Common use of Counseling Services Clause in Contracts

Counseling Services. Counseling is not easily described in general statements. It varies depending on the per- sonalities of the counselor and client, and the particular problems you are experiencing. There are many different methods I may use to deal with problems you want to address. Counseling calls for an active effort on your part. It is most successful when you work on things we talk about during our sessions and in between sessions. Counseling can have benefits and risks. Since it often involves discussing unpleasant as- pects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustra- tion, loneliness, and helplessness. On the other hand, counseling has been shown to have many benefits. It often leads to better relationships, solutions to specific problems, and significant re- ductions in feelings of distress. Often, with counseling, people know themselves better and live happier, more fulfilling lives. There are no guarantees of what you will experience. COUNSELING SESSIONS Our first few sessions will involve an evaluation of your needs. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treat- ment goals. I will offer my impressions of what our work will include and make suggestions for a treatment plan. Please evaluate this information and decide whether you feel comfortable work- ing with me. Counseling involves a large commitment of time, money, and energy, so be mindful about the therapist you choose. If you have questions about my procedures, we can discuss them at any time. If your doubts persist, you may consult with another mental health professional for a second opinion. If we work together, I will usually schedule one 50-minute session per week at a time we agree on, although sessions may be longer or more frequent. Once an appointment is sched- uled, you will be expected to pay for it unless you provide at least 24 hours advance notice of cancellation. Please note that insurance companies do not provide reimbursement for cancelled sessions. If possible, I will find another time to reschedule your appointment.

Counseling Services. Counseling is not easily described in general statements. It varies depending on the per- sonalities personalities of the counselor and client, and the particular problems you are experiencingbring forward. There are many different methods I may use to deal with the problems that you want hope to address. Counseling is not like a visit to your family doctor. Instead, it calls for an a very active effort on your part. It is In order for the counseling to be most successful when successful, you will have to work on things we talk about both during our sessions and in between sessionsat home. Counseling can have benefits and risks. Since it counseling often involves discussing unpleasant as- pects aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustra- tionfrustration, loneliness, and helplessness. On the other hand, counseling has also been shown to have many benefitsbenefits for people who go through it. It Counseling often leads to better relationships, solutions to specific problems, and significant re- ductions reductions in feelings of distress. Often, with counseling, people know themselves better and live happier, more fulfilling lives. There But there are no guarantees of what you will experience. COUNSELING SESSIONS Our first few sessions will involve an evaluation During the time of your needs. During this timeinitial assessment, we can both decide if I am the best person to provide the services you need in order to meet your treat- ment treatment goals. I will offer my impressions of what our work will include and make suggestions for a treatment plan. Please evaluate this information and decide whether you feel comfortable work- ing with me. Counseling involves a large commitment of time, money, and energy, so be mindful about the therapist you choose. If you have questions about my procedures, we can discuss them at any time. If your doubts persist, you may consult with another mental health professional for a second opinion. If we work togethercounseling is begun, I will usually schedule one 50-minute session per week appointment hour of not more than 50 minutes duration at a frequency and time we agree on, although some sessions may be longer or more frequentfrequency may change. Once an appointment hour is sched- uledscheduled, you will be expected to attend unless you provide 24 hours advance notice of cancellation, or unless we both agree that you were unable to attend due to circumstances beyond your control. You will be expected to pay $50 if you cancel less than 24 hours in advance and $70 if you provide no notice of cancellation since insurance providers do not pay for missed sessions. PROFESSIONAL FEES All fees and co-pays are due at time of service Mental Health/Substance Abuse Evaluation $185 for 45 - 50 minute session Individual / Couples Counseling Session $135 for 45 - 50 minute session Attendance At Any legal Proceeding (including preparation, travel to and from court, and time spent at the legal proceeding) $200 per hour Consultation (including report writing, phone conversation, text or email over 10 minutes) $60 per hour BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held unless you have insurance coverage. If you have insurance coverage, I will accept the insurance reimbursement for covered services and will only expect co-pay fees, if any, to be paid at the time of service unless we agree otherwise. In circumstances of unusual financial hardship, I may be willing to negotiate a payment installment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve going through small claims court. If such legal action is necessary, its costs will be included in the claim. In most collection situations, the only information I release regarding a client's treatment is his or her name, the nature of services provided, and the amount due. INSURANCE REIMBURSEMENT In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. For example, certain insurance providers may not allow some services and you will be expected to pay for it unless all services not covered by your insurance plan. It is very important that you provide at least 24 hours advance notice of cancellationfind out exactly what mental health services your insurance policy covers. Please note You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. CONTACTING ME I am sometimes not provide reimbursement for cancelled sessionsimmediately available by telephone. I probably will not answer the phone when I am with a client. When I am unavailable, my telephone is answered by voice mail that I continually monitor. I will return your call on the same day. If possibleyou are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or call Rescue Mental Health Services at 419.255.2801. If it is an emergency, call 911 or go to the nearest emergency room and ask for the psychiatrist on call. If I will be unavailable for an extended time, I will find another time provide you with the name of a colleague to reschedule your appointmentcontact, if necessary.

Counseling Services. Counseling Your first appointment (or more, in some cases) will involve an assessment of your needs. By the end of the assessment your counselor will be able to offer you some first impressions of what your work may include and recommendations for getting help. One of the recommendations may be psychotherapy. If so, ABO may or may not be able to provide you with psychotherapy, depending on your overall needs. If psychotherapy or any other recommendations suggested by your counselor include things that ABO cannot provide, you will be given suggestions of where you might receive those services. Wherever you choose to obtain treatment, you should evaluate the information from your initial assessment along with your own opinions of what sort of treatment you are willing to do and whether you feel comfortable working with the treating clinician. Therapy involves a large commitment of time, energy, and often money, so you should be very careful about the therapist you select. If you have questions about the procedures used or conclusions made by your counselor at ABO, please discuss them whenever they arise. If your doubts persist, your counselor will be happy to help you set up a meeting with another mental health professional for a second opinion. Psychotherapy is not easily described in general statements. It varies depending on the per- sonalities particular problems you are experiencing, the therapeutic methods used by your counselor, and the personalities of the counselor and client, and the particular problems you are experiencing. There are many different methods I counselors may use to deal with the problems that you want hope to address. Counseling Psychotherapy is not like a medical doctor visit. Instead, it calls for an a very active effort on your part. It is In order for the therapy to be most successful when successful, you will have to work on things we talk about that are discussed both during our your sessions and in between sessionson your own. Counseling Psychotherapy can have benefits and risks. Since it therapy often involves discussing unpleasant as- pects aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustra- tionshame, frustration, loneliness, and helplessness. On the other hand, counseling The changes you make in therapy may also affect your relationships in unexpected ways. Psychotherapy has also been shown to have many benefits. It Therapy often leads to better relationships, solutions to specific problems, and significant re- ductions reductions in feelings of distress. Often, with counseling, people know themselves better and live happier, more fulfilling lives. There But there are no guarantees of what you will experience. COUNSELING SESSIONS Our first few sessions MEETINGS The initial assessment will involve an evaluation of your needslast from one to two sessions. During this time, we you and your counselor can both decide if I am she/he is the best person to provide the services you need in order to meet your treat- ment treatment goals. I will offer my impressions of what our work will include and make suggestions for a treatment plan. Please evaluate this information and decide whether you feel comfortable work- ing with me. Counseling involves a large commitment of timeIf psychotherapy is begun, money, and energy, so be mindful about the therapist you choose. If you have questions about my procedures, we can discuss them at any time. If your doubts persist, you may consult with another mental health professional for a second opinion. If we work together, I counselor will usually schedule one 50-minute session meeting per week at a time we you each agree on, although sessions may be longer or more frequent. Once an appointment is sched- uledscheduled, you will be expected to pay for it attend unless you provide at least 24 hours advance notice of cancellation. Please note If you need to cancel an appointment, it is your responsibility to contact us to cancel. PROFESSIONAL FEES Fees will be collected when services are rendered. In addition to therapy services fees may include assessment administration, scoring, and reporting; creating reports; creating copies of records on request; and consulting with other professionals at the client’s request. There will be an additional $25 fee assessed for any returned check. CHANGES AND CANCELLATIONS We understand that there are unforeseeable circumstances like sick children or bad weather. Your appointment is important though, and your therapist is happy to contact you for a phone session or a session via our HIPPA-compliant virtual therapy system so you don't need to leave your sick child or worry about traffic and weather. As long as you are in a confidential location, we can help you keep your regularly scheduled appointment. If you still must change or cancel your counseling appointment please know: • Cancellations must be made during business hours. • Cancellations must be made within 48 hours of session time if using our online scheduling program. • We cannot accommodate cancellations made via email as we do not monitor email on a regular basis. • We cannot accommodate cancellations made after hours or on holidays to our main number as we do not accept voice mail. If you have an appointment on a Monday or the first day following a holiday, you must make your change or cancellation the last business day before your appointment. • Cancellations with less than 24 hours notice will result in a fee equal to the total amount of the missed session that will be collected at your next appointment, or, if payment information is on file, it will be debited from your credit card. • After two no-shows/late cancellations, you will pre-pay a retainer before scheduling any future appointments. • Clients who have pre-paid agree to have the entire fee deducted from their pre-payment in cases of other no-shows and late changes/cancellations. COURT TESTIMONY • Court testimony costs begin at $250 per hour with a minimum charge of three hours. A retainer of $1000 is due one week prior to the court date. Travel is billed at .55/mile. Failure to provide the specific fees as described constitutes a release from the requested court appearance. • It is required that a minimum of 36 hours’ notice be given if the testimony is not required, otherwise the entire retainer is forfeited. If proper notice is given, the retainer will be refunded. • Additional services related to court preparation including all correspondence with attorneys or other service providers via phone, email, or letter, documentation review and/or documentation preparation are also billed at $250 per hour, rounded to the nearest 15 minute increment. You (not your insurance companies company) are responsible for full payment of fees. It is very important that you find out exactly what mental health services your insurance policy covers. You must pay your xxxx first, then contact your insurance company regarding reimbursement. CONTACTING US We answer our main office number 8:00 AM – 5:00 PM Monday through Friday (except holidays). You may have your counselor’s cell phone number in order to coordinate administrative tasks (defined as appointment arrival, appointment time, and directions). Email, and text messaging are not secure mediums in terms of privacy and confidentiality so our policy regarding, electronic communication, and cell phone use includes the following: • We do not provide reimbursement therapy/counseling via email or text messaging. • Text messaging and email will be used for cancelled sessionsadministrative tasks only (as defined above). • Therapists may not acknowledge or return emails or text messages that are not administrative. This includes emergency texts and emails. • If possible, I your therapist leaves for an extended period of time you will find be given the information for another time to reschedule licensed therapist with whom you may schedule if you need an appointment during your appointmenttherapist’s absence.

