Common use of Client Services Agreement Clause in Contracts

Client Services Agreement. Welcome to my practice. This document (the Agreement) contains important information about my professional services and business policies. Therapy services offered by ▇▇▇▇▇▇ ▇▇▇▇▇▇▇, LMFT include evaluation, assessment, consultation, psychotherapy, and intervention. The use of such services varies depending upon particular problems you are experiencing or issues you hope to address. Psychotherapy is not like medical doctor visits. Instead, a very active effort on your part is required for improvement. In order for the psychotherapy to be most successful, you will have to work on things we talk about both during our sessions and at home. My sincere hope is that the therapy I provide will be of help to you. However, as with all medical and psychological treatment, there may risks and benefits. Therapy sometimes may lead to increased emotional distress. Other risks include possible disagreement with my professional opinion. Clients are advised that there are a variety of psychological services or treatment alternatives for any given problem. On the other hand, potential benefits of psychological services may include obtaining a professional opinion and an increased understanding of yourself, which may help resolve your problems and decrease emotional distress. However, there are no guarantees of results or improvement in any condition. Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and, if you enter into psychotherapy, a treatment plan to follow. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Psychotherapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to assist you in locating another mental health professional for a second opinion. Initial: _ ▇▇▇ ▇. ▇▇▇▇▇ ▇▇▇. Unit H. Grover Beach, CA 93433 * (▇▇▇) ▇▇▇-▇▇▇▇ * ▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ Each appointment hour is a 50-60 minute session. My initial assessment will last from 2 to 3 sessions. During this time, we can both decide if I am the best person to provide the services that you need in order to meet your treatment goals. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation, or you will be responsible for the full fee for the missed appointment. My fees are based on one (1) appointment hour of 50-60 minutes duration. My fee is $150 for individual psychotherapy. My fee for couples/conjoint/and families is $175 per session. In addition to appointments, I charge $120.00-$500 for other professional services you may need, though I will break down the hourly cost if I work for periods of less than 45 minutes. Such services include report writing, telephone conversations lasting longer than 15 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of me or that is necessary to provide effective clinical care. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $200-$500 per hour for review or preparation of documents, testimony, office depositions, and attendance at any legal proceeding.

Client Services Agreement. Welcome to my practice. This document (the Agreement) contains important information about my professional services and business policies. Therapy services offered by ▇▇▇▇▇▇ ▇▇▇▇▇▇▇, LMFT include evaluation, assessment, consultation, psychotherapy, and intervention. The use of such services varies depending upon particular problems you are experiencing or issues you hope to address. Psychotherapy is not like medical doctor visits. Instead, a very active effort on your part is required for improvement. In order for the psychotherapy to be most successful, you will have to work on things we talk about both during our sessions and at home. My sincere hope is that the therapy I provide will be of help to you. However, as with all medical and psychological treatment, there may risks and benefits. Therapy sometimes may lead to increased emotional distress. Other risks include possible disagreement with my professional opinion. Clients are advised that there are a variety of psychological services or treatment alternatives for any given problem. On the other hand, potential benefits of psychological services may include obtaining a professional opinion and an increased understanding of yourself, which may help resolve your problems and decrease emotional distress. However, there are no guarantees of what you will experience or of results or improvement in any condition. Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and, if you enter into psychotherapy, a treatment plan to follow. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Psychotherapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to assist you in locating another mental health professional for a second opinion. Initial: _ ▇▇▇ ▇. ▇▇▇ ▇▇, ▇▇▇▇ ▇▇ ▇▇▇▇▇▇ ▇▇▇. Unit H. Grover Beach▇▇, CA 93433 ▇▇ ▇▇▇▇▇ * (▇▇▇) ▇▇▇-▇▇▇▇ * ▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ Each appointment hour is a 50-60 50 minute session. My initial assessment I normally conduct an evaluation that will last from 2 to 3 sessions. During this time, we can both decide if I am the best person to provide the services that you need in order to meet your treatment goals. If psychotherapy is begun, I will usually schedule one 50 minute session per week at a time we agree on, although the frequency of sessions may vary. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation, or you will be responsible for the full fee for the missed appointment. My fees are based on one (1) appointment hour of 50-60 50 minutes duration. My fee is $150 for individual psychotherapy. My fee for couples/conjoint/and families is $175 per session. In addition to appointments, I charge $120.00-$500 120.00-$250 for other professional services you may need, though I will break down the hourly cost if I work for periods of less than 45 minutes. Such services include report writing, telephone conversations lasting longer than 15 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of me or that is necessary to provide effective clinical care. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $200-$500 per hour for review or preparation of documents, testimony, office depositions, and attendance at any legal proceeding. Due to my work schedule, I am often not immediately available by telephone. My phone is answered by voice mail when I am unavailable, however, it is often difficult to check messages until the end of the day. If you leave a message, I will make every effort to respond in a timely manner, usually within 24 hours, except for weekends and holidays. Telephone contact should be limited to canceling, rescheduling, and confirming appointments, obtaining directions, or other pertinent information. In such cases, I may return your call the next business day. In the rare emergency where we have an extended phone conversation over 15 minutes, Initial: _ you will be charged a pro-rated amount of my hourly fee. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and you feel that you cannot wait for me to return your call or it is a life threatening emergency, please call 911 and/or contact the nearest emergency room. Please then contact me at your earliest possible convenience. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. The law protects the privacy of all communications between a client and a Licensed Marriage and Family Therapist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by state law and/or HIPAA. However, there are some situations where I am permitted or required to disclose information without either your consent or Authorization:  I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you do not object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record.  Although I share office space with other health professionals in this office, I am completely independent in providing you with clinical services and I alone am fully responsible for those services.  If you threaten to harm yourself, I may be obligated to seek hospitalization for you, or to contact your family members or others who can help provide protection.  If you are involved in a court proceeding and a request is made for information about the professional services that I have provided you and/or the records thereof, such information is protected by psychotherapist-patient privilege law. I cannot provide any information without your (or your legally-appointed representative’s) written authorization, a court order, or compulsory process (a subpoena) or discovery request from another party to the court proceeding where that party has given you proper notice (when required), has stated valid legal grounds for obtaining PHI, and I do not have grounds for objecting under state law (or you have instructed me not to object). If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information.  If a government agency is requesting the information for health oversight activities pursuant to their legal authority, I may be required to provide it for them.  If you file a complaint or lawsuit against me, I may disclose relevant information regarding you in order to defend myself.  If you file a worker’s compensation claim, I must, upon appropriate request, disclose information relevant to your condition, to the worker’s compensation insurer.  There are some situations in which I am legally obligated to take actions that which I believe are necessary to attempt to protect others from harm. In such situations, I may have to reveal some information about your treatment. These situations are unusual in my practice. They include the following:  If I have knowledge of a child under 18 or I reasonably suspect that a child under 18 that I have observed has been the victim of child abuse or neglect, the law requires that I file a report with the appropriate governmental agency, usually the county welfare department. I also may make a report if I know or reasonably suspect that mental suffering has been inflicted upon a child or that his or her emotional well- being is endangered in any other way (other than physical or sexual abuse, or neglect). Once such a report is filed, I may be required to provide additional information.  If I observe or have knowledge of an incident that reasonably appears to be physical abuse, abandonment, abduction, isolation, financial abuse or neglect of an elder or dependent adult, or if an elder or dependent adult credibly reports that he or she has experienced behavior including an act or omission constituting physical abuse, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, the law requires that I report to the appropriate government agency. Once such a report is filed, I may be required to provide additional information.  If you communicate a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization for you, or contact others who can assist in protecting the victim. I am also required to take such protective actions described above if your family informs me that you communicated a serious threat of physical violence against an identifiable victim.  If I have reasonable cause to believe that you are in such mental or emotional condition as to be dangerous to yourself, I may be obligated to take protective action, including seeking hospitalization or contacting family members or others who can help provide protection. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed. The laws and standards of my profession require that I keep Protected Health Information (PHI) about you in your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that disclosure would physically endanger you and/or others or makes reference to another person (unless such other person is a health care provider) and I believe that access is reasonably likely to cause substantial harm to such other person or where information has been supplied to me confidentially by others, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. There will be a copying fee of 35 cents per page. If I refuse your request for access to your records, you have a right of review, (except for information supplied to me confidentially by others) which I will discuss with you upon request. Patients under 18 years of age who are not emancipated can consent to psychological services subject to the involvement of their parents or guardian unless the therapist determines that their involvement would be inappropriate. A patient over age 12 may consent to psychological services if he or she is mature enough to participate intelligently in such services, and the minor patient either would present a danger of serious physical or mental harm to him or herself or others, or is the alleged victim of incest or child abuse. In addition, patients over age 12 may consent to alcohol and drug treatment in some circumstances. However, un-emancipated patients under 18 years of age and their parents should be aware that the law may allow parents to examine their child’s treatment records unless I determine that access would have a detrimental effect on my professional relationship with the patient, or to his/her physical safety or psychological well- being. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, and parental involvement, is also essential, it is usually my policy to request an agreement with minors (over age 12) and their parents about access to information. This agreement provides that during treatment, I will provide parents with only with general information about the progress of the treatment, and the patient’s attendance at scheduled sessions. In some instances, I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.

Client Services Agreement. Welcome to my practice. This document (the Agreement) contains important information about my professional services and business policies. Therapy services offered It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a new federal law that provides new privacy protection and new patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment and health care operations. HIPPA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information at the end of this session. Although these documents are long and sometimes complex, it is very important that you read them carefully before our next session. We can discuss any questions you have about the procedures at that time. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have taken action in reliance on it; if there are obligations imposed on me by ▇▇▇▇▇▇ ▇▇▇▇▇▇▇, LMFT include evaluation, assessment, consultation, psychotherapyyour health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the counselor and client, and intervention. The use of such services varies depending upon the particular problems you are experiencing or issues experiencing. There are many different methods I may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visitsvisit. Instead, it calls for a very active effort on your part is required for improvementpart. In order for the psychotherapy therapy to be most successful, you will have to work on things we talk about both during our sessions and at home. My sincere hope is that the Psychotherapy can have benefits and risks. Since therapy I provide will be often involves discussing unpleasant aspects of help to you. Howeveryour life, as with all medical you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and psychological treatment, there may risks and benefits. Therapy sometimes may lead to increased emotional distress. Other risks include possible disagreement with my professional opinion. Clients are advised that there are a variety of psychological services or treatment alternatives for any given problemhelplessness. On the other hand, potential benefits psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of psychological services may include obtaining a professional opinion and an increased understanding of yourself, which may help resolve your problems and decrease emotional distress. However, But there are no guarantees of results or improvement in any conditionwhat you will experience. Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and, if you enter into psychotherapy, and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Psychotherapy Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to assist help you in locating set up a meeting with another mental health professional for a second opinion. Initial: _ ▇▇▇ ▇. ▇▇▇▇▇ ▇▇▇. Unit H. Grover Beach, CA 93433 * (▇▇▇) ▇▇▇-▇▇▇▇ * ▇▇▇▇▇▇▇▇▇▇@▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ Each appointment hour is a 50-60 minute session. My initial assessment will last from 2 to 3 sessions. During this time, we can both decide if I am the best person to provide the services that you need in order to meet your treatment goals. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation, or you will be responsible for the full fee for the missed appointment. My fees are based on one (1) appointment hour of 50-60 minutes duration. My fee is $150 for individual psychotherapy. My fee for couples/conjoint/and families is $175 per session. In addition to appointments, I charge $120.00-$500 for other professional services you may need, though I will break down the hourly cost if I work for periods of less than 45 minutes. Such services include report writing, telephone conversations lasting longer than 15 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of me or that is necessary to provide effective clinical care. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $200-$500 per hour for review or preparation of documents, testimony, office depositions, and attendance at any legal proceeding.