting more than 15 minutes between sessions Services Related to Legal Proceedings $400/hour Court Appearance/Testimony $2,000/day Payment is due at the time of services. I accept cash, check, or credit card. A $50-dollar fee will be charged for all returned checks It is your responsibility to provide my office with your most current contact/billing information at all times. First Session: In order for therapy to work best, it is important that both the therapist and patient feel comfortable with each other. Our initial session is an intake assessment lasting 60-90 minutes. During this time, I want to find out more about your concerns and goals for treatment in order to determine if our skills and experience are a good match for what you need help you continue your psychotherapywith. You should This initial session is also be aware that most insurance companies require an opportunity for you to authorize me determine if our approach feels like a good match for you. A therapeutic relationship will not officially be established until after we have discussed your presenting problems and we agree to provide them work together on your goals for therapy. Weekly Sessions: After the initial visit, sessions are typically at least once a week for 45-50 minutes, which includes time for scheduling, payment, and therapy. Our fee schedule will be discussed at the time you set your intake appointment with a clinical diagnosismy office manager. Sometimes Half Sessions: In general, I have do not offer 30-minute psychotherapy sessions. The only exception to provide additional clinical information such as treatment plans or summariesthis is in the case of younger children, or copies of the entire record (in rare cases)who may only be appropriate for half sessions. This information will become part of decision is on a case-by-case basis depending on the insurance company files and will probably be stored in a computerneed. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. Phone Sessions: In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. Once we have all of the information about your insurance coveragewhen an appointment can only be held remotely, we will discuss what we can expect may agree on a scheduled video or phone session. Late Cancelations or No Shows: I respectfully request 24 hours’ notice when canceling an appointment so that I may offer the time to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessionssomeone on my wait-list. It My hourly rate is important to remember that you always have the right to pay charged as a cancelation fee for my services yourself to avoid the problems described above, unless prohibited by contract. CONTACTING ME I am often not immediately available by telephone. While I am usually in my office between 10 AM and 7 PM Monday throughThursday and between 9 AM and 4 PM on Friday, I probably will not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by an answering machine when I am in the office which I monitor frequently and voice mail when I am away missed appointments or cancelations made less than 24 hours from the office . I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available scheduled time as well as for me to return your call. If you have a life threatening emergency, please call 911 or go to the nearest emergency room. For other types of crises, my pager late shows (cell phone) number is 000-000-0000. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of your records, or I can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or may be upsetting to untrained readers. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents. There may be a fee charged to conduct a review meeting. Patients will be charged an appropriate fee for any professional time spent in responding to information requests. MINORS If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from parents that they agree to give up access to your records. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. I will also provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss. At the end of your treatment, I will prepare a summary of our work together for your parents, and we will discuss it before I send it to themmore than 10 minutes late).

TERMINATION OF TREATMENT. During the initial intake process and the first few sessions, I will assess if I can be of benefit to you. If you have requested online counseling, my assessment will include your suitability to psychotherapy delivered via technology. Not everyone is suited to distance counseling. Also, each therapist’s skills and styles are different. I want to be sure that we have a good match between client and therapist. I do not accept clients who, in my opinion, I cannot help. In such a case, I will give you a number of referrals that you may contact. If at any point during psychotherapy psychotherapy, I assess that I am not effective in helping you reach the your therapeutic goals, I am obliged obligated to discuss it this with you andyou, if appropriate, up to terminate and including termination of treatment. In such a case, I will give you a number of referrals that may be of help to you. If you request it and authorize it in writing, I will talk to with 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, qualified and if I have you provide a written consent, I will provide him or her 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 the names of other qualified professionals whose services you might prefer. PROFESSIONAL FEES My hourly fee CONFIDENTIALITY & PRIVACY All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is $150required by law. Likewise, you are expected to keep our communications confidential and you understand that all records of communication between client and therapist remain the property of Xxxxx Xxxxxx. Most of the provisions explaining when the law requires disclosure were described to you in the Notice of Privacy Practices that you received with this form. WHEN DISCLOSURE IS REQUIRED BY LAW Some of the circumstances in which disclosure is required by law include: 1) when there is a reasonable suspicion of child, dependent, or elder abuse or neglect; 2) when a client presents a danger to self, to others, to property, or is gravely disabled. For more details, see the Notice of Privacy Practices form. WHEN DISCLOSURE MAY BE REQUIRED Disclosure may be required pursuant to a legal proceeding. If you are involved in a custody dispute or if you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by me. In addition couples and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between