Counseling Services. Counseling People choose to participate in counseling for a variety of reasons. For most, the purpose of counseling is not easily described to generally improve one’s overall quality of life by addressing issues of concern, such as anxiety, depression, marital difficulties, addiction, or grief. Individual experiences in general statements. It varies counseling can be different, depending on factors such as the per- sonalities personalities of the counselor client and clienttherapist, the mode of counseling techniques that the therapist utilizes, the issue(s) being addressed, and the particular problems amount of effort that the client puts forth. Your initial sessions with Encourage Counseling Services will involve an evaluation of your needs. By the end of the evaluation, your therapist will be able to offer you are experiencingsome first impressions of what your work will include and a treatment plan to follow, if you decide to continue with therapy. There are many different methods I You should evaluate this information along with your own opinions of whether you feel comfortable working with us. Therapy involves a commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about our procedures, you should discuss them with your therapist whenever they arise. If you wish, we will willingly provide you with referrals to other mental health professionals for a second opinion, as you always have the right to choose to continue to receive counseling services from us or to ask to be referred to someone else. Following the assessment period, which is typically one to two sessions, one 50-minute session will be scheduled per week. Sessions will occur at a time you and your therapist agree upon, although sessions may use be scheduled more or less frequently according to deal with problems you want to address. Counseling calls for an active effort on your partneeds. It is most successful when important to note that if you work on things we talk about during our sessions and in between sessionsare late to your appointment, your session will still end at the originally scheduled time. Counseling It should be noted that therapy can have benefits and benefits, as well as potential risks. Since it often therapy oftentimes involves discussing unpleasant as- pects difficult aspects of your life, you may experience uncomfortable feelings like such as sadness, guilt, anger, frustra- tionfrustration, loneliness, and helplessness. On the other handMaking changes in your beliefs or behaviors can be anxiety provoking, counseling and can be disruptive to your current relationships. However, therapy has also been shown to have many benefits. It For example, therapy often leads to better relationships, solutions to specific problems, and significant re- ductions reductions in feelings of distress. OftenOf course, with counseling, people know themselves better every individual’s experience is different and live happier, more fulfilling lives. There there are no guarantees of what you will experience. COUNSELING SESSIONS Our first It is important that you carefully consider whether these risks are worth the benefits to you of changing. Most people who take these risks find that therapy is helpful. Finally, the therapeutic relationship is ended after the last scheduled appointment, or when so stated by you or your therapist. As the client, you typically will be the one who decides when therapy will end, which usually occurs once you and your therapist agree that you have met your treatment goals. However, there are a few sessions will involve an evaluation of exceptions. One such exception is if your therapist does not believe that he/she is professionally able to meet your needs. During this timeThis could possibly be because your therapist does not believe that he/she holds the proper training and skills to help you, we can both decide if I am due to the best person type of presenting problem that you have. In such a situation your therapist will refer you to provide the services you need in order another therapist who may be able to meet your treat- ment goals. I will offer my impressions of what our work will include and make suggestions for a treatment plan. Please evaluate this information and decide whether you feel comfortable work- ing with me. Counseling involves a large commitment of time, money, and energy, so be mindful about the therapist you choose. If you have questions about my procedures, we can discuss them at any time. If your doubts persist, you may consult with another mental health professional for a second opinion. If we work together, I will usually schedule one 50-minute session per week at a time we agree on, although sessions may be longer or more frequent. Once an appointment is sched- uled, you will be expected to pay for it unless you provide at least 24 hours advance notice of cancellation. Please note that insurance companies do not provide reimbursement for cancelled sessions. If possible, I will find another time to reschedule your appointmentcounseling needs.

Counseling Services. Counseling Your first appointment (or more, in some cases) will involve an assessment of your needs. By the end of the assessment Xxxx Xxxxxx will be able to offer you some first impressions of what your work may include and recommendations for getting help. One of the recommendations may be psychotherapy. If so, Xxxx Xxxxxx may or may not be able to provide you with psychotherapy, depending on your overall needs. If psychotherapy or any other recommendations suggested by your counselor include things that Xxxx Xxxxxx Counseling, Inc. cannot provide, you will be given suggestions of where you might receive those services. Wherever you choose to obtain treatment, you should evaluate the information from your initial assessment along with your own opinions of what sort of treatment you are willing to do and whether you feel comfortable working with Xxxx Xxxxxx. Therapy involves a large commitment of time, energy, and often money, so you should be very careful about the therapist you select. If you have questions about the procedures used or conclusions made by Xxxx Xxxxxx, please discuss them whenever they arise. If your doubts persist, your counselor will be happy to help you set up a meeting with another mental health professional for a second opinion. Psychotherapy is not easily described in general statements. It varies depending on the per- sonalities particular problems you are experiencing, the therapeutic methods used by your counselor, and the personalities of the counselor and client, and the particular problems you are experiencing. There are many different methods I counselors may use to deal with the problems that you want hope to address. Counseling Psychotherapy is not like a medical doctor visit. Instead, it calls for an a very active effort on your part. It is In order for the therapy to be most successful when successful, you will have to work on things we talk about that are discussed both during our your sessions and in between sessionson your own. Counseling Psychotherapy can have benefits and risks. Since it therapy often involves discussing unpleasant as- pects aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustra- tionshame, frustration, loneliness, and helplessness. On the other hand, counseling The changes you make in therapy may also affect your relationships in unexpected ways. Psychotherapy has also been shown to have many benefits. It Therapy often leads to better relationships, solutions to specific problems, and significant re- ductions reductions in feelings of distress. Often, with counseling, people know themselves better and live happier, more fulfilling lives. There But there are no guarantees of what you will experience. COUNSELING SESSIONS Our first few sessions MEETINGS The initial assessment will involve an evaluation of your needslast from one to two sessions. During this time, we you and Xxxx Xxxxxx can both decide if I am she is the best person to provide the services you need in order to meet your treat- ment treatment goals. I will offer my impressions of what our work will include and make suggestions for a treatment plan. Please evaluate this information and decide whether you feel comfortable work- ing with me. Counseling involves a large commitment of time, money, and energy, so be mindful about the therapist you choose. If you have questions about my procedures, we can discuss them at any time. If your doubts persist, you may consult with another mental health professional for a second opinion. If we work together, I will usually psychotherapy is begun it is typical to schedule one 50-minute session meeting per week at a time we you each agree on, although sessions may be longer or more frequent. Once an appointment is sched- uledscheduled, you will be expected to pay for it attend unless you provide at least 24 hours advance notice of cancellation. Please note If you need to cancel an appointment, it is your responsibility to contact us to cancel. PROFESSIONAL FEES Fees will be collected when services are rendered. The fee per 50 minute counseling session is $135, and will be adjusted accordingly when 50 minutes is exceeded. In addition to therapy services fees may include creating reports; creating copies of records on request; and consulting with other professionals at the client’s request. There will be an additional $25 fee assessed for any returned check. CHANGES AND CANCELLATIONS We understand that there are unforeseeable circumstances like sick children or bad weather. Your appointment is important though, and Xxxx Xxxxxx is happy to contact you for a phone session or a session via our HIPPA-compliant virtual therapy system so you don't need to leave your sick child or worry about traffic and weather. As long as you are in a confidential location, we can help you keep your regularly scheduled appointment. If you still must change or cancel your counseling appointment, please know: ● Cancellations must be made within 24 hours of session time. ● We cannot accommodate cancellations made via email as we do not monitor email on a regular basis. ● We cannot accommodate cancellations made after hours or on holidays. If you have an appointment on a Monday or the first day following a holiday, you must make your change or cancellation the last business day before your appointment. ● Cancellations with less than 24 hours’ notice will result in a $90 fee that will be collected at your next appointment, or, if payment information is on file, it will be debited from your credit card. ● After two no-shows/late cancellations, a pre-paid retainer will be required before scheduling any future appointments. ● Clients who have pre-paid agree to have the entire fee deducted from their pre-payment in cases of other no-shows and late changes/cancellations. COURT TESTIMONY ● Court testimony costs begin at $300 per hour with a minimum charge of three hours. A retainer of $1000 is due one week prior to the court date. Travel is billed at .55/mile. Failure to provide the specific fees as described constitutes a release from the requested court appearance. ● It is required that a minimum of 36 hours notice be given if the testimony is not required, otherwise the entire retainer is forfeited. If proper notice is given, the retainer will be refunded. ● Additional services related to court preparation including all correspondence with attorneys or other service providers via phone, email, or letter, documentation review and/or documentation preparation are also billed at $300 per hour, rounded to the nearest 15-minute increment. You (not your insurance companies company) are responsible for full payment of fees. It is very important that you find out exactly what mental health services your insurance policy covers. You must pay your xxxx first, then contact your insurance company regarding reimbursement. CONTACTING US You can contact our main office number (281-350-1277) 24 hours a day/7 days a week. If an administrative assistant or Xxxx Xxxxxx, does not answer, please leave a message on the internal/secure voicemail system. Messages are typically returned within 24 hours during the business week, or 48 hours for messages left on the weekend. You may have your counselor’s cell phone number in order to coordinate administrative tasks (defined as appointment arrival, appointment time, and directions). Email, and text messaging are not secure mediums in terms of privacy and confidentiality so our policy regarding, electronic communication, and cell phone use includes the following: ● We do not provide reimbursement therapy/counseling via email or text messaging. ● Text messaging and email will be used for cancelled sessionsadministrative tasks only (as defined above). ● Xxxx Xxxxxx Counseling, Inc., may not acknowledge or return emails or text messages that are not administrative. This includes emergency texts and emails. ● If possible, I Xxxx Xxxxxx leaves for an extended period of time you will find be given the information for another time to reschedule licensed therapist with whom you may schedule if you need an appointment during your appointmenttherapist’s absence.

