Common use of TERMINATION OF TREATMENT Clause in Contracts

TERMINATION OF TREATMENT. Length of treatment: The length of time required for therapy will be determined by your personal situation. I will do my best to 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 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 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 with. This initial session is also an opportunity for you to 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 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 my office manager. Half Sessions: In general, I do not offer 30-minute psychotherapy sessions. The only exception to this is in the case of younger children, who may only be appropriate for half sessions. This decision is on a case-by-case basis depending on the need. Phone Sessions: In some cases, when an appointment can only be held remotely, we 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 someone on my wait-list. My hourly rate is charged as a cancelation fee for missed appointments or cancelations made less than 24 hours from the scheduled time as well as for late shows (more than 10 minutes late).

TERMINATION OF TREATMENT. Length If at any point during psychotherapy I assess that I am not effective in helping you reach your therapy goals I am obliged to discuss it with you and if appropriate, to terminate treatment. In such cases, I will give referrals that may be of treatment: The length help or direct you back to your insurance company. I will talk to the psychotherapist of your choice in order to help with the transition if it is requested and a release of information is provided. If at any time required 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. My hourly fee, or Usual and Customary Rate (UCR), is $145. In addition to weekly appointments, I charge this amount for therapy 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 determined 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 $275 per hour for preparation and attendance at any legal proceedings. Travel to and from my office is billed at the same rate. 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 personal situationaccount 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 costs will be included in the claim. In most collection situations, the only information I release regarding a patient’s treatment is name, the type of services provided (psychotherapy), and the amount due. 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 understand the information you receive from your insurance company. If it is necessary to clarify any confusion, I would be willing to call the insurance company on your behalf. Due to the rising costs of health care, insurance benefits have become increasingly 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 fulfill find another provider who will help you continue your therapeutic needs 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 can become part of the insurance company files. All insurance companies are required to keep such information confidential. I will review any information I am required to submit for insurance purposes with you 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. I am often not immediately available by telephone. While I am usually in my office between 4 PM and 9 PM Monday through Friday, I will not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by an answering machine. I will make every effort to return your call on the same day I 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 situations, call my office (000) 000-0000 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 best therapeutic carename of a colleague to contact, if necessary. For your part, you agree The laws and standards of my profession require that I keep treatment records. You are entitled to participate in the process to the best receive a copy of your abilityrecords, or I can prepare a summary for you instead. It is intended that when your needs Because these are metprofessional records, to the extent they can be, we will terminate our relationship. Client Termination: You may terminate services at any time. This be misinterpreted and may be done in several ways. These include, but are not limited to, putting it in writing or informing me verballyupsetting to untrained readers. If you choose wish to terminate therapy with mesee your records, it will be I recommend that you review them in my decision as to whether presence so that we can re-establish our therapeutic relationship if you request discuss the content. There may be a fee charged to do so in the futureconduct a review meeting. 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 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 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 Patients 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 with. This initial session is also an opportunity for you to 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 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 my office manager. Half Sessions: In general, I do not offer 30-minute psychotherapy sessions. The only exception to this is in the case of younger children, who may only be appropriate for half sessions. This decision is on a case-by-case basis depending on the need. Phone Sessions: In some cases, when an appointment can only be held remotely, we 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 someone on my wait-list. My hourly rate is charged as a cancelation fee for missed appointments or cancelations made less than 24 hours from any professional time spent in responding to information requests if your insurance company does not cover the scheduled time as well as for late shows (more than 10 minutes late)service. Typically they do not.

TERMINATION OF TREATMENT. Length 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 treatment: The length 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 required 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. My hourly fee is $150. In addition to weekly appointments, I charge this amount for therapy 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 determined 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. 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 personal situationaccount 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. 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 fulfill find another provider who will help you continue your therapeutic needs 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. 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 best therapeutic carename of a colleague to contact, if necessary. For your part, you agree The laws and standards of my profession require that I keep treatment records. You are entitled to participate in the process to the best receive a copy of your abilityrecords, 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. 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 intended my policy to request an agreement from parents that when they agree to give up access to 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 verballyrecords. 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 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 futureseriously harm yourself or someone else. 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 youthis case, I maywill 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, after discussing reasons I will discuss the matter with you, refer if possible, and do my best to handle any objections you may have with what I am prepared to another provider or agencydiscuss. Furthermore, I reserve At the right to terminate service if dangerous/risky behaviors are continued or if sessions are attended after consuming drugs or alcohol. Regardless end of the reason for ending your 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 will prepare a summary 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 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 unethicallyfor your parents, and we will discuss it before 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 send it 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 with. This initial session is also an opportunity for you to 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 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 my office manager. Half Sessions: In general, I do not offer 30-minute psychotherapy sessions. The only exception to this is in the case of younger children, who may only be appropriate for half sessions. This decision is on a case-by-case basis depending on the need. Phone Sessions: In some cases, when an appointment can only be held remotely, we 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 someone on my wait-list. My hourly rate is charged as a cancelation fee for missed appointments or cancelations made less than 24 hours from the scheduled time as well as for late shows (more than 10 minutes late)them.

