Terms & Policies

MEETINGS:

The initial session lasts approximately 60 minutes. During this time, we discuss your goals and issues related to
your seeking treatment. Upon my evaluation, we both decide whether I am the best person to provide the
services you need in order to meet your treatment goals. Should you or I decide that I am not the best person to
provide the services you are seeking, I will make an effort to refer you to another practitioner or to provide you
with advice on how to find a practitioner to best meet your needs. Sessions are generally scheduled once a week
for 50-60 minutes and this given hour is considered blocked for a particular client. If you arrive late for a
scheduled appointment, only the remainder that session will be available. If I run late with a prior appointment
for some reason, you will still receive the full amount of time. If local schools are closed due to weather
conditions, please check my voicemail to see if I will be in the office. We may need to reschedule the
appointment and you will not be billed for not attending due to inclement weather conditions.

Late Cancellation/Missed Appointment POLICY:

Clients are required to provide 24 hour notice if they need to cancel appointment. Missing an appointment
or making a late cancellation results in an open hour, loss of revenue, and disruption to the therapy process.
Therefore, a missed appointment or cancellation under 24 hours advance notice of
cancellation, will result in a $100.00 charge. Exceptions include emergencies, significant
illness, and childcare problems. You can avoid the fee if you are able to reschedule within the same week.
Please note that several missed appointments may impact your ability to maintain a specific or preferred time
slot.

Financial Policy & Insurance Reimbursement:

You are responsible for your payment at each session, unless we agree otherwise. Payment schedules for other
professional services will be agreed to when they are requested. Cash, check, or credit card is an acceptable
form of payment. There will be a $30 charge for the return of a check from the bank. Payments not received
after 90 days are subject to collections. If we do accept your insurance and you would like to file claims through
insurance, you can provide permission for us to submit claims on your behalf. If we are not a participator with
your insurance, your insurance company may reimburse you according to guidelines they have established for
out of network providers. Your health insurance policy will usually provide some coverage for mental health
treatment. We will fill out forms and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees.

Forensic and Litigative Services

It is the stated philosophy of this practice that I do not participate in lawsuits of any type on a plaintiff’s behalf,
unless compelled to do so by subpoena or court order. If you become involved in legal proceedings that require
my participation, you will be expected to pay for my professional time, including preparation, deposition,
telephone time, transportation costs, court appearance, report writing, consultation and supervision, even if I
am called to testify by another party. Because of the complexity of legal involvement, we charge $200 per hour
for preparation and attendance at any legal proceeding.

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 by and/or upsetting to untrained readers. If you wish to see your records, I recommend
you review them in my presence so that we can discuss the contents. Clients will be charged an appropriate fee
for any professional time spent in responding to information requests.

Minors

If you are under 18 years of age, please be aware that the law may provide your parents the right to examine
your treatment records. It is our policy to request that we will provide parents only with general information about our work together, unless we feel there is a high risk that you will seriously harm yourself or someone else. In this case, we will notify them of our concerns. We will also provide them with a summary of your treatment when it is complete. Before giving them any information, we will discuss the matter with you, if possible, and do our best to handle any objections you may have about it.

Confidentiality

In general, the law protects the privacy of all communications between a client and a psychologist, and I can
release information about our work to others only with your written permission. But there are a few exceptions.
There are some situations in which we are legally obligated to take action to protect others from harm, even if we
have to reveal some information about a client’s treatment. For example, if we believe that a child, elderly, or
disabled person is being abused, we are required to file a report with the appropriate state agency. If we believe
that a client is threatening serious bodily harm to another, we may be required to take protective actions. These
actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the
client. If the client threatens to harm himself or herself, we may be obligated to seek hospitalization for him or
her or to contact family members or others who can help provide protection. We will make every effort to fully
discuss this with a client before taking any action. In most legal proceedings, you have the right to prevent us
from providing any information about your treatment. In some proceedings involving child custody and those
in which your emotional condition is an important issue, a judge may order our testimony if he or she
determines that the issues demand it.