Counseling Services. Counseling Therapy is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the per- sonalities of the counselor As a client in mental health counseling, you have certain rights and client, and the particular problems responsibilities that are important for you are experiencingto understand. There are many different methods I also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. Mental Health Counseling has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to deal with problems you want have benefits for individuals who undertake it. Therapy often leads to addressa significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. Counseling calls for an But, there are no guarantees about what will happen. Psychotherapy requires a very active effort on your part. It is In order to be most successful when successful, you will have to work on things we talk about during our sessions and discuss in between treatment outside of sessions, as a kind of homework. Counseling can have benefits and risks. Since it often involves discussing unpleasant as- pects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustra- tion, loneliness, and helplessness. On the other hand, counseling has been shown to have many benefits. It often leads to better relationships, solutions to specific problems, and significant re- ductions in feelings of distress. Often, with counseling, people know themselves better and live happier, more fulfilling lives. There are no guarantees of what you will experience. COUNSELING SESSIONS Our The first few 2 sessions will involve an a comprehensive evaluation of your needs. During this timeBy the end of the evaluation, we can both decide if I am the best person to provide the services you need in order to meet your treat- ment goals. I will be able to offer my you some initial impressions of what our work might include. At that point, we will include discuss your treatment goals and make suggestions for a create an initial treatment plan. Please You should evaluate this information and decide make your own assessment about whether you feel comfortable work- ing working with me. Counseling involves a large commitment of time, money, and energy, so be mindful about the therapist you choose. If you have questions about my procedures, we can should discuss them at any timewhenever they arise. If your doubts persist, I will be happy to help you may consult set up a meeting with another mental health professional for a second opinionopinion or to make a move to another therapist that feels like a better fit. If we work togetherAPPOINTMENTS: Appointments will ordinarily be 60 minutes in duration, I will usually schedule one 50-minute session once per week at a time we agree on, although some sessions may be longer more or more frequentless frequent as needed. Once an The time scheduled for your appointment is sched- uledassigned to you and you alone. If you need to cancel or reschedule a session, you will be expected to pay for it unless I ask that you provide at least me with 24 hours advance notice of cancellationnotice. Please It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, if I do not receive enough notice to fill that spot with another client I have no income for that time slot. If it is possible, I will try to find another time to reschedule the appointment. In addition, you are responsible for coming to your appointmentsession on time; if you are late, your appointment will still need to end on time.

Counseling Services. Counseling Your first appointment (or more, in some cases) will involve an assessment of your needs. By the end of the assessment I will be able to offer you some first impressions of what your work may include and recommendations for getting help. One of the recommendations may be psychotherapy. If so, ABO may or may not be able to provide you with psychotherapy, depending on your overall needs. If psychotherapy or any other recommendations suggested by me include things that ABO cannot provide, you will be given suggestions of where you might receive those services. Wherever you choose to obtain treatment, you should evaluate the information from your initial assessment along with your own opinions of what sort of treatment you are willing to do and whether you feel comfortable working with the treating clinician. Therapy involves a large commitment of time, energy, and often money, so you should be very careful about the counselor you select. If you have questions about the procedures used or conclusions made by me, please discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. Psychotherapy is not easily described in general statements. It varies depending on the per- sonalities particular problems you are experiencing, the therapeutic methods used by your counselor, and the personalities of the counselor and client, and the particular problems you are experiencing. There are many different methods I counselors may use to deal with the problems that you want hope to address. Counseling Psychotherapy is not like a medical doctor visit. Instead, it calls for an a very active effort on your part. It is In order for the therapy to be most successful when successful, you will have to work on things we talk about that are discussed both during our your sessions and in between sessionson your own. Counseling Psychotherapy can have benefits and risks. Since it therapy often involves discussing unpleasant as- pects aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustra- tionshame, frustration, loneliness, and helplessness. On the other hand, counseling The changes you make in therapy may also affect your relationships in unexpected ways. Psychotherapy has also been shown to have many benefits. It Therapy often leads to better relationships, solutions to specific problems, and significant re- ductions reductions in feelings of distress. Often, with counseling, people know themselves better and live happier, more fulfilling lives. There But there are no guarantees of what you will experience. COUNSELING SESSIONS Our first few sessions MEETINGS The initial assessment will involve an evaluation of your needslast from one to four sessions. During this time, we you and I can both decide if I am is the best person to provide the services you need in order to meet your treat- ment treatment goals. I will offer my impressions of what our work will include and make suggestions for a treatment plan. Please evaluate this information and decide whether you feel comfortable work- ing with me. Counseling involves a large commitment of time, money, and energy, so be mindful about the therapist you choose. If you have questions about my procedures, we can discuss them at any time. If your doubts persist, you may consult with another mental health professional for a second opinion. If we work togetherchoose to begin psychotherapy, I will usually schedule one 50-minute session per week meeting at a time we agree on, although sessions may be longer or more frequentupon. Once an appointment is sched- uledscheduled, you will be expected to pay for it attend unless you provide at least 24 hours advance notice of cancellationcancelation. Please note If you need to cancel an appointment, it is your responsibility to contact me to cancel. PROFESSIONAL FEES Fees will be collected when services are rendered. In addition to therapy services fees may include assessment administration, scoring, and reporting; creating reports; creating copies of records on request; and consulting with other professionals at the client’s request. There will be an additional $25 fee assessed for any returned check. The fee for my services is $200 per hour. CHANGES AND CANCELATIONS I understand that there are unforeseeable circumstances like sick children or bad weather. Your appointment is important though, and I am happy to contact you for a phone session or a session via a HIPAA-compliant virtual therapy system so you don't need to leave your sick child or worry about traffic and weather. As long as you are in a confidential location, I can help you keep your regularly scheduled appointment. If you still must change or cancel your counseling appointment, please know: • Cancelations must be made within 48 hours of session time by: o Contacting us at 000-000-0000 and leaving a voice mail o Using our online scheduling program, log in to your account and change or cancel your appointment. • We do not take cancelations via email. Emails from our scheduling software are automated and clearly marked ‘no reply.’ Replies to our email are not monitored. • I may not accommodate cancelations made after hours or on holidays to our main number as I cannot check voice mail regularly. If you have an appointment on a Monday or the first day following a holiday, you must make your change or cancelation the last business day before your appointment. • Cancelations with less than 24 hours’ notice will result in a fee equal to the total amount of the missed session that will be collected at your next appointment, or, if payment information is on file, it will be debited from your credit card. • *After two no-shows/late cancelations, you will pre-pay a retainer before scheduling any future appointments. • Clients who have pre-paid agree to have the entire fee deducted from their pre-payment in cases of other no-shows and late changes/cancelations. Any money left over from retainer after no-show fee is deducted will be refunded. COURT TESTIMONY • Court testimony costs begin at $250 per hour with a minimum charge of three hours. A retainer of $1000 is due one week prior to the court date. Travel is billed at .55/mile. Failure to provide the specific fees as described constitutes a release from the requested court appearance. • It is required that a minimum of 36 hours’ notice be given if the testimony is not required, otherwise the entire retainer may be forfeited. If proper notice is given, the retainer will be refunded. • Additional services related to court preparation including all correspondence with attorneys or other service providers via phone, email, or letter, documentation review and/or documentation preparation are also billed at $250 per hour, rounded to the nearest 15 minute increment. You (not your insurance companies company) are responsible for full payment of fees. It is very important that you find out exactly what mental health services your insurance policy covers. You must pay your xxxx first, then contact your insurance company regarding reimbursement. CONTACTING ME I answer the main office number 9:00 AM – 5:00 PM Monday through Friday (except holidays). Email, and text messaging are not secure mediums in terms of privacy and confidentiality so my policy is: • I do not provide reimbursement therapy/counseling via email or text messaging. • I may not acknowledge or return emails or text messages. Our scheduling software uses ‘No reply’ email confirmations and text messaging so I will not see any emails or text message replies to that service. • If I leave for cancelled sessionsan extended period of time you will be given the information for another licensed therapist with whom you may schedule if you need an appointment during my absence. Keep in mind you will need to fill out other paperwork. • Social media is not a means of communication. If possibleyou find me on social media, I will find another time to reschedule your appointmentnot communicate with you.