TERMINATION OF TREATMENT. Length of treatment: The length of time required for therapy will be determined by your personal situation. I will do my best to 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 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 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 $275.00 230.00 45 Minute (Individual) Session $180.00 150.00 25 minute (Individual) Session $90.00 75.00 90 Minute Session $275.00 230.00 Additional Services- 1-30 minutes: $85.00 75.00 dollars 31-60 minutes: $170.00 150.00 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 $400300/hour Court Appearance/Testimony $2,0001,500/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 with. This initial session is also an opportunity for you to 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 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 my office manager. Half Sessions: In general, I do not offer 30-minute psychotherapy sessions. The only exception to this is in the case of younger children, who may only be appropriate for half sessions. This decision is on a case-by-case basis depending on the need. Phone Sessions: In some cases, when an appointment can only be held remotely, we 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 someone on my wait-list. My hourly rate is charged as a cancelation fee for missed appointments or cancelations made less than 24 hours from the scheduled time as well as for late shows (more than 10 minutes late).

TERMINATION OF TREATMENT. Length If I determine that I cannot provide appropriate services to you for any reason, I will terminate our treatment and refer you to other professionals. If you request and authorize it in writing, I will talk to the 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 treatment: The length of time required therapy for therapy any reason, the termination will be determined by confirmed in writing. Professional Fees: My fee for individual therapy is set at $140 per 50 minute session. Other services or no-show/late cancellation fees may have varying charges. You are expected to pay for each session at the time it is held. In addition to psychotherapy sessions, 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 personal situationwritten permission, and preparation of records or treatment summaries. The time spent performing any other service you may request of me will 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 50 minutes in length, and is the usual session duration. Insurance Reimbursement: Generally I do my best not participate in network with any insurance programs. I am licensed in Texas as a Psychologist. Your insurance company may reimburse you according to fulfill guidelines they have established for out of network providers. Your health insurance policy will usually provide some coverage for mental health treatment. I will give you a receipt after each session so you can file with your therapeutic needs and provide you with the best therapeutic careinsurance company. For your partHowever, you agree to participate in the process to the best (not your insurance company) are responsible for full payment of my fees. You are responsible for knowing what mental health services 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 verballyinsurance policy covers. If you choose to terminate therapy with mehave questions about the coverage, it will call your plan administration. Charge for Missed Appointments: There is a fee charge for missed appointments or cancellations made without 24 hour notice. The charge may be my decision as to whether we can re-establish our therapeutic relationship if you request to do so waived in the futurecase of a reasonable emergency. 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 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 request that you allow yourself/your child provide a credit card number 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 be kept on file so that you have received the HIPAA notice. X Client/Guardian Printed Name X X Client/Guardian Signature Date 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 it may be charged for all returned checks It is your responsibility to provide any missed appointments. Please see 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 with. This initial session is also an opportunity for you to 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 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 my office manager. Half Sessions: In general, I do not offer 30-minute psychotherapy sessions. The only exception to this is in the case of younger children, who may only be appropriate for half sessions. This decision is on a case-by-case basis depending on the need. Phone Sessions: In some cases, when an appointment can only be held remotely, we 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 someone on my wait-list. My hourly rate is charged as a cancelation fee for missed appointments or cancelations made less than 24 hours from the scheduled time as well as for late shows (more than 10 minutes late)charges.

TERMINATION OF TREATMENT. Length of treatment: The length of time required for therapy will be determined by your personal situation. I will do my best to 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 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 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 $275.00 250.00 45 Minute (Individual) Session $180.00 170.00 25 minute (Individual) Session $90.00 90 Minute Session $275.00 250.00 Additional Services- 1-30 minutes: $85.00 75.00 dollars 31-60 minutes: $170.00 150.00 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 with. This initial session is also an opportunity for you to 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 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 my office manager. Half Sessions: In general, I do not offer 30-minute psychotherapy sessions. The only exception to this is in the case of younger children, who may only be appropriate for half sessions. This decision is on a case-by-case basis depending on the need. Phone Sessions: In some cases, when an appointment can only be held remotely, we 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 someone on my wait-list. My hourly rate is charged as a cancelation fee for missed appointments or cancelations made less than 24 hours from the scheduled time as well as for late shows (more than 10 minutes late).