I am pleased and consider it a privilege to be of service to you and look forward to working with you. Please read the following information carefully and sign at the bottom. Please bring this with you for our next session.

CONFIDENTIALITY: All information disclosed in our sessions is strictly confidential and is not revealed to anyone without your written permission. However, there are circumstances where I am ethically and legally obligated to breach confidentiality. These situations are:

• If you present a serious or imminent danger to yourself or others (e.g., suicide threats, threats to hurt a specific person or persons, etc.).
• In cases of apparent abuse or neglect of a child, elderly person or a disabled person.
• When a judge orders the release of information.

Note: If you use your health insurance benefits, the insurance company will require a psychiatric diagnosis and the dates and types of service provided.

FEES: The initial visit is typically 90-minutes long (the “intake” session) and the fee is $175.00. Subsequent sessions will be $125.00 per 50-minute session. If you carry Highmark BC/BS (the only insurance policy I accept at this time), we will bill it once we have all of your information (name, date of birth, policy and group number). You are responsible for any DEDUCTIBLE and CO-PAYMENT amounts, which are to be paid at the time of service or upon receipt of an invoice. If your insurance company fails to provide reimbursement, you will be responsible for the full cost of services provided. Outstanding balances not paid within 60 days are subject to a $10.00 per month rebilling fee. Failure to pay for services will result in your charges being sent to a collection agency. Any questions about fees should be discussed with me as soon as possible.

For any services not covered by insurance (phone contact, reports, conference calls with schools or other third parties, therapy sessions etc.), you will be responsible for payment at the rate of $35 per 15 minute increment. 

• REPORTS, EVALUATIONS, ASSESSMENTS, CONSULTATIONS, AND COURT APPEARANCES: These ancillary services are frequently requested in addition to therapy. They will be billed at the rate of $130 per hour on a time-used basis.Court testimony is not covered by insurance.  Payment for travel time, waiting  time, and court time is the responsibility of the party who issues the subpoena.  A deposit of 4 hours is required to be paid no less than 48 hours before the hearing, which will also allow for other clients to be rescheduled.

•  If you provide notice of cancellation or rescheduling less than 24 hours before your appointment time, you will be charged for the appointment (your insurance will not cover this).

APPOINTMENTS: The usual sessions are 50 minutes. You will be informed if more time will be needed. Twenty-four (24) hour notice is required for cancellations. Failure to provide such notice will result in you being charged for the appointment. Your insurance will not pay for this. Like the cancellation policy indicates, there is a charge for the reservation of our time. I am unable to extend time if people are late. This ensures that therapy services are on time and available to all clients.

PLEASE NOTE: When treating a child, I am usually not able to determine which parent is responsible for payment, nor any split payment (or other provision) that may be court ordered. Whichever parent brings in the child will be responsible for payment at the time of service.

TERMINATION OF THERAPY SERVICES: Most people engaging in therapy can expect the duration to be from three months to a year (and occasionally longer if there is a severe and persistent mental illness), either on a weekly, bi-weekly or monthly basis. Termination will usually be mutually agreed upon, but you are free to terminate at any time, and I will support your decision. However, I believe that it is important for you to end well. For this reason, I strongly suggest that discuss this as early as possible when you are planning to stop. It is almost always helpful to have one or more sessions to look back on what has happened during our work together, to understand your reasons for leaving and to talk about what gains you have made. On occasion, client’s develop an aversion to exploring an issue deeply or because an issue becomes too painful or intolerable, and avoiding it to protect this most vulnerable and important material can serve as an escape. So I highly encourage you to talk with me about how you are triggered by this, rather than stop therapy. If there are unresolved issues we can plan how you will deal with them on your own. If you feel that you have not made the progress that you expected and would like see a different therapist, I will provide you with some referrals.

However, in a few special instances I may decide to stop working with you even though you wish to continue. These instances may include a failure to meet the terms of our fee agreement, a need for special services outside of the area of my competency, and prolonged failure to make progress in our work together. Should this occur, the reason for termination will be discussed with you, and you will be helped to make different plans for yourself, including a referral to a more appropriate resource.

In our sessions, you will be provided information regarding psychotherapy treatment and you have the right to additional information concerning the following:

a. the benefits of proposed treatment;

b. the way the treatment is to be administered;

c. alternative treatment modes;

d. the probable consequences of not receiving proper treatment;

e. the time period for which the Informed Consent is effective;

f. the right to withdraw the Informed Consent at any time in writing.