Counseling Services. Counseling Your first appointment (or more, in some cases) will involve an assessment of your needs. By the end of the assessment Xxxx Xxxxxx will be able to offer you some first impressions of what your work may include and recommendations for getting help. One of the recommendations may be psychotherapy. If so, Xxxx Xxxxxx may or may not be able to provide you with psychotherapy, depending on your overall needs. If psychotherapy or any other recommendations suggested by your counselor include things that Xxxx Xxxxxx Counseling, Inc. cannot provide, you will be given suggestions of where you might receive those services. Wherever you choose to obtain treatment, you should evaluate the information from your initial assessment along with your own opinions of what sort of treatment you are willing to do and whether you feel comfortable working with Xxxx Xxxxxx. Therapy involves a large commitment of time, energy, and often money, so you should be very careful about the therapist you select. If you have questions about the procedures used or conclusions made by Xxxx Xxxxxx, please discuss them whenever they arise. If your doubts persist, your counselor will be happy to help you set up a meeting with another mental health professional for a second opinion. Psychotherapy is not easily described in general statements. It varies depending on the per- sonalities particular problems you are experiencing, the therapeutic methods used by your counselor, and the personalities of the counselor and client, and the particular problems you are experiencing. There are many different methods I counselors may use to deal with the problems that you want hope to address. Counseling Psychotherapy is not like a medical doctor visit. Instead, it calls for an a very active effort on your part. It is In order for the therapy to be most successful when successful, you will have to work on things we talk about that are discussed both during our your sessions and in between sessionson your own. Counseling Psychotherapy can have benefits and risks. Since it therapy often involves discussing unpleasant as- pects aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustra- tionshame, frustration, loneliness, and helplessness. On the other hand, counseling The changes you make in therapy may also affect your relationships in unexpected ways. Psychotherapy has also been shown to have many benefits. It Therapy often leads to better relationships, solutions to specific problems, and significant re- ductions reductions in feelings of distress. Often, with counseling, people know themselves better and live happier, more fulfilling lives. There But there are no guarantees of what you will experience. COUNSELING SESSIONS Our first few sessions MEETINGS The initial assessment will involve an evaluation of your needslast from one to two sessions. During this time, we you and Xxxx Xxxxxx can both decide if I am she is the best person to provide the services you need in order to meet your treat- ment treatment goals. I will offer my impressions of what our work will include and make suggestions for a treatment plan. Please evaluate this information and decide whether you feel comfortable work- ing with me. Counseling involves a large commitment of time, money, and energy, so be mindful about the therapist you choose. If you have questions about my procedures, we can discuss them at any time. If your doubts persist, you may consult with another mental health professional for a second opinion. If we work together, I will usually psychotherapy is begun it is typical to schedule one 50-minute session meeting per week at a time we you each agree on, although sessions may be longer or more frequent. Once an appointment is sched- uledscheduled, you will be expected to pay for it attend unless you provide at least 24 hours advance notice of cancellation. Please note If you need to cancel an appointment, it is your responsibility to contact us to cancel. PROFESSIONAL FEES Fees will be collected when services are rendered. The fee per 50 minute counseling session is $110, and will be adjusted accordingly when 50 minutes is exceeded. In addition to therapy services fees may include creating reports; creating copies of records on request; and consulting with other professionals at the client’s request. There will be an additional $25 fee assessed for any returned check. CHANGES AND CANCELLATIONS We understand that there are unforeseeable circumstances like sick children or bad weather. Your appointment is important though, and Xxxx Xxxxxx is happy to contact you for a phone session or a session via our HIPPA-compliant virtual therapy system so you don't need to leave your sick child or worry about traffic and weather. As long as you are in a confidential location, we can help you keep your regularly scheduled appointment. If you still must change or cancel your counseling appointment, please know: ● Cancellations must be made within 24 hours of session time. ● We cannot accommodate cancellations made via email as we do not monitor email on a regular basis. ● We cannot accommodate cancellations made after hours or on holidays. If you have an appointment on a Monday or the first day following a holiday, you must make your change or cancellation the last business day before your appointment. ● Cancellations with less than 24 hours’ notice will result in a $75 fee that will be collected at your next appointment, or, if payment information is on file, it will be debited from your credit card. ● After two no-shows/late cancellations, a pre-paid retainer will be required before scheduling any future appointments. ● Clients who have pre-paid agree to have the entire fee deducted from their pre-payment in cases of other no-shows and late changes/cancellations. COURT TESTIMONY ● Court testimony costs begin at $250 per hour with a minimum charge of three hours. A retainer of $1000 is due one week prior to the court date. Travel is billed at .55/mile. Failure to provide the specific fees as described constitutes a release from the requested court appearance. ● It is required that a minimum of 36 hours’ notice be given if the testimony is not required, otherwise the entire retainer is forfeited. If proper notice is given, the retainer will be refunded. ● Additional services related to court preparation including all correspondence with attorneys or other service providers via phone, email, or letter, documentation review and/or documentation preparation are also billed at $250 per hour, rounded to the nearest 15-minute increment. You (not your insurance companies company) are responsible for full payment of fees. It is very important that you find out exactly what mental health services your insurance policy covers. You must pay your bill first, then contact your insurance company regarding reimbursement. CONTACTING US You can contact our main office number (281-350-1277) 24 hours a day/7 days a week. If an administrative assistant or Xxxx Xxxxxx, does not answer, please leave a message on the internal/secure voicemail system. Messages are typically returned within 24 hours during the business week, or 48 hours for messages left on the weekend. You may have your counselor’s cell phone number in order to coordinate administrative tasks (defined as appointment arrival, appointment time, and directions). Email, and text messaging are not secure mediums in terms of privacy and confidentiality so our policy regarding, electronic communication, and cell phone use includes the following: ● We do not provide reimbursement therapy/counseling via email or text messaging. ● Text messaging and email will be used for cancelled sessionsadministrative tasks only (as defined above). ● Xxxx Xxxxxx Counseling, Inc., may not acknowledge or return emails or text messages that are not administrative. This includes emergency texts and emails. ● If possible, I Xxxx Xxxxxx leaves for an extended period of time you will find be given the information for another time to reschedule licensed therapist with whom you may schedule if you need an appointment during your appointmenttherapist’s absence.