couple or among family members. I will use my clinical judgment when revealing such information. I will not release records to weekly appointmentsany outside party unless I am authorized do so by all adult family members who were part of the treatment or unless compelled to do so by law or a valid court order. HARM TO SELF OR OTHERS If there is an emergency during our work together or if in the future after termination I become concerned about your personal safety, the possibility of your injuring someone else, or about you receiving proper psychiatric care, I charge will do whatever I can within the limits of the law to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this amount for other professional services purpose, I may also contact law enforcement, hospital, or an emergency contact whose name you may needhave provided. CONFIDENTIALITY OF EMAIL, though CHAT, CELL PHONE, AND FAX COMMUNICATIONS Therapeutic e-mail and chat exchanges are delivered via HushMail. You agree to work with me online using HushMail or anther encrypted email/chat service determined to be suitable by Xxxxx Xxxxxx. If you choose to e-mail me from your personal email account, please limit the contents to housekeeping issues such as cancellation or change in contact information. I will break down not respond to personal and clinical concerns via regular email. If you call me, please be aware that unless we are both on land line phones, the hourly cost conversation is not confidential. Likewise, text messages are not confidential. If you send a fax to me, my fax line is in a secure location. Any computer files referencing our communication are maintained using secure and encrypted measures. If you wish to use email as a way to “journal” information between sessions, you understand that I may not have the opportunity to review your journal emails until our next scheduled session. You understand that emails between sessions that contain confidential information will be sent using encryption. I make every effort to keep all information confidential. Likewise, if we are working online together, I work ask that you determine who has access to your computer and electronic information from your location. This would include family members, co-workers, supervisors, and friends. I encourage you to only communicate through a computer that you know is safe (where confidentiality can be ensured). Be sure to fully exit all online counseling sessions and emails. If we are unable to connect or are disconnected during a session due to a technological breakdown, please try to reconnect within 10 minutes. If reconnection is not possible, e-mail me to schedule a new session time. LITIGATION LIMITATION Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to: divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) nor your attorney, nor anyone else acting on your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested. CONSULTATION I consult regularly with other professionals regarding my clients, however, the client’s name or other identifying information is never disclosed. The client’s identity remains completely anonymous and confidentiality is fully maintained. RELEASE OF INFORMATION Considering all the above exclusions, if it is still appropriate, upon your request and signed Release of Information, I will release information to any agency/person you specify unless I conclude that releasing such information might be harmful in any way. If you were referred by your family physician, a release of information signed by you would be necessary to discuss matters regarding your treatment. Also please be aware that for periods purposes of billing insurance, your diagnosis and dates of service will be required to collect payment of services. EMERGENCY PROCEDURES Established clients who need to make contact with me between appointments to alert me of an emergency may call 000-000-0000 but an immediate response is not guaranteed. Your call will be returned as soon as possible. Messages are checked daily during regular business hours (less than one hourfrequently after hours, weekends, or holidays). Other My practice does NOT have the capability to respond immediately to counseling emergencies. In the event of a life- threatening emergency, please call the emergency National Suicide Hotline at 000-000-0000 or dial 911. Additional crisis hotlines are listed on my website. If a life-threatening crisis should occur, you agree to contact a crisis hotline, dial 911, or go to a hospital emergency room. FEES Current rates for therapeutic services are generally posted on my website. PAYMENT INFORMATION Payment is expected prior to your appointment. Session payments via debit or credit card can be processed through PayPal, Google Checkout, or XxxxxxxxxxxxXxxxxxx.xxx. Sessions are usually purchased in 30 and 60 minute increments. Therapeutic email exchanges can be purchased one at a time or as a package. Clients who are attending therapeutic sessions face-to-face (in person) in my office may provide payment at the time of their session. In-person session payments may be cash, check, or money order. INSURANCE PLANS Please note that most insurance companies only cover services that are provided face-to-face. Insurance plans do no usually cover services that are provided at a distance. For clients who are attending therapeutic sessions face-to-face (in person) in my office, I am able to accept some insurance plans and would be pleased to bill them for you. Please have your insurance card and co-payment amount with you to help accelerate this process. Although a claim for your session is issued to your insurance company that does not reimbursed by guarantee payment from the insurance company (you will be responsible for payment). If your insurance provider is not one of the insurance plans I accept, you have the option to pay privately or use your insurance provider’s “out of network” service (if that is part of your insurance plan). These other services include report writing, telephone conversations lasting longer than 10 minutes, attendance That would involve your paying in full at meetings with other professionals time of service and then you have authorized, preparation would submit a super bill to the insurance provider to recover whatever percentage they pay. There is usually an upfront “out of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $300 per hour for preparation and attendance at any legal proceeding. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatmentnetwork” deductible. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course I will provide you with whatever information I can based on my experience and will be happy to help you with this process. MEDIATION & ARBITRATION All disputes arising out of or in understanding relation to this agreement to provide therapeutic services shall first be referred to mediation before, and as a precondition of, the information you receive from initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of Xxxxx Xxxxxx and the client(s). The cost, if any, of such mediation shall be split equally, unless otherwise agreed in writing. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration 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 insurance companyaccount is overdue (unpaid) and there is no agreement on a payment plan, I 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. CANCELLATION Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours notice is required for rescheduling or cancelling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification. If it is necessary I am not able to clear confusionkeep the scheduled appointment and did not give you 24 hours prior notice, I will be willing offer you a session free of charge. Our time is equally valuable. CONSENT FOR EVALUATION AND TREATMENT You as the client understand that phone and email sessions have limitations compared to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to shortin-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of person sessions. While a lot can be accomplished This includes the lack of “personal” face-to-face interactions, the lack of visual and audio cues in short-term therapythe therapy process, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is and the case, I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware fact that most insurance companies require will not cover this type of therapy. You understand that psychotherapy with me is not a substitute for medication under the care of a psychiatrist or doctor. You understand that online and telephone therapy is not appropriate if you are experiencing a crisis or having suicidal or homicidal thoughts. As stated previously, if a life-threatening crisis should occur, you agree to authorize me to provide them with contact a clinical diagnosis. Sometimes I have to provide additional clinical information such as treatment plans or summariescrisis hotline, call 911, or copies go to a hospital emergency room. You also understand that I follow the laws and professional regulations of the entire record State of Arizona (USA) and the psychotherapy treatment will be considered to take place in rare casesthe State of Arizona (USA). This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I You signature below indicates that you have no control over what they do with it once it is in their hands. In some cases, they may share reviewed the information with a national medical information databankavailable on my website and have read and understand this Informed Consent and the HIPPA Notice of Privacy Practices. I will provide you with a copy of any report I submit, if you request it. Once we have all of Consent is hereby given for evaluation and treatment under the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessionsterms described in this consent document. It is important to remember agreed that either of us may discontinue the treatment at any time and that you always have are free to accept or reject the right to pay for my services yourself to avoid the problems described above, unless prohibited by contracttreatment provided. CONTACTING ME I am often not immediately available by telephone. While I am usually in my office between 10 AM and 7 PM Monday throughThursday and between 9 AM and 4 PM on Friday, I probably will not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by an answering machine when I am in the office which I monitor frequently and voice mail when I am away from the office . I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available for me to return your call. If you have a life threatening emergency, please call 911 or go to the nearest emergency room. For other types of crises, my pager Client Name (cell phone) number is 000-000-0000. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of your records, or I can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or may be upsetting to untrained readers. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents. There may be a fee charged to conduct a review meeting. Patients will be charged an appropriate fee for any professional time spent in responding to information requests. MINORS If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from parents that they agree to give up access to your records. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. I will also provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss. At the end of your treatment, I will prepare a summary of our work together for your parents, and we will discuss it before I send it to them.printed): Client Signature: Date:

TERMINATION OF TREATMENT. If at any point during psychotherapy I assess that I am not effective in helping you reach the therapeutic goals, I am obliged to discuss it with you and, if appropriate, to terminate Length of treatment. In such a case, I : The length of time required for therapy will give a number of referrals that may be of help to you. If you request it and authorize it in writing, I will 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 you provide a written consent, I will provide 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 the names of other qualified professionals whose services you might prefer. PROFESSIONAL FEES My hourly fee is $150. In addition to weekly appointments, I charge this amount for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services are generally not reimbursed determined by your insurance planpersonal situation. These other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $300 per hour for preparation and attendance at any legal proceeding. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find fulfill your therapeutic needs and provide you with the best therapeutic care. For your part, you agree to participate in the process to the best of your ability. It is intended that when your needs are met, to the extent they can be, we will terminate our relationship. Client Termination: You may terminate services at any time. This may be done in several ways. These include, but are not limited to, putting it in writing or informing me verbally. If you choose to terminate therapy with me, it will be my decision as to whether we can re-establish our therapeutic relationship if you request to do so in the future. In such circumstances, referrals to other therapists or agencies will be provided if requested. Therapist Termination: A pattern of frequently canceled or missed appointments will result in termination. Non-payment for services may result in termination. If I feel that the services I can offer are not or will not be appropriate for you, I may, after discussing reasons with you, refer you to another provider who or agency. Furthermore, I reserve the right to terminate service if dangerous/risky behaviors are continued or if sessions are attended after consuming drugs or alcohol. Regardless of the reason for ending treatment, I ask that you allow yourself/your child to have 1-3 closure sessions. HIPAA The information about HIPAA included in this agreement, along with the Texas Notice Form describes your rights with regards to your Clinical Record and disclosures of protected health information. Your signature below serves as an acknowledgement that you have received the HIPAA notice. X Client/Guardian Printed Name X X Client/Guardian Signature Date Complaint Procedure: If you are dissatisfied with any aspect of the counseling process, please inform my office so I can determine if our work together can be more efficient and effective or whether a referral would be appropriate. If you believe you have been treated unfairly or unethically, and I cannot resolve the problem, contact: Texas State Board of Examiners of Professional Counselor Complaint Process Complaints Management and Investigative Section P.O. Box 141369 Austin, Texas 00000-0000 Or call 0-000-000-0000 Session and Fees: Schedule of Fees Type of Service Fee Initial Consultation $230.00 45 Minute (Individual) Session $150.00 25 minute (Individual) Session $75.00 90 Minute Session $230.00 Additional Services- 1-30 minutes: $75.00 dollars 31-60 minutes: $150.00 Time therapist works outside of session on behalf of the client: 1. Talking to teachers/administration on behalf of your child 2. Consulting with a medical doctor, another psychologist or psychiatrist with whom you have given me permission to speak 3. Report writing 4. Scoring tests/reports 5. Contact between sessions via phone or text lasting more than 15 minutes between sessions Services Related to Legal Proceedings $300/hour Court Appearance/Testimony $1,500/day Payment is due at the time of services. I accept cash, check, or credit card. A $50-dollar fee will be charged for all returned checks It is your responsibility to provide my office with your most current contact/billing information at all times. First Session: In order for therapy to work best, it is important that both the therapist and patient feel comfortable with each other. Our initial session is an intake assessment lasting 60-90 minutes. During this time, I want to find out more about your concerns and goals for treatment in order to determine if our skills and experience are a good match for what you need help you continue your psychotherapywith. You should This initial session is also be aware that most insurance companies require an opportunity for you to authorize me determine if our approach feels like a good match for you. A therapeutic relationship will not officially be established until after we have discussed your presenting problems and we agree to provide them work together on your goals for therapy. Weekly Sessions: After the initial visit, sessions are typically at least once a week for 45-50 minutes, which includes time for scheduling, payment, and therapy. Our fee schedule will be discussed at the time you set your intake appointment with a clinical diagnosismy office manager. Sometimes Half Sessions: In general, I have do not offer 30-minute psychotherapy sessions. The only exception to provide additional clinical information such as treatment plans or summariesthis is in the case of younger children, or copies of the entire record (in rare cases)who may only be appropriate for half sessions. This information will become part of decision is on a case-by-case basis depending on the insurance company files and will probably be stored in a computerneed. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. Phone Sessions: In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. Once we have all of the information about your insurance coveragewhen an appointment can only be held remotely, we will discuss what we can expect may agree on a scheduled video or phone session. Late Cancelations or No Shows: I respectfully request 24 hours’ notice when canceling an appointment so that I may offer the time to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessionssomeone on my wait-list. It My hourly rate is important to remember that you always have the right to pay charged as a cancelation fee for my services yourself to avoid the problems described above, unless prohibited by contract. CONTACTING ME I am often not immediately available by telephone. While I am usually in my office between 10 AM and 7 PM Monday throughThursday and between 9 AM and 4 PM on Friday, I probably will not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by an answering machine when I am in the office which I monitor frequently and voice mail when I am away missed appointments or cancelations made less than 24 hours from the office . I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available scheduled time as well as for me to return your call. If you have a life threatening emergency, please call 911 or go to the nearest emergency room. For other types of crises, my pager late shows (cell phone) number is 000-000-0000. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of your records, or I can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or may be upsetting to untrained readers. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents. There may be a fee charged to conduct a review meeting. Patients will be charged an appropriate fee for any professional time spent in responding to information requests. MINORS If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from parents that they agree to give up access to your records. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. I will also provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss. At the end of your treatment, I will prepare a summary of our work together for your parents, and we will discuss it before I send it to themmore than 10 minutes late).

