Therapist/Client Agreement

Before making your first appointment, please take the time to review the policies and agreements on this page.  If needed, I can set up a free 15 minute consultation to review this with you via telephone or videochat.  By making your first appointment, it is understood that you have reviewed and accepted the terms of these rights and responsibilities.

AS A CLIENT, YOU HAVE THE FOLLOWING RIGHTS:

You have the right to confidentiality.

• As explained on the Privacy and Confidentiality Page

You have the right to withdraw from client status at any time.

You have the right to ethical treatment as defined by the National Association of Social Workers.

Right to request where we contact you

• On the intake form, you must indicate where I can contact you.  You will be asked to provide where I can contact you on your home telephone, your office telephone, your cell phone, your email, or another point of contact.  You will be asked to indicate if it is acceptable to leave voicemails at these numbers.

Right to release your medical records

• Written authorization is required for your therapist to release your records.  To do this, you may complete, sign, and return the release of information form.
• You have the right to revoke the release of information at any time.
• Revocation is not valid to the extent your therapist has already acted on the release of information prior to its being revoked.

Right to inspect and copy your medical billing records

• You have the right to inspect and copy any billing records we have, related to your services.
• We have the right to decline such request if it is deemed that honoring that request would be harmful to you in some way.
• If the request is honored, you will be responsible to cover the costs of copying, mailing, etc.

Right to add information or amend your medical records

• You may request to make an amendment to your records, and this request must be in writing.
• The request may be denied if it clearly contradicts factual information in the record.
• If the amendment is denied, you have the right to file a disagreement statement.
• The disagreement statement and your therapist's response to it will be filed in the medical record.

Right to accounting of disclosures

• When your therapist discloses your information based on your request to do so, she may keep some records of who she sent it to, when she sent it, and what she sent.  You can get an accounting (a list) of many of these disclosures.

Right to request restrictions on uses and disclosures of your healthcare information

• You may request certain restrictions on how your information is used and disclosed; however, I am not obligated to agree if it is deemed inappropriate or harmful in some way.

Right to complain

• If you have a complaint, I request you first address it with me (your therapist) to see if we can resolve it.
• If you still feel unsatisfied, you may contact the U.S. Department of Health and Human Services.

Right to receive changes in policy

• There may be a time or times when I update practice policies and procedures and you are entitled to a copy of those changes.

AS A CLIENT, YOU HAVE THE FOLLOWING RESPONSIBILITIES:

1. You have the responsibility to keep your scheduled appointment.   

   a. Any missed appointment not cancelled with at least 24 hours notice will result in 100% of your regular session fee being due.

   b. Telephone and Videochat clients may CALL or EMAIL to cancel their appointment and the automatic date/time stamp will be used.

   c. Email clients do not need to cancel, as appointments are not scheduled for those services.

2. You have the responsibility to take charge of your own growth. The therapy process is designed to support you and encourage you to make positive changes in your life, not to make those positive changes for you.
3. You have the responsibility to obtain help in an emergency, as described in the options for obtaining emergency or crisis assistance.

IN MAKING YOUR FIRST & SUBSEQUENT APPOINTMENTS, YOU UNDERSTAND:

1. You understand engaging in therapy/ counseling is a voluntary process, and you can terminate your therapy at any tine preferably by informing me of your desire to end therapy.
2. You understand results of any kind are NOT guaranteed.  However, we DO assure you that you will be offered support, encouragement, feedback, and treatment suggestions to you when appropriate, and will work with you to help you achieve your therapy goals.
3. You understand you must cancel your appointment 24 hours in advance; otherwise, you will be responsible for paying for the missed session.
4. You understand if you arrive late for your scheduled appointment, the session will end at the regularly scheduled time, and the full amount for that session will still be due.
5. You understand, in receiving therapy, there may be periods of emotional discomfort either during or between our sessions.
6. You understand that clinical records will be maintained as long as you are my client.  After a period of six months of not engaging with you for therapy, all records will be destroyed by shredding.  If you return as a client after that time, a new file will need to be created.
7. You understand, while I have a broad knowledge about a variety of clinical issues, I am not a specialist for every possible clinical diagnosis.  Therefore, in keeping with generally accepted standards of practice, there may be occasions when I might consult with other mental health professionals regarding the management of your case.  The purpose of this consultation is to ensure quality of care, and during these consultations every effort will be made to protect your identity and maintain your confidentiality.
8. You understand all prepaid fees for all services are NON-REFUNDABLE. There are no exceptions.
9. You understand sessions purchased in multiples are good for one year from the date of purchase.  (For example, if you purchase 5 email sessions, you do not have to use them all at once.  You could use one or two now, then six months later use the rest if you choose. Keep in mind, therapy is most effective when it is consistent over a substantial period of time based on your needs and treatment plan.)
10. You understand that in cases where there may be technical difficulties preventing our scheduled session (e.g., power failure, internet down, etc.), the session will be rescheduled for another time. (a) If the difficulty is on our end, your therapist will telephone you to inform you of the problem as soon as possible, but no later than the scheduled time.  If you go online to the designated videochat session and your therapist does not show up within 10 minutes, please have available the telephone you list as your primary contact so your therapist can call you during that time. (b) If the difficulty is on your end, you must telephone me to inform of the problem no later than the scheduled appointment time or 10 minutes thereafter.  If you do not telephone me by the time our session would have ended, you will be charged for that session as a missed appointment.
11. You understand that I do not offer a sliding scale fee for any telephone, videochat, or email therapy services.  All fees are listed on the Rates & Insurance page of my website.  You can, however, purchase packages of sessions or emails, and the more sessions you purchase at one time the lower the individual session price.