Counseling Services. Counseling is not easily described in general statements. It varies depending on the per- sonalities personality of the counselor and the client, as well as the problems and the particular problems challenges you are experiencingbring forward. There are many different different methods I may use to deal with the problems you want to address. Counseling calls for an is not like a medical doctor visit. Instead, it requires a very active effort effort on your part. It is In order for the counseling to be most successful when successful, you will need to work on things the areas we talk about both during our sessions and especially in between sessions. Counseling can have benefits both benefits and risks. Since it counseling often involves discussing unpleasant as- pects aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustra- tionfrustration, loneliness, loneliness and helplessness. On the other hand, counseling has been shown to have many benefits. It Counseling often leads to better relationships, solutions to specific problems, specific problems and significant re- ductions significant reductions in feelings of distress. Often, with counselinghowever, people know themselves better and live happier, more fulfilling lives. There there are no guarantees of what you will experience. COUNSELING SESSIONS By signing this document, you agree to not hold Cara Damier liable or responsible for any results or outcomes of counseling or coaching and to also not seek out legal action against Xxxx Xxxxxx for any reason. Our first first few sessions will involve an evaluation of your needs. During this timeBy the end of the evaluation, we can both decide if I am the best person to provide the services you need in order to meet your treat- ment goals. I will offer my be able to offer you some first impressions of what our work will include entail and make suggestions for develop a treatment planplan to follow should you decide to continue with counseling. Please You should evaluate this information and decide along with your own opinions of whether you feel comfortable work- ing working with me. Counseling involves a large significant commitment of time, money, money and energy, so you should be mindful very careful about the therapist counselor you chooseselect. If you have any questions about my approach or procedures, we can should discuss them whenever they arise. This agreement is for Counseling or Coaching. While counseling and coaching can work with issues such as identifying and reaching life goals, and changing the behaviors that aren’t working well for you, counseling/coaching is not intended to work through issues such as schizophrenia and suicidal behaviors. For issues such as these, you must see a Physician or Licensed Mental Health Professional in your location. By signing this agreement, you are agreeing that you understand the difference in these two functions and you will get appropriate professional help for mental health issues if necessary. Please feel free to ask questions at any time. If time about your doubts persistcounselor’s/coach’s background, you may consult with another mental health experience and professional for a second opinion. If we work together, I will usually schedule one 50-minute session per week at a time we agree on, although sessions may be longer or more frequent. Once an appointment is sched- uled, you will be expected to pay for it unless you provide at least 24 hours advance notice of cancellation. Please note that insurance companies do not provide reimbursement for cancelled sessions. If possible, I will find another time to reschedule your appointmentorientation.

Counseling Services. Counseling Your first appointment (or more, in some cases) will involve an assessment of your needs. By the end of the assessment Xxxx Xxxxxx will be able to offer you some first impressions of what your work may include and recommendations for getting help. One of the recommendations may be psychotherapy. If so, Xxxx Xxxxxx may or may not be able to provide you with psychotherapy, depending on your overall needs. If psychotherapy or any other recommendations suggested by your counselor include things that Xxxx Xxxxxx Counseling, Inc. cannot provide, you will be given suggestions of where you might receive those services. Wherever you choose to obtain treatment, you should evaluate the information from your initial assessment along with your own opinions of what sort of treatment you are willing to do and whether you feel comfortable working with Xxxx Xxxxxx. Therapy involves a large commitment of time, energy, and often money, so you should be very careful about the therapist you select. If you have questions about the procedures used or conclusions made by Xxxx Xxxxxx, please discuss them whenever they arise. If your doubts persist, your counselor will be happy to help you set up a meeting with another mental health professional for a second opinion. Psychotherapy is not easily described in general statements. It varies depending on the per- sonalities particular problems you are experiencing, the therapeutic methods used by your counselor, and the personalities of the counselor and client, and the particular problems you are experiencing. There are many different methods I counselors may use to deal with the problems that you want hope to address. Counseling Psychotherapy is not like a medical doctor visit. Instead, it calls for an a very active effort on your part. It is In order for the therapy to be most successful when successful, you will have to work on things we talk about that are discussed both during our your sessions and in between sessionson your own. Counseling Psychotherapy can have benefits and risks. Since it therapy often involves discussing unpleasant as- pects aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustra- tionshame, frustration, loneliness, and helplessness. On the other hand, counseling The changes you make in therapy may also affect your relationships in unexpected ways. Psychotherapy has also been shown to have many benefits. It Therapy often leads to better relationships, solutions to specific problems, and significant re- ductions reductions in feelings of distress. Often, with counseling, people know themselves better and live happier, more fulfilling lives. There But there are no guarantees of what you will experience. COUNSELING SESSIONS Our first few sessions MEETINGS The initial assessment will involve an evaluation of your needslast from one to two sessions. During this time, we you and Xxxx Xxxxxx can both decide if I am she is the best person to provide the services you need in order to meet your treat- ment treatment goals. I will offer my impressions of what our work will include and make suggestions for a treatment plan. Please evaluate this information and decide whether you feel comfortable work- ing with me. Counseling involves a large commitment of time, money, and energy, so be mindful about the therapist you choose. If you have questions about my procedures, we can discuss them at any time. If your doubts persist, you may consult with another mental health professional for a second opinion. If we work together, I will usually psychotherapy is begun it is typical to schedule one 50-minute session meeting per week at a time we you each agree on, although sessions may be longer or more frequent. Once an appointment is sched- uledscheduled, you will be expected to pay for it attend unless you provide at least 24 hours advance notice of cancellation. Please note If you need to cancel an appointment, it is your responsibility to contact us to cancel. PROFESSIONAL FEES Fees will be collected when services are rendered. The fee per 50 minute counseling session is $110, and will be adjusted accordingly when 50 minutes is exceeded. In addition to therapy services fees may include creating reports; creating copies of records on request; and consulting with other professionals at the client’s request. There will be an additional $25 fee assessed for any returned check. CHANGES AND CANCELLATIONS We understand that there are unforeseeable circumstances like sick children or bad weather. Your appointment is important though, and Xxxx Xxxxxx is happy to contact you for a phone session or a session via our HIPPA-compliant virtual therapy system so you don't need to leave your sick child or worry about traffic and weather. As long as you are in a confidential location, we can help you keep your regularly scheduled appointment. If you still must change or cancel your counseling appointment, please know: ● Cancellations must be made within 24 hours of session time. ● We cannot accommodate cancellations made via email as we do not monitor email on a regular basis. ● We cannot accommodate cancellations made after hours or on holidays. If you have an appointment on a Monday or the first day following a holiday, you must make your change or cancellation the last business day before your appointment. ● Cancellations with less than 24 hours’ notice will result in a $75 fee that will be collected at your next appointment, or, if payment information is on file, it will be debited from your credit card. ● After two no-shows/late cancellations, a pre-paid retainer will be required before scheduling any future appointments. ● Clients who have pre-paid agree to have the entire fee deducted from their pre-payment in cases of other no-shows and late changes/cancellations. COURT TESTIMONY ● Court testimony costs begin at $250 per hour with a minimum charge of three hours. A retainer of $1000 is due one week prior to the court date. Travel is billed at .55/mile. Failure to provide the specific fees as described constitutes a release from the requested court appearance. ● It is required that a minimum of 36 hours’ notice be given if the testimony is not required, otherwise the entire retainer is forfeited. If proper notice is given, the retainer will be refunded. ● Additional services related to court preparation including all correspondence with attorneys or other service providers via phone, email, or letter, documentation review and/or documentation preparation are also billed at $250 per hour, rounded to the nearest 15-minute increment. You (not your insurance companies company) are responsible for full payment of fees. It is very important that you find out exactly what mental health services your insurance policy covers. You must pay your xxxx first, then contact your insurance company regarding reimbursement. CONTACTING US You can contact our main office number (281-350-1277) 24 hours a day/7 days a week. If an administrative assistant or Xxxx Xxxxxx, does not answer, please leave a message on the internal/secure voicemail system. Messages are typically returned within 24 hours during the business week, or 48 hours for messages left on the weekend. You may have your counselor’s cell phone number in order to coordinate administrative tasks (defined as appointment arrival, appointment time, and directions). Email, and text messaging are not secure mediums in terms of privacy and confidentiality so our policy regarding, electronic communication, and cell phone use includes the following: ● We do not provide reimbursement therapy/counseling via email or text messaging. ● Text messaging and email will be used for cancelled sessionsadministrative tasks only (as defined above). ● Xxxx Xxxxxx Counseling, Inc., may not acknowledge or return emails or text messages that are not administrative. This includes emergency texts and emails. ● If possible, I Xxxx Xxxxxx leaves for an extended period of time you will find be given the information for another time to reschedule licensed therapist with whom you may schedule if you need an appointment during your appointmenttherapist’s absence.