TERMINATION OF TREATMENT. If at any point during psychotherapy I assess that I am not effective in helping you reach the therapeutic goals, your therapy goals I am obliged to discuss it with you and, and if appropriate, to terminate treatment. In such a casecases, I will give a number of referrals that may be of help or direct you back to youyour insurance company. If you request it and authorize it in writing, I will talk to the psychotherapist of your choice in order to help with the transitiontransition if it is requested and a release of information is provided. 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 you provide a written consent, I will provide 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 the names of other qualified professionals whose services you might prefer. PROFESSIONAL FEES My hourly fee fee, or Usual and Customary Rate (UCR), is $150145. In addition to weekly appointments, I charge this amount for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other ‘Other’ services are generally not reimbursed by your insurance plan. These other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $300 275 per hour for preparation and attendance at any legal proceedingproceedings. Travel to and from my office is billed at the same rate. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its necessary costs will be included in the claim. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature type of services providedprovided (psychotherapy), and the amount due. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course I will provide you with whatever information I can based on my experience and will be happy to help you in understanding understand the information you receive from your insurance company. If it is necessary to clear clarify any confusion, I will would be willing to call the insurance company on your behalf. Due to the rising costs of health care, insurance benefits have become increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will can become part of the insurance company files and will probably be stored in a computerfiles. Though all All insurance companies claim are required to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide review any information I am required to submit for insurance purposes with you with a copy of any report I submit, if you request it, before submission. I will always inform you a request has been made. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above, unless prohibited by contract. The advantage here is that records stay with me and with the exception of a court order I will not release them to anyone. On court order or any other required disclosure (legally speaking) I will contact my patient first, and when necessary seek legal counsel on such requests prior to releasing records. CONTACTING ME I am often not immediately available by telephone. While I am usually in my office between 10 AM 4 PM and 7 9 PM Monday throughThursday and between 9 AM and 4 PM on through Friday, I probably will not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by an answering machine when I am in the office which I monitor frequently and voice mail when I am away from the office machine. I will make every effort to return your call on the same day you make itI receive the call, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available for me to return your call. If you have a life threatening emergency, please call 911 or go to the nearest emergency room. For other types of crisessituations, call my pager office (cell phone000) number is 000-000-00000000 Opt 2 and mark the message as urgent and I will return your call as quickly as possible. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of your records, or I can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or and may be upsetting to untrained readers. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contentscontent. There may be a fee charged to conduct a review meeting. Patients will be charged an appropriate fee for any professional time spent in responding to information requestsrequests if your insurance company does not cover the service. MINORS If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from parents that Typically they agree to give up access to your records. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. I will also provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss. At the end of your treatment, I will prepare a summary of our work together for your parents, and we will discuss it before I send it to themnot.

TERMINATION OF TREATMENT. If at any point during psychotherapy I assess that I am not effective in helping you reach the Ending therapy is a natural progression of meeting your therapeutic goals; however, I am obliged it is difficult to discuss quantify in simple time frames the length of therapy as it is different for every client. Some clients complete therapy in a short time while others may require extended therapeutic support. Every person’s therapeutic journey is unique. Your progress is reviewed with you andyour therapist periodically to ensure treatment gains are made, if appropriate, modification of therapy goals and to terminate treatmentpromote therapeutic collaboration. In such If it is determined that a case, I will give a number of referrals that referral may be necessary after a given length of help to time during therapy with LifeCare, your therapist will discuss your options with you. If you request it and authorize it in writing, I will 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 you provide a written consent, I will provide the essential information needed. You have the right to terminate end therapy at any time, however, when you do decide to end therapy, we ask that you discuss this with your therapist so that a final/closure session can be completed. If you choose to do soThis is always beneficial in reviewing progress made, I will offer to provide you sharing feedback with the names of other qualified professionals whose services you might prefer. PROFESSIONAL FEES My hourly fee is $150. In addition to weekly appointments, I charge this amount for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services are generally not reimbursed by your insurance plan. These other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summariesanother, and the time spent performing any other service you may request closing out with that part of meyour therapeutic journey. If you become involved in legal proceedings that require my participationPlease know though as life circumstances occur, you will be expected welcome to pay reach back out for my professional time even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $300 per hour for preparation and attendance at any legal proceeding. BILLING AND PAYMENTS You will be expected to pay for each session at the time therapeutic support should you need it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claimfuture. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources Just as you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay terminate services at any time, LifeCare Counseling and/or your therapist also reserves the right to terminate services if at any time any of the provisions contained in this Informed Consent and Counseling Agreement and/or LifeCare Policies & Procedures are violated. LifeCare will also not tolerate any disrespectful, inappropriate and/or aggressive toward its staff or therapists. COURT PROCEEDINGS LifeCare does not offer court-related services to include court appearances, proceedings, documentations or providing recommendations regarding child custody arrangements or divorce related issues. CLIENT CONTACT INFORMATION Please be aware that by signing this informed consent & clinical agreement, you give consent for my services yourself LifeCare Counseling to avoid the problems described above, unless prohibited by contract. CONTACTING ME I am often not immediately available by telephone. While I am usually in my office between 10 AM and 7 PM Monday throughThursday and between 9 AM and 4 PM on Friday, I probably will not answer contact you at the phone when I am with a patientnumber, email and address provided. When I am unavailableFor appointment scheduling or reminders, my telephone is answered by clients receive an answering machine when I am in automated text or email reminder the office which I monitor frequently and voice mail when I am away from day prior to the office . I will make every effort to return your call on the same day you make it, with the exception of weekends and holidaysappointment. If you there are difficult to reachspecific questions for clients, please inform me of some times when you will be available for me contacted by phone and a general voice mail will be left with request to return your call. If you have a life threatening emergencyvoice mail messages are left, please call 911 or go to the nearest emergency room. For other types of crises, my pager (cell phone) number is 000-000-0000. If I they will be unavailable for an extended time, I will provide you general in nature with the a contact name of a colleague to contact, respond to. Please inform LifeCare if necessary. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy any of your records, or I can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or may be upsetting to untrained readers. If you wish to see your records, I recommend that you review them in my presence contact information changes so that we can discuss update your records. CONTACTING LIFECARE Xxxxx Xxxxxxx’x contact number is 000.000.0000. Lifecare’s email is xxxx@xxxxxxxxxxxxxxxxxxxx.xxx and fax is 000.000.0000. Xxxxx’s email is xxxxxxxxxxxxxxxxxxxxx@xxxxx.xxx. EVERY EFFORT IS MADE TO RESPOND WITHIN 24-48 HOURS. Please DO NOT INCLUDE PRIVATE OR PROTECTED HEALTH INFORMATION IN TEXT OR EMAIL. APPOINTMENTS & CANCELLATIONS When you schedule an appointment with LifeCare Counseling, that time slot is specifically reserved just for you. That is why we require 24-hour advance notification of cancellation. Leaving a message on our voicemail, texting or emailing your therapist is acceptable for notification. Should you fail to show for your scheduled appointment or cancel less than the contents. There may be a fee charged to conduct a review meeting. Patients will be charged an appropriate fee for any professional time spent required 24 hours in responding to information requests. MINORS If you are under eighteen years of ageadvance, please be aware that LifeCare normally allows waiving the law may provide your parents $25 late cancel or missed appointment fee; however, should future occurrences occur, LifeCare reserves the right to examine charge the $25 fee. We understand that life circumstances do occur (i.e., medical, inclement weather, family issues, etc.), and try to work with clients when extenuating circumstances arise. We appreciate the courtesy you extend to us by honoring this agreement. Please note that we cannot bill your treatment recordsinsurance company for missed sessions or for late cancellations. Medicaid clients are not charged a fee per the law. Clients who repeatedly miss appointments may be discharged from services. Clients that do provide adequate notice but habitually cancel appointments, will no longer be offered a standing appointment. Additionally, LifeCare reserves the right to discontinue services until late or missed appointment fees are paid. BILLING & PAYMENTS It is my our policy to request receive payment for services at the time they are provided. LifeCare Counseling will obtain your credit card information to be securely kept in our HIPAA compliant electronic health platform to be used for automatic payment when services are rendered. Other acceptable forms of payment include cash or personal check. INSURANCE LifeCare Counseling LLC is currently in-network with BCBS, United Health Care/Optum, Cigna, Medicaid and is in the process of credentialing with other insurance providers. Upon scheduling an agreement from parents appointment with LifeCare, Counseling, insurance information is obtained so that they agree to give up access to your recordsmental health benefits can be verified. If they agree, I While LifeCare will provide them only with general information about our work together, unless I feel there verify your benefit coverage; It is a high risk recommended that clients contact their insurance company directly since you will seriously harm yourself or someone elseare responsible for payment of services as well as any plan coverage changes. In this case, I will notify them of my concern. I will also provide them with a summary Call the Member Services phone number on the back of your treatment when it is completeinsurance card. Before giving them any information, I Some will discuss the matter with you, if possible, and do my best have a specific number to handle any objections you may have with what I am prepared call for mental/behavioral health. Questions to discuss. At the end of your treatment, I will prepare a summary of our work together for your parents, and we will discuss it before I send it to them.ask include:

TERMINATION OF TREATMENT. If at any point during psychotherapy I assess that I am not effective in helping you reach the therapeutic goals, I am obliged to discuss it with you and, if appropriate, to terminate Length of treatment. In such a case, I : The length of time required for therapy will give a number of referrals that may be of help to you. If you request it and authorize it in writing, I will 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 you provide a written consent, I will provide 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 the names of other qualified professionals whose services you might prefer. PROFESSIONAL FEES My hourly fee is $150. In addition to weekly appointments, I charge this amount for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services are generally not reimbursed determined by your insurance planpersonal situation. These other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $300 per hour for preparation and attendance at any legal proceeding. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find fulfill your therapeutic needs and provide you with the best therapeutic care. For your part, you agree to participate in the process to the best of your ability. It is intended that when your needs are met, to the extent they can be, we will terminate our relationship. Client Termination: You may terminate services at any time. This may be done in several ways. These include, but are not limited to, putting it in writing or informing me verbally. If you choose to terminate therapy with me, it will be my decision as to whether we can re-establish our therapeutic relationship if you request to do so in the future. In such circumstances, referrals to other therapists or agencies will be provided if requested. Therapist Termination: A pattern of frequently canceled or missed appointments will result in termination. Non-payment for services may result in termination. If I feel that the services I can offer are not or will not be appropriate for you, I may, after discussing reasons with you, refer you to another provider who or agency. Furthermore, I reserve the right to terminate service if dangerous/risky behaviors are continued or if sessions are attended after consuming drugs or alcohol. Regardless of the reason for ending treatment, I ask that you allow yourself/your child to have 1-3 closure sessions. HIPAA The information about HIPAA included in this agreement, along with the Texas Notice Form describes your rights with regards to your Clinical Record and disclosures of protected health information. Your signature below serves as an acknowledgement that you have received the HIPAA notice. X Client/Guardian Printed Name X X Client/Guardian Signature Date Complaint Procedure: If you are dissatisfied with any aspect of the counseling process, please inform my office so I can determine if our work together can be more efficient and effective or whether a referral would be appropriate. If you believe you have been treated unfairly or unethically, and I cannot resolve the problem, contact: Texas State Board of Examiners of Professional Counselor Complaint Process Complaints Management and Investigative Section P.O. Box 141369 Austin, Texas 00000-0000 Or call 0-000-000-0000 Session and Fees: Schedule of Fees Type of Service Fee Initial Consultation $275.00 45 Minute (Individual) Session $180.00 25 minute (Individual) Session $90.00 90 Minute Session $275.00 Additional Services- 1-30 minutes: $85.00 dollars 31-60 minutes: $170.00 Time therapist works outside of session on behalf of the client: 1. Talking to teachers/administration on behalf of your child 2. Consulting with a medical doctor, another psychologist or psychiatrist with whom you have given me permission to speak 3. Report writing 4. Scoring tests/reports 5. Contact between sessions via phone or text lasting more than 15 minutes between sessions Services Related to Legal Proceedings $400/hour Court Appearance/Testimony $2,000/day Payment is due at the time of services. I accept cash, check, or credit card. A $50-dollar fee will be charged for all returned checks It is your responsibility to provide my office with your most current contact/billing information at all times. First Session: In order for therapy to work best, it is important that both the therapist and patient feel comfortable with each other. Our initial session is an intake assessment lasting 60-90 minutes. During this time, I want to find out more about your concerns and goals for treatment in order to determine if our skills and experience are a good match for what you need help you continue your psychotherapywith. You should This initial session is also be aware that most insurance companies require an opportunity for you to authorize me determine if our approach feels like a good match for you. A therapeutic relationship will not officially be established until after we have discussed your presenting problems and we agree to provide them work together on your goals for therapy. Weekly Sessions: After the initial visit, sessions are typically at least once a week for 45-50 minutes, which includes time for scheduling, payment, and therapy. Our fee schedule will be discussed at the time you set your intake appointment with a clinical diagnosismy office manager. Sometimes Half Sessions: In general, I have do not offer 30-minute psychotherapy sessions. The only exception to provide additional clinical information such as treatment plans or summariesthis is in the case of younger children, or copies of the entire record (in rare cases)who may only be appropriate for half sessions. This information will become part of decision is on a case-by-case basis depending on the insurance company files and will probably be stored in a computerneed. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. Phone Sessions: In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. Once we have all of the information about your insurance coveragewhen an appointment can only be held remotely, we will discuss what we can expect may agree on a scheduled video or phone session. Late Cancelations or No Shows: I respectfully request 24 hours’ notice when canceling an appointment so that I may offer the time to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessionssomeone on my wait-list. It My hourly rate is important to remember that you always have the right to pay charged as a cancelation fee for my services yourself to avoid the problems described above, unless prohibited by contract. CONTACTING ME I am often not immediately available by telephone. While I am usually in my office between 10 AM and 7 PM Monday throughThursday and between 9 AM and 4 PM on Friday, I probably will not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by an answering machine when I am in the office which I monitor frequently and voice mail when I am away missed appointments or cancelations made less than 24 hours from the office . I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available scheduled time as well as for me to return your call. If you have a life threatening emergency, please call 911 or go to the nearest emergency room. For other types of crises, my pager late shows (cell phone) number is 000-000-0000. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of your records, or I can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or may be upsetting to untrained readers. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents. There may be a fee charged to conduct a review meeting. Patients will be charged an appropriate fee for any professional time spent in responding to information requests. MINORS If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my policy to request an agreement from parents that they agree to give up access to your records. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. I will also provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss. At the end of your treatment, I will prepare a summary of our work together for your parents, and we will discuss it before I send it to themmore than 10 minutes late).

