Common use of Psychotherapist-Patient Privilege Clause in Contracts

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- cally, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 per 50-minute session. Sessions longer than 50-minutes are charged for the additional time pro rata. Therapist reserve the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance companies, managed care organizations, or other third-party payers, or by agreement with Therapist. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, or major credit cards.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received receives a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or a person with the authority to waive the privilege on Patient’s representativebehalf. Patient When a patient is a minor child, the holder of the psychotherapist-patient privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-patient privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-patient privilege with his/her attorney. Patient, or Representative, should be aware that he/she might be waiving the psychotherapist-psychotherapist- patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient Patient, or Representative, should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 240 per intake session. The fee for service is $160 per 45-50-minute therapy session. Sessions longer than 50-minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient Representative will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-party payerspayors, or by agreement with Therapist. Fees are payable at the time that services are rendered. Please ask your therapist if you wish to discuss a written agreement that specifies an alternative payment procedure. Therapist accepts cash, checks, and major credit cards. The agreed upon fee between Therapist and Representative is $160.00/45-50 minute session. Therapist reserves the right to periodically adjust fee. Representative will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient Representative for purposes other than sched- uling scheduling sessions. Patient Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay In addition, from time-to- time, Therapist may engage in telephone contact with third parties at Representative’s request and with Patient’s advance written authorization. Representative is responsible for services at payment of the time services are rendered. Therapist accepts cash, or major credit cardsagreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-psychotherapist- patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 $ per 50-minute session for initial assessment, couples/family therapy. The fee for service for individual therapy is $ per 50-minute session. Sessions longer than 50-minutes are charged for the additional time pro rataat a pro-rated rate in 15 minute increments. Therapist reserve reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-party payers, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is $ for individual, $ for assessment/couples or other agreed upon fee of . Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, or checks, and major credit cards, including Visa, MasterCard, American Express & Discover.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received receives a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or a person with the authority to waive the privilege on Patient’s representativebehalf. Patient When a patient is a minor child, the holder of the psychotherapist-patient privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-patient privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-patient privilege with his/her attorney. Patient, or Representative, should be aware that he/she might be waiving the psychotherapist-psychotherapist- patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient Patient, or Representative, should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 240 per intake session. The fee for service is $160 per 45-50-minute therapy session. The fee for service is $50/per session for 12-week group therapy session. Sessions longer than 50-minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient Representative will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-party payerspayors, or by agreement with Therapist. Fees are payable at the time that services are rendered. Please ask your therapist if you wish to discuss a written agreement that specifies an alternative payment procedure. Therapist accepts cash, checks, and major credit cards. The agreed upon fee between Therapist and Representative is $160.00/45-50 minute session. Therapist reserves the right to periodically adjust fee. Representative will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient Representative for purposes other than sched- uling scheduling sessions. Patient Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay In addition, from time-to- time, Therapist may engage in telephone contact with third parties at Representative’s request and with Patient’s advance written authorization. Representative is responsible for services at payment of the time services are rendered. Therapist accepts cash, or major credit cardsagreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-psychotherapist- patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 150.00 per 50-minute session. Sessions longer than 50-50- minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-party payers, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is $ . Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, or major credit cardscash and checks.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-psychotherapist- patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-doctor- patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received receives a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or a person with the authority to waive the privilege on Patient’s representativebehalf. Patient When a patient is a minor child, the holder of the psychotherapist-patient privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-patient privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-patient privilege with his/her attorney. Patient, or Representative, should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient Patient, or Representative, should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 130.00 per 50-minute session. Sessions longer than 50-50- minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient Representative will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, HMOs, managed care organizations, or other third-third- party payerspayors, or by agreement with Therapist. The agreed upon fee between Therapist and Representative is . Therapist reserves the right to periodically adjust fee. Representative will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient or Representative for purposes other than sched- uling scheduling sessions. Patient Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are In addition, from time-to-time, Therapist may engage in telephone contact with third parties at the request of Patient or Representative and with the advance written authorization of Patient or Representative. Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Representative is expected to pay for services at the time services are rendered. Therapist accepts cash, or major credit cardscash and checks.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient Patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual Usual and customary fee for service is fees are as follows: Initial Assessments (60 minutes): $100.00 per 50-minute session. 