Counseling Services. Counseling Your first appointment (or more, in some cases) will involve an assessment of your needs. By the end of the assessment your counselor will be able to offer you some first impressions of what your work may include and recommendations for getting help. One of the recommendations may be psychotherapy. If so, APC may or may not be able to provide you with psychotherapy, depending on your overall needs. If psychotherapy or any other recommendations suggested by your counselor include things that APC cannot provide, you will be given suggestions of where you might receive those services. Wherever you choose to obtain treatment, you should evaluate the information from your initial assessment along with your own opinions of what sort of treatment you are willing to do and whether you feel comfortable working with the treating clinician. Therapy involves a large commitment of time, energy, and often money, so you should be very careful about the therapist you select. If you have questions about the procedures used or conclusions made by your counselor at APC, please discuss them whenever they arise. If your doubts persist, your counselor will be happy to help you set up a meeting with another mental health professional for a second opinion. Psychotherapy is not easily described in general statements. It varies depending on the per- sonalities particular problems you are experiencing, the therapeutic methods used by your counselor, and the personalities of the counselor and client, and the particular problems you are experiencing. There are many different methods I counselors may use to deal with the problems that you want hope to address. Counseling Psychotherapy is not like a medical doctor visit. Instead, it calls for an a very active effort on your part. It is In order for the therapy to be most successful when successful, you will have to work on things we talk about that are discussed both during our your sessions and in between sessionson your own. Counseling Psychotherapy can have benefits and risks. Since it therapy often involves discussing unpleasant as- pects aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustra- tionshame, frustration, loneliness, and helplessness. On the other hand, counseling The changes you make in therapy may also affect your relationships in unexpected ways. Psychotherapy has also been shown to have many benefits. It Therapy often leads to better relationships, solutions to specific problems, and significant re- ductions reductions in feelings of distress. Often, with counseling, people know themselves better and live happier, more fulfilling lives. There But there are no guarantees of what you will experience. COUNSELING SESSIONS Our first few sessions will involve an evaluation of your needs. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treat- ment goals. I will offer my impressions of what our work will include and make suggestions for a treatment plan. Please evaluate this information and decide whether you feel comfortable work- ing with me. Counseling involves a large commitment of time, money, and energy, so be mindful about the therapist you choose. If you have questions about my procedures, we can discuss them at any time. If your doubts persist, you may consult with another mental health professional for a second opinion. If we work together, I will usually schedule one 50-minute session per week at a time we agree on, although sessions may be longer or more frequent. Once an appointment is sched- uled, you will be expected to pay for it unless you provide at least 24 hours advance notice of cancellation. Please note that insurance companies do not provide reimbursement for cancelled sessions. If possible, I will find another time to reschedule your appointment.

Counseling Services. Counseling Your first appointment (or more, in some cases) will involve an assessment of your needs. By the end of the assessment your counselor will be able to offer you some first impressions of what your work may include and recommendations for getting help. One of the recommendations may be psychotherapy. If so, ABO may or may not be able to provide you with psychotherapy, depending on your overall needs. If psychotherapy or any other recommendations suggested by your counselor include things that ABO cannot provide, you will be given suggestions of where you might receive those services. Wherever you choose to obtain treatment, you should evaluate the information from your initial assessment along with your own opinions of what sort of treatment you are willing to do and whether you feel comfortable working with the treating clinician. Therapy involves a large commitment of time, energy, and often money, so you should be very careful about the counselor you select. If you have questions about the procedures used or conclusions made by your counselor at ABO, please discuss them whenever they arise. If your doubts persist, your counselor will be happy to help you set up a meeting with another mental health professional for a second opinion. Psychotherapy is not easily described in general statements. It varies depending on the per- sonalities particular problems you are experiencing, the therapeutic methods used by your counselor, and the personalities of the counselor and client, and the particular problems you are experiencing. There are many different methods I counselors may use to deal with the problems that you want hope to address. Counseling Psychotherapy is not like a medical doctor visit. Instead, it calls for an a very active effort on your part. It is In order for the therapy to be most successful when successful, you will have to work on things we talk about that are discussed both during our your sessions and in between sessionson your own. Counseling Psychotherapy can have benefits and risks. Since it therapy often involves discussing unpleasant as- pects aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustra- tionshame, frustration, loneliness, and helplessness. On the other hand, counseling The changes you make in therapy may also affect your relationships in unexpected ways. Psychotherapy has also been shown to have many benefits. It Therapy often leads to better relationships, solutions to specific problems, and significant re- ductions reductions in feelings of distress. Often, with counseling, people know themselves better and live happier, more fulfilling lives. There But there are no guarantees of what you will experience. COUNSELING SESSIONS Our first few sessions MEETINGS The initial assessment will involve an evaluation of your needslast from one to four sessions. During this time, we you and your counselor can both decide if I am she/he is the best person to provide the services you need in order to meet your treat- ment treatment goals. I will offer my impressions of what our work will include and make suggestions for a treatment plan. Please evaluate this information and decide whether you feel comfortable work- ing with me. Counseling involves a large commitment of time, money, and energy, so be mindful about the therapist you choose. If you have questions about my procedureschoose to begin psychotherapy, we can discuss them at any time. If your doubts persist, you may consult with another mental health professional for a second opinion. If we work together, I counselor will usually schedule one 50-minute session per week meeting at a time we you each agree on, although sessions may be longer or more frequent. Once an appointment is sched- uledscheduled, you will be expected to pay for it attend unless you provide at least 24 hours advance notice of cancellation. Please note If you need to cancel an appointment, it is your responsibility to contact us to cancel. PROFESSIONAL FEES Fees will be collected when services are rendered.*In addition to therapy services fees may include assessment administration, scoring, and reporting; creating reports; creating copies of records on request; and consulting with other professionals at the client’s request. There will be an additional $25 fee assessed for any returned check. CHANGES AND CANCELLATIONS We understand that there are unforeseeable circumstances like sick children or bad weather. Your appointment is important though, and your therapist is happy to contact you for a phone session or a session via our HIPPA-compliant virtual therapy system so you don't need to leave your sick child or worry about traffic and weather. As long as you are in a confidential location, we can help you keep your regularly scheduled appointment. If you still must change or cancel your counseling appointment, please know: • Cancellations must be made during business hours. • Cancellations must be made within 48 hours of session time if using our online scheduling program. • We cannot accommodate cancellations made via email as we do not monitor email on a regular basis. • We may not accommodate cancellations made after hours or on holidays to our main number as we cannot check voice mail regularly. If you have an appointment on a Monday or the first day following a holiday, you must make your change or cancellation the last business day before your appointment. • Cancellations with less than 24 hours’ notice will result in a fee equal to the total amount of the missed session that will be collected at your next appointment, or, if payment information is on file, it will be debited from your credit card. • *After two no-shows/late cancellations, you will pre-pay a retainer before scheduling any future appointments. • Clients who have pre-paid agree to have the entire fee deducted from their pre-payment in cases of other no-shows and late changes/cancellations. COURT TESTIMONY • Court testimony costs begin at $250 per hour with a minimum charge of three hours. A retainer of $1000 is due one week prior to the court date. Travel is billed at .55/mile. Failure to provide the specific fees as described constitutes a release from the requested court appearance. • It is required that a minimum of 36 hours’ notice be given if the testimony is not required, otherwise the entire retainer may be forfeited. If proper notice is given, the retainer will be refunded. • Additional services related to court preparation including all correspondence with attorneys or other service providers via phone, email, or letter, documentation review and/or documentation preparation are also billed at $250 per hour, rounded to the nearest 15 minute increment. You (not your insurance companies company) are responsible for full payment of fees. It is very important that you find out exactly what mental health services your insurance policy covers. You must pay your xxxx first, then contact your insurance company regarding reimbursement. CONTACTING US We answer our main office number 9:00 AM – 5:00 PM Monday through Friday (except holidays). You may have your counselor’s cell phone number in order to coordinate administrative tasks (defined as appointment arrival, appointment time, and directions). Email, and text messaging are not secure mediums in terms of privacy and confidentiality so our policy regarding, electronic communication, and cell phone use includes the following: • We do not provide reimbursement therapy/counseling via email or text messaging. • Text messaging and email will be used for cancelled sessionsadministrative tasks only (as defined above). • Therapists may not acknowledge or return emails or text messages that are not administrative. This includes emergency texts and emails. • If possible, I your therapist leaves for an extended period of time you will find be given the information for another time licensed therapist with whom you may schedule if you need an appointment during your therapist’s absence. You may need to reschedule your appointmentfill out other paperwork if therapist is in another practice.

Counseling Services. Counseling is not easily described in general statements. It varies depending on the per- sonalities personalities of the counselor and client, and the particular problems problem you are experiencing. There are many different methods I may use bring to deal with problems you want to addresscounseling. Counseling calls will frequently involve discussing your personal concerns, thoughts and feelings. In order for an active effort on your part. It is the counseling to be most successful when successful, you will have to work on things we talk about both during our sessions and in between sessions. Counseling can have benefits risks and risksbenefits. Since it often involves discussing unpleasant as- pects of your lifeInitially, you may experience uncomfortable feelings like levels of sadness, guilt, anxiety, anger, frustra- tionfrustration, loneliness, and helplessness, or other negative feelings. On While you consider these risks, you should always know that the other hand, counseling has benefits of psychotherapy have been shown to have many benefitsby scientists in hundreds of well-designed research studies. It Therapy often leads to better relationships, solutions to specific problems, and significant re- ductions reductions in feelings of distress, improvements in relationships, acquisition of skills to cope with stress, and improvement in overall well-being. Often, with counseling, people know themselves better and live happier, more fulfilling lives. There But there are no guarantees of what you will experience. COUNSELING SESSIONS Our first few sessions session together will involve include an evaluation of your needs. During this timeAt the end of that meeting, we can both decide if I am the best person to provide the services you need in order to meet your treat- ment goals. I will offer my you some first impressions of what our work will include and make suggestions for a treatment planplan that we will follow. If you have questions about our process, we should discuss them whenever they arise. I will be glad to provide outside referrals if your concerns continue. CONSULTATION SERVICES As an expert and experienced geriatric social service and mental health professional, I am available to offer consultation on specific situations or concerns you’d like suggestions or advice about. Consultation is not a psychotherapeutic service and we will not be discussing your feelings or personal needs, however I would be glad to begin psychotherapy services if we agree that they would be beneficial. Common concerns that clients might ask for professional advice on are decisions about retirement, housing options, decisions about moving to a higher level of care, or advice about managing difficult situations in caregiving, navigating the health care system or end-of-life decisions. I am careful not to offer advice about legal or medical situations or decision making. While my suggestions and recommendations are based upon professional expertise and experience, the outcome of the particular situation is not guaranteed. Consultation is generally conducted over a few meetings. Reports with impressions and recommendations can be provided. TELEMENTAL HEALTH SERVICES In addition to meeting together in my office, I offer counseling over the phone or on video chat. Telemental health is the use of telephone and video technology for delivery of counseling services. These services can be beneficial in the situation where clients are unable to meet in my office for some reason. Telemental health has been shown to be beneficial as a mode of providing psychotherapy but does come with some potential risks including: less control over confidentiality, decreased emotional connection between therapist and client and reducing the likelihood of insurance reimbursement. While we may agree that telemental health is effective in your situation, we will need to discuss how often you will return for face-to-face visits. We will regularly review whether telemental health is continuing to be beneficial. My license covers telemental health services to residents of California only. If telemental health is appropriate for you, then I will provide this services through a HIPAA compliant system. These services claim to be HIPAA compliant and reliable, however I cannot guarantee there will not be concerns of service reliability, potential interruptions of services, security, or confidentiality. A session may have to be moved to phone or discontinued if service interruptions or delays occur. Clients are encouraged to research and understand the benefits and limits of this form of technology before using it. To increase security, it is recommended that you use a computer or mobile device that has up to date antivirus software and a personal firewall installed. It is recommended that videoconferencing be completed on an internet service at a bandwidth of 384 kbps or higher in each of the downlink and uplink directions. Such services should provide a minimum of 640 x 360 resolution at 30 frames per second. As a client of telemental health services, you are responsible for maintaining privacy on your end of the communication (e.g., storing electronic documents securely, ensuring sessions are not overheard, verifying that you are sending information to the correct recipient, avoiding use of employer-owned computers if employers have access to materials on the computer or network). Signing this consent indicates that you understand the risks in using technology for counseling. HOME VISITS On some occasions, I may be able to meet you in your home to conduct therapy. In these cases, I will arrive 10 minutes early so that we can get comfortable, start on time and end at 50 minutes, just like a traditional session. Please assure that we have privacy and are not interrupted. CRISIS SERVICES My practice is part-time and I may not be available when you need crisis counseling. If you need more frequent contact than I am able to provide in our regular sessions, I can provide referrals to clinicians who can provide this service. In the case of an emergency, please call the Santa Clara County Crisis Line (000-000-0000), dial 911 or go to your local emergency room. MEETINGS, PROFESSIONAL FEES AND CANCELLATION POLICIES A free 30-minute meeting is available prior to beginning counseling. You should evaluate this information and decide our conversation along with your own opinions of whether you feel comfortable work- ing working with me. Counseling Therapy involves a large commitment of time, money, money and energy, so you should be mindful very careful about the therapist you chooseselect. If you have questions about my procedures, we can discuss them at any timeI offer traditional 50-minute appointments. If your doubts persist, you may consult with another mental health professional The fee for a second opinion. If we work together, I will usually schedule one 50-minute session per week at a time we agree on, although sessions may be longer or more frequentis $170.00. Once an appointment is sched- uled, you Mileage will be expected charged for home visits at the following rate: $50.00 within 2 miles of my office $75.00 within 5 miles of my office $100.00 within 8 miles of my office In addition to pay for it unless you provide at least 24 hours advance notice of cancellation. Please note that insurance companies do not provide reimbursement for cancelled sessions. If possiblethese fees, I charge for additional services you may need: Consultation reports are billed at the rate of $170/hour broken down into 10-minute increments. Legal proceedings that require my participation will find another time to reschedule your appointmentalso be billed.

Counseling Services. Counseling is not easily described in general statements. It Therapy varies depending on the per- sonalities personalities of the counselor therapist and client, and the particular problems you are experiencing. There are many different methods I we may use to deal with the problems that you want hope to address. Counseling Therapy is not like a medical doctor visit. Instead, it calls for an a very active effort on your part. It is In order for the therapy to be most successful when successful, you will have to work on things we talk about both during our sessions and in between sessionsat home. Counseling Homework will often be given when deemed necessary for therapy. Therapy can have benefits and risks. Since it therapy often involves discussing unpleasant as- pects aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustra- tion, loneliness, and helplessnessfeelings. On the other hand, counseling therapy has also been shown to have many benefits. It Therapy often leads to better relationships, solutions to specific problems, and significant re- ductions reductions in feelings of distress. Often, with counseling, people know themselves better and live happier, more fulfilling lives. There But there are no guarantees of what you will experience. COUNSELING SESSIONS Our first few sessions will involve an evaluation of your needs. During this timeBy the end of the evaluation, we can both decide if I am the best person to provide the services you need in order to meet your treat- ment goals. I will be able to offer my you some first impressions of what our work will include and make suggestions for a treatment planplan to follow, if you decide to continue with therapy. Please You should evaluate this information and decide along with your own opinions of whether you feel comfortable work- ing working with me. Counseling Therapy involves a large commitment of time, money, and energy, so you should be mindful very careful about the therapist you chooseselect. If you have questions about my any procedures, we can should discuss them at any timewhenever they arise. If your doubts persist, I will be happy to help you may consult set up a meeting with another mental health professional for a second opinion. My goal is for you to ultimately get the help you need, whether that is with me or with another therapist. If therapy is begun, we work together, I will usually schedule one 50-minute session per week (one appointment hour of 50 minutes duration) at a time we agree on, although some sessions may be longer or more frequent. Please be on time as I will often have another session scheduled after you. Once an appointment is sched- uledscheduled, you will be expected to pay for it $75 unless you provide at least 24 hours advance notice of cancellationcancellation (unless we both agree that you were unable to attend due to circumstances beyond your control). Please It is important to note that insurance companies do not provide reimbursement for cancelled sessions, meaning you will have to pay for these out of pocket. If possiblePlease remember that both of our time is valuable and when you cancel with late or no notice, I someone else could have taken advantage of that time slot. We will try to find another time to reschedule your the appointment.

