Policies and Procedures

It is important that you are aware of a few policies and procedures. Please read each item below carefully and then indicate if you accept them by signing at the bottom of the page. Please feel free to ask any questions or request additional information.

Financial arrangements

• You have been quoted the following fee: $200 / Initial Session $175 / Regular Session.
• This fee will be adjusted should your economic circumstances change. It is your responsibility to keep me informed of those changes. A review of your financial status will occur after each year of calendar year, and you may be asked to complete a financial disclosure statement and/or provide documentation regarding your finances.
• You are responsible for the payment of the fee at the time of each session. If a balance begins to accrue, services may be discontinued pending proper arrangements.
• You will be charged your regular fee for appointments not kept or cancelled without at least a 24 hour notice (48 hours if the appointment is on a Monday or day following a holiday).

Confidentiality

• All discussions between you and I are confidential. I am generally prohibited from disclosing information to other parties without your permission. If you would like information regarding your involvement with my practice to be shared with outside parties, you must sign a written request for each person to which the information is intended.

• There are three situations in which information may be released without your consent, (although if any of these circumstances were to occur I will make reasonable attempts to discuss them with you).

  • If there is imminent danger to you or others
  • If there is reason to believe that a child’s well-being or safety is compromised
  • If there is reason to believe that a dependent adult’s safety or well-being is compromised

Emergencies

• Emergency services are not provided at this office. Therefore, in the event of an unforeseen clinical emergency, please go the nearest emergency room.

Thank you for taking the time to read the policies and procedures listed here. Should you feel the need to discuss any of these matters with me please feel to do so. By signing below, you indicate that you have read, understood, and agree to the aforementioned policies and procedures, and that all questions have been answered to your satisfaction.