140.00 Family Sessions/Consults or Couples Sessions (60 minutes): $140.00 Individual Sessions (50 minutes): $120.00 Sessions longer than 50-that 50 minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-party payerspayors, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is noted above under usual and customary fees. Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone telephone calls longer than ten 10 minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten 10 minutes. Patients are expected to pay for services service at the time services are rendered. Therapist accepts cash, or checks, and major credit cardscards Visa or MasterCard.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-psychotherapist- patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is is, initial session, $100.00 175.00 and $150.00 for subsequent sessions per 50-minute session. Sessions longer than 50-minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-party payers, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is _. Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, or checks, and major credit cards.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $150.00 dollars per 50 minute session and $100.00 per 50-dollars for a 30 minute session. Sessions can be either secure teleconferencing, phone, in person or via text messaging. Sessions longer than 50-minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient Representative will be notified of any fee adjustment in advance. In addition, this The agreed upon fee may between Therapist and Representative is $150.00 per 50 minute session and $100.00 dollars for a 30 minute session. Therapist reserves the right to periodically adjust fee. Representative will be adjusted by contract with in- surance companies, managed care organizations, or other third-party payers, or by agreement with Therapistnotified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient or Representative for purposes other than sched- uling scheduling sessions. Patient Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are In addition, from time-to-time, Therapist may engage in telephone contact with third parties at the request of Patient or Representative and with the advance written authorization of Patient or Representative. Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Representative is expected to pay for services at the time services are rendered. Therapist accepts cash, or major checks, PayPal and credit cards.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 130.00 per 50-minute session. Sessions longer than 50-minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-party payerspayors, or by agreement with Therapist. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, or cash and major credit cards. In the event that your account is overdue (unpaid) and there is no agreement on a payment plan, Therapist can use legal means (court, collection agency, etc.) to obtain payment.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-psychotherapist- patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received receives a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or a person with the authority to waive the privilege on Patient’s representativebehalf. Patient When a patient is a minor child, the holder of the psychotherapist-patient privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-patient privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-patient privilege with his/her attorney. Patient, or Representative, should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient Patient, or Representative, should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 120 per 50-minute session. Sessions longer than 50-minutes are charged for the additional time pro ratarate. Therapist reserve reserves the right to periodically adjust this fee. Patient Representative will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, HMOs, managed care organizations, or other third-party payerspayors, or by agreement with Therapist. The agreed upon fee between Therapist and Representative $ . Therapist reserves the right to periodically adjust fee. Representative will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient or Representative for purposes other than sched- uling scheduling sessions. Patient Representative is responsible for payment of the agreed upon fee (on a pro rata rate basis) for any tele- phone telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact contact with third parties at Patient’s the request of Patient or Representative and with Patient’s the advance written authorizationauthorization of Patient or Representative. Patient Representative is respon- sible responsible for payment of the agreed upon fee (on a pro rata rate basis) for any telephone calls longer than ten minutes. Patients are Representative is expected to pay for services at the time services are rendered. Therapist accepts cash, or major credit cardscash and checks.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-psychotherapist- patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-psychotherapist- patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is one hundred and sixty five dollars $100.00 165.00 per 50-minute session. Sessions longer than 50-minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-party payerspayors, or by agreement with Therapist. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, or checks, and major credit cards.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- cally, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 50.00 per 50-minute session. Sessions longer than 50-minutes are charged for the additional time pro rata. Therapist reserve the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance companies, managed care organizations, or other third-party payers, or by agreement with Therapist. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, or major credit cards.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received receives a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or a person with the authority to waive the privilege on Patient’s representativebehalf. Patient When a patient is a minor child, the holder of the psychotherapist-patient privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-patient privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-patient privilege with his/her attorney. Patient, or Representative, should be aware that he/she might be waiving the psychotherapist-psychotherapist- patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient Patient, or Representative, should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 300 per intake session. The fee for service is $195 per 45-50-minute therapy session. Sessions longer than 50-minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient Representative will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-party payerspayors, or by agreement with Therapist. Fees are payable at the time that services are rendered. Please ask your therapist if you wish to discuss a written agreement that specifies an alternative payment procedure. Therapist accepts cash, checks, and major credit cards. The agreed upon fee between Therapist and Representative is $195.00/45-50 minute session. Therapist reserves the right to periodically adjust fee. Representative will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient Representative for purposes other than sched- uling scheduling sessions. Patient Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay In addition, from time-to- time, Therapist may engage in telephone contact with third parties at Representative’s request and with Patient’s advance written authorization. Representative is responsible for services at payment of the time services are rendered. Therapist accepts cash, or major credit cardsagreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- cally• Typically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. • Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. • Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Initials Fee and Fee Arrangements • The usual and customary fee for service is $100.00 240.00 per 50-minute session. Sessions longer than 50-minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-party payerspayors, or by agreement with Therapist. • The agreed upon fee between Therapist and Patient is $240.00. Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment 30 days in advance. • From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient’s request and with Patient’s advance written authorization. • Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. • Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, or checks, and major credit cards.. If payment is not received, Therapist can xxxx Patient a $125.00 late fee along with full session fee. Initials