Counseling Services. Counseling SUD therapy/counseling is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on As a client in the per- sonalities of the counselor SUD counseling process, you have certain rights and client, and the particular problems responsibilities that are important for you are experiencingto understand. There are many different methods I also legal limitations to those rights that you should be aware of. I, as your SUD counselor, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections. SUD therapy/counseling has both benefits and risks. Risks may use include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of therapy often requires discussing the unpleasant aspects of your life. However, therapy has been shown to deal with problems you want have benefits for individuals who undertake it. Therapy often leads to addressa significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. Counseling calls for an But, there are no guarantees about what will happen. Therapy requires a very active effort on your part. It is In order to be most successful when successful, you work on will want to put into practice things we talk about during our sessions and in between discuss outside of sessions. Counseling can have benefits and risks. Since it often involves discussing unpleasant as- pects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustra- tion, loneliness, and helplessness. On the other hand, counseling has been shown to have many benefits. It often leads to better relationships, solutions to specific problems, and significant re- ductions in feelings of distress. Often, with counseling, people know themselves better and live happier, more fulfilling lives. There are no guarantees of what you will experience. COUNSELING SESSIONS Our The first few 2-3 sessions will involve an a comprehensive evaluation of your needs. During this timeBy the end of the evaluation, we can both decide if I am the best person to provide the services you need in order to meet your treat- ment goals. I will be able to offer my you some initial impressions of what our work might include. At that point, we will include discuss your treatment goals and make suggestions for a create an initial treatment plan. Please You should evaluate this information and decide make your own assessment about whether you feel comfortable work- ing working with me. Counseling involves a large commitment of time, money, and energy, so be mindful about the therapist you choose. If you have questions about my procedures, we can should discuss them at any timewhenever they arise. If your doubts persist, I will be happy to help you may consult set up a meeting with another mental health SUD professional for a second opinion. If we work together, I will usually schedule one PROFESSIONAL FEES The standard fee for a 50-minute individual session is $125.00 and the standard fee for a 90 minute couples session is $175.00 You are responsible for paying the full amount at the time of your session, unless prior arrangements have been made. Payment must be made by cash, or credit card. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment. APPOINTMENTS Appointments will ordinarily be 45-60 minutes in duration, once per week at a time we agree on, although some sessions may be longer more, or more frequentless frequent as needed. Once an The time scheduled for your appointment is sched- uledassigned to you and you alone. If you need to cancel or reschedule a session, you will be expected to pay for it unless I ask that you provide at least 24 me with 24-hours advance notice notice. If you miss a session without canceling, or cancel with less than 24-hour notice, my policy is to collect the full session fee of cancellation$125.00/individual or $175.00/couples. Please It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for 100% of the full rate. If it is possible, I will try to find another time to reschedule the appointment. In addition, you are responsible for coming to your appointmentsession on time; if you are late, your appointment will still need to end at the scheduled time. Finally, I have the right to terminate treatment after 2 missed appointments or habitual tardiness. Thank you for understanding. To schedule, cancel or change and appointment you may call, text or email me. You can expect a response before the end of the business day. INSURANCE I am not a participating provider for any insurance plan. If you would like, I will supply you with a receipt of payment for services, which you can submit to your insurance company for reimbursement. Please note that not all insurance companies reimburse for out-of-network providers. PROFESSIONAL RECORDS I am required to keep appropriate records of the SUD therapy/counseling services that I provide. Your records are maintained in a secured, encrypted, HIPAA compliant web-based system. I keep brief records noting that you were here, your reasons for seeking SUD therapy/counseling, the goals and progress we set for treatment, your diagnosis, topics we discussed, your medical, social, and treatment history, records I receive from other providers, copies of records I send to others, and your billing records. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and / or upsetting to untrained readers. For this reason, I recommend that you initially review them with me, or have them forwarded to another mental health professional to discuss the contents. You also have the right to request that a copy of your file be made available to any other health care provider at your written request.

Counseling Services. Counseling Psychotherapy is not easily described in general statements. It Therapy varies depending on the per- sonalities personalities of the counselor psychotherapist and client, and the particular problems you are experiencing. There are many different methods I may use to deal with the problems that you want hope to address. Counseling Psychotherapy calls for an a very active effort on your part. It is In order for the therapy to be most successful when successful, you work will be working on things we talk about both during our sessions and at home. My theoretical orientation is generally Cognitive-Behavioral (CBT). However, I also rely on attachment theory and object relations to work on long-standing patterns. For individuals dealing with interpersonal and emotional issues, my approach is influenced by research that indicates the importance of relationships upon the formation of one’s personality. Your task is to express what you are thinking and feeling as openly as possible, and mine is to listen and help you to understand yourself better, in between sessionsorder to more effectively deal with the problems you are facing. Counseling Cognitive-Behavioral work is based on the theory that our thoughts about events lead to our emotions and behaviors and that we can have benefits some control over these thoughts to improve our feelings and risksbehaviors. This theory has shown very good results in research. Psychotherapy can have both risks and benefits. Since it therapy often involves discussing troubling and unpleasant as- pects aspects of your life, you may experience uncomfortable some discomfort with feelings like such as sadness, guilt, anger, frustra- tionfrustration, loneliness, and helplessness. On Some of the other hand, counseling has been shown to have many benefits. It often leads benefits of therapy are that it can lead to better relationships, solutions to specific problems, and significant re- ductions reductions in feelings of distress. Often, with counseling, people know themselves better and live happier, more fulfilling lives. There are no specific predictions, certainties, or guarantees of what you will experience. COUNSELING SESSIONS Our first few sessions will involve an evaluation of your needs. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treat- ment goals. I will offer my impressions of what our work will include and make suggestions for a treatment plan. Please You should evaluate this information and decide along with your own opinions of whether you feel comfortable work- ing working with me. Counseling Therapy involves a large commitment of time, money, and energy, so be mindful about ; I will do my best to help you make the therapist you choosebest use of these resources. If you have questions about my proceduresprocedures or any aspects of my work with you, we can will discuss them at any timewhenever they arise. If your doubts persistyou have persisting questions or doubts, I will be happy to help you may consult set up a meeting with another mental health professional for a second opinionopinion or a referral to a different therapist. If we work together, You have the right to refuse treatment. It is your responsibility to choose the provider and treatment modality that may best suit your needs. MEETINGS I will usually schedule one 50-minute session sessions (one appointment hour of 50 minutes duration) per week at a time we agree on, although sessions may be longer or more frequent. Once an appointment hour is sched- uledscheduled, you are responsible to pay for that time and will be billed for that hour unless you notify me of your cancellation at least 24 hours prior to the scheduled appointment. (If a cancellation is unavoidable and my schedule allows, I will schedule you at a different time.) I charge a fee of $25 for no show or late cancelled appointments. PROFESSIONAL FEES My hourly fee is $140. In addition to in-office appointments, I charge this amount for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 15 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, video taping and assessment, and the time spent performing any other service you may request of me. 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. I charge a $1400 retainer before becoming involved in legal proceedings. BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held, unless you provide at least 24 hours advance notice we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. In some cases monthly payment arrangements may be made. In circumstances of cancellation. Please note that insurance companies do not provide reimbursement for cancelled sessionsunusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. If possibleyour account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going though small claims court which will find another time require me to reschedule your appointment.disclose otherwise confidential information. In most collection situations, the only information I release regarding a client’s treatment is his/her name, the nature of the services provided, and the amount due. When such legal action is necessary, its costs will be included in the claim. INSURANCE REIMBURSEMENT

Counseling Services. Counseling is not easily described a relationship between people that works in general statementspart because of clearly defined rights and responsibilities held by each person. It varies depending on the per- sonalities of the counselor As a client in counseling, you have certain rights and client, and the particular problems responsibilities that are important for you are experiencingto understand. There are many different methods also legal limitations to those rights that you should be aware of. As your counselor I may use have corresponding responsibilities to deal with problems you want to addressyou. These rights and responsibilities are described in the following sections. Counseling calls for an active effort on your part. It is most successful when you work on things we talk about during our sessions and in between sessions. Counseling can have has both benefits and risks. Since it often involves discussing unpleasant as- pects of your lifeRisks may include experiencing uncomfortable feelings, you may experience uncomfortable feelings like such as sadness, guilt, anxiety, anger, frustra- tionfrustration, loneliness, loneliness and helplessness, because the process of counseling often requires discussing the unpleasant aspects of your life. On the other handHowever, counseling has been shown to have many benefitsbenefits for individuals who undertake it. It Counseling often leads to better relationships, solutions to specific problems, and a significant re- ductions reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. OftenBut, with counseling, people know themselves better and live happier, more fulfilling lives. There there are no guarantees of about what will happen. Counseling requires a very active effort on your part. In order to be most successful, you will experiencehave to work on things we discuss outside of sessions. COUNSELING SESSIONS Our The first few sessions session will involve an a comprehensive evaluation of your needs. During this timeBy the end of the evaluation, we can both decide if I am the best person to provide the services you need in order to meet your treat- ment goals. I will be able to offer my you some initial impressions of what our work might include. At that point, we will include discuss your treatment goals and make suggestions for a create an initial treatment plan. Please You should evaluate this information and decide make your own assessment about whether you feel comfortable work- ing working with me. Counseling involves a large commitment of time, money, and energy, so be mindful about the therapist you choose. If you have questions about my procedures, we can should discuss them at any timewhenever they arise. If your doubts persist, I will be happy to help you may consult set up a meeting with another mental health professional for a second opinion. If we work togetherAPPOINTMENTS Appointments will ordinarily be 45-50 minutes in duration, I will usually schedule one 50-minute session once per week at a time we agree on, although some sessions may be more or less frequent as needed.. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours notice. If you miss a session without canceling, or cancel with less than 24 hour notice, you will be responsible for a $30.00 no show fee. If it is possible, I will try to find another time to reschedule the appointment. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time. PROFESSIONAL FEES The standard fee for the initial intake is $110.00 and each subsequent session is $90.00. You are responsible for paying at the time of your session unless prior arrangements have been made. Payment can be made by cash, debit or credit card. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment. In addition to weekly appointments, it is my practice to charge this amount on a prorated basis (I will break down the hourly cost) for other professional services that you may require such as report writing, telephone conversations that last longer than 15 minutes, attendance at meetings or more frequentconsultations which you have requested, or the time required to perform any other service which you may request of me. Once an appointment is sched- uledIf you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for it unless you provide at least 24 hours advance notice of cancellation. Please note that insurance companies do not provide reimbursement for cancelled sessions. If possible, I will find the professional time required even if another time party compels me to reschedule your appointmenttestify.