COUNSELING & FINANCIAL AGREEMENT
understand that whatever transpires between myself and my therapist is
confidential. The therapist will not release any information about my
therapy unless I agree in writing to permit such release. The therapist
does have the right and responsibility to inform the proper persons and/or
authorities if I intend to harm myself or another person(s), or if I inform
her of child abuse.
I will call the office
for information about your fee schedule. I understand that payment for
therapeutic services is to be made at each session including insurance
co-payment. If I have insurance, I will be reimbursed for fees already
paid to my therapist. I understand that if I have a session of extended
length, I also agree to pay the additional fee for that session.
understand my appointment time is reserved for me. If I need to cancel
an appointment, I understand a minimum of 24 hours is required or a charge
equivalent to my regular session fee will be made. I understand, also,
that your Phone Message Center is always available to take messages on
a 24 hour basis. I will be sure to page you if it is necessary to cancel
or reschedule an appointment.
I understand my therapist will be available for telephone calls and will
return them at the earliest opportunity. Calls exceeding 10 minutes will
be considered a counseling session and will be charged accordingly.