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-psychotherapist- patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual agreed upon fee between Therapist and customary fee for service Patient is $100.00 100 per 50-45 minute session. Sessions longer than 50-50- minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance companies, managed care organizations, or other third-party payers, or by agreement with Therapist. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, or checks, and most major credit cards.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-psychotherapist- patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-doctor- patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 130.00 per 50-minute session. Sessions longer than 50-50- minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-party payerspayors, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is . Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, or major credit cardscash and checks.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements Arrangements: The usual and customary fee for Individual service is $100.00 150.00 per 50-50- minute session, $180.00 for Couple and $200.00 for Family Sessions. Sessions longer than 50-minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-party payerspayors, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is [insert usual and customary fee, or other agreed upon fee] . Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, or checks, and major credit cards. There is a $4 transaction fee for those using a credit card. A $25 service fee is added for all returned checks. If you wish to discuss a written agreement that specifies an alternative payment procedure, please do so prior to session. If for some reason you find that you are unable to continue paying for your therapy, please inform me and I will help you consider any options that may be available to you at that time. My fees may change over the course of treatment, but with consideration to your financial ability to continue in treatment. Typically, fees will be raised once yearly. Past due payments -- Payment for services which is past due over 120 days may be subject to collection using a collection agency. However, efforts will be made to make other arrangements with you as needed.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-psychotherapist- patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-psychotherapist- patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 105 per 50-minute sessionsession (for individuals), or $120 for an 80 min. Sessions longer than 50-minutes session (in the case of couples and family sessions). Longer sessions are charged for the additional time pro ratarata (based on the usual fee). Therapist reserve reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-party payerspayors, or by agreement with Therapist. Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance, by at least 30 days. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, or checks, PayPal, and major credit cards.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-psychotherapist- patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-psychotherapist- patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 300 per intake session. The fee for service is $195 per 45-50-minute therapy session. Sessions longer than 50-minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-third- party payerspayors, or by agreement with Therapist. Fees are payable at the time that services are rendered. Please ask your therapist if you wish to discuss a written agreement that specifies an alternative payment procedure. Therapist accepts cash, checks, and major credit cards. The agreed upon fee between Therapist and Patient is $195.00/45-50 minute session. Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is responsible for services at payment of the time services are rendered. Therapist accepts cash, or major credit cardsagreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received receives a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or a person with the authority to waive the privilege on Patient’s representativebehalf. Patient When a patient is a minor child, the holder of the psychotherapist-patient privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-patient privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-patient privilege with his/her attorney. Patient, or Representative, should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient Patient, or Representative, should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 150 per 50-minute session. Sessions longer than 50-50- minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient Representative will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, HMOs, managed care organizations, or other third-party payerspayors, or by agreement with Therapist. The agreed upon fee between Therapist and Representative is . Therapist reserves the right to periodically adjust fee. Representative will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient or Representative for purposes other than sched- uling scheduling sessions. Patient Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are In addition, from time-to-time, Therapist may engage in telephone contact with third parties at the request of Patient or Representative and with the advance written authorization of Patient or Representative. Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Representative is expected to pay for services at the time services are rendered. Therapist accepts cash, or checks, and major credit cards. Cancellation Policy Representative is responsible for payment of the agreed upon fee for any missed session(s). Representative is also responsible for payment of the agreed upon fee for any session(s) for which Representative failed to give Therapist at least 24 hours notice of cancellation. Cancellation notice should be left on Therapist’s voice mail at 000-000-0000. Therapist Availability Therapist provides Patient/Representative with a confidential voice mail system that allows Patient or Representative to leave a message at any time. Therapist will make every effort to return calls within 24 hours (or by the next business day), but cannot guarantee the calls will be returned immediately. Therapist is unable to provide 24-hour crisis service. In the event that Patient is feeling unsafe or requires immediate medical or psychiatric assistance, Patient or Representative should call 911, or go to the nearest emergency room.