TERMINATION OF TREATMENT. If at any point during psychotherapy I assess determine that I am cannot effective in helping provide appropriate services to you reach the therapeutic goals, I am obliged to discuss it with you and, if appropriate, to terminate treatment. In such a casefor any reason, I will give a number of referrals that may be of help terminate our treatment and refer you to youother professionals. If you request it and authorize it in writing, I will talk to the psychotherapist of your choice new therapist 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 with referrals. Upon termination of therapy for any reason, the termination will be confirmed in finding someone qualified, and, if you provide a written consent, I will provide the essential information neededwriting. You have the right to terminate Professional Fees: My fee for individual therapy is set at any time. If you choose to do so, I will offer to provide you with the names of other qualified professionals whose services you might prefer. PROFESSIONAL FEES My hourly fee is $150. In addition to weekly appointments, I charge this amount for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour140 per 50 minute session. Other services or no-show/late cancellation fees may have varying charges. You are generally not reimbursed by your insurance plan. These other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $300 per hour for preparation and attendance at any legal proceeding. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held. In addition to psychotherapy sessions, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules I charge this amount for other professional services you may need or request, such as report writing, telephone conversations of ten minutes or more, consultation with other professionals with your written permission, and preparation of records or treatment summaries. The time spent performing any other service you may request of me will be agreed incur additional charges. I will pro-rate the cost if I work for periods of less than 45 minutes. Please note that the “therapy hour” is actually 45- to when they are requested50 minutes in length, and is the usual session duration. In circumstances of unusual financial hardship, I may be willing Litigation Policy: Due to negotiate a fee adjustment or payment installment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, the therapeutic process and the amount due. INSURANCE REIMBURSEMENT In order for us fact that it often involves making a full disclosure with regard to set realistic treatment goals and prioritiesmany matters which may be of a confidential nature, it is important agreed that should there be legal proceedings (including but not limited to evaluate what resources divorce and custody disputes, injuries, lawsuits, etc..), neither you, your attorneys or anyone acting on your behalf will subpoena records from my office, or subpoena me to testify in court or in any legal proceeding. By your signature below, you have available agree to abide by this agreement. If I am subpoenaed to provide records or testimony in violation of this agreement, you acknowledge and agree you will pay for your treatmentall of my professional time, including preparation and transportation costs, even if I am called to testify by another party. If you become involved in any legal matter that requires my services, there is a fee of $250 per hour and this includes preparation time, travel time, attendance at any legal proceeding or any other time spent in this endeavor. I also reserve the right to terminate our professional, therapeutic relationship immediately and refer you to other mental health providers. I will NOT provide custody evaluations or recommendations of any kind. I will NOT provide medication or prescription recommendations. I will NOT provide legal advice. None of these activities are within scope of my practice. I do not do counseling for the purpose of meeting court or probation related assessments or counseling. It important that each client in the initial interview or at the first opportunity disclose fully to me if he/she has past, current, pending or potential legal issues. Insurance Reimbursement: Generally I do not participate in network with any insurance programs. I am licensed in Texas as a Psychologist. Your insurance company may reimburse you according to guidelines they have a established for out of network providers. Your health insurance policy, it policy will usually provide some coverage for mental health treatment. I will fill out forms and provide give you a receipt after each session so you can file with whatever assistance I can in helping you receive the benefits to which you are entitled; howeveryour insurance company. However, you (not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly You are responsible for knowing what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administratoradministration. Of course I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance companyCharge for Missed Appointments: There is a fee charge for missed appointments or cancellations made without 24 hour notice. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It The charge may be necessary to seek approval for more therapy after waived in the case of a certain number of sessions. While a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databankreasonable emergency. I will provide you with a copy of any report I submit, if you request it. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have reserve the right to pay for my services yourself request that you provide a credit card number to avoid the problems described above, unless prohibited by contract. CONTACTING ME I am often not immediately available by telephone. While I am usually in my office between 10 AM and 7 PM Monday throughThursday and between 9 AM and 4 PM be kept on Friday, I probably will not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by an answering machine when I am in the office which I monitor frequently and voice mail when I am away from the office . I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available for me to return your call. If you have a life threatening emergency, please call 911 or go to the nearest emergency room. For other types of crises, my pager (cell phone) number is 000-000-0000. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. PROFESSIONAL RECORDS The laws and standards of my profession require file so that I keep treatment records. You are entitled to receive a copy of your records, or I can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or it may be upsetting to untrained readers. If you wish to see your records, I recommend that you review them in my presence so that we can discuss the contents. There may be a fee charged to conduct a review meeting. Patients will be charged an appropriate fee for any professional time spent in responding to information requestsmissed appointments. MINORS If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is Please see my policy to request an agreement from parents that they agree to give up access to your records. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. I will also provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss. At the end of your treatment, I will prepare a summary of our work together fee schedule for your parents, and we will discuss it before I send it to themcharges.