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Capistrano Bay Counseling Center

CLIENT/THERAPIST COUNSELING & FINANCIAL AGREEMENT

STATEMENT OF CONFIDENTIALITY
I 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.

FEES
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.

CANCELLATION OF SESSIONS
I 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.

PHONE CONSULTATION
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.

 

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