Psychotherapist-Patient Privilege. The information disclosed by Patientclient, as well as any records created, is subject to the psychotherapist-psychotherapist- patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist therapist and Patient client in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist your therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will he/she would assert the psychotherapist-patient privilege on Patient’s client's behalf until instructed, in writing, to do otherwise by Patient client or Patient’s client's representative. Patient A client should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service service, is $100.00 115, per 50-minute session. Sessions longer than 50-minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this The agreed upon fee may between Therapist and Patient is . Patient will be adjusted by contract with in- surance companies, managed care organizations, or other third-party payers, or by agreement with Therapistnotified of any fee adjustment in advance. From time-to-time, Therapist your therapist may engage in telephone contact with Patient you for purposes other than sched- uling scheduling sessions. Patient is You are responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, or checks, and major credit cards, including Visa and Mastercard.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received receives a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or a person with the authority to waive the privilege on Patient’s representativebehalf. Patient When a patient is a minor child, the holder of the psychotherapist-patient privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-patient privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-patient privilege with his/her attorney. Patient, or Representative, should be aware that he/she might be waiving the psychotherapist-psychotherapist- patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient Patient, or Representative, should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 150 per 50-minute session. Sessions longer than 50-50- minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient Representative will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, HMOs, managed care organizations, or other third-party payerspayors, or by agreement with Therapist. The agreed upon fee between Therapist and Representative is $150 per 50-minute session. Therapist reserves the right to periodically adjust fee. Representative will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient or Representative for purposes other than sched- uling sessionsscheduling sessions (including crisis related phone calls). Patient Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are In addition, from time-to-time, Therapist may engage in telephone contact with third parties at the request of Patient or Representative and with the advance written authorization of Patient or Representative. Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Representative is expected to pay for services at the time services are rendered. Therapist accepts cash, or checks, and major credit cards (there is a $5 dollar service fee for credit cards).

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received receives a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or a person with the authority to waive the privilege on Patient’s representativebehalf. Patient When a patient is a minor child, the holder of the psychotherapist-patient privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-patient privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-patient privilege with his/her attorney. Patient, or Representative, should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient Patient, or Representative, should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 120 per 50-minute session. Sessions longer than 50-minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient Representative will be be~ notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, HMOs, managed care organizations, or other third-party payerspayors, or by agreement with Therapist. The agreed upon fee between Therapist and Representative $90. Therapist reserves the right to periodically adjust fee. Representative will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient or Representative for purposes other than sched- uling scheduling sessions. Patient Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are In addition, from time-to-time, Therapist may engage in telephone contact with third parties at the request of Patient or Representative and with the advance written authorization of Patient or Representative. Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Representative is expected to pay for services at the time services are rendered. Therapist accepts cash, or major credit cardscash and checks.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received receives a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or a person with the authority to waive the privilege on Patient’s representativebehalf. Patient When a patient is a minor child, the holder of the psychotherapist-patient privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-patient privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-patient privilege with his/her attorney. Patient, or Representative, should be aware that he/she might be waiving the psychotherapist-psychotherapist- patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient Patient, or Representative, should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 322.50 per intake session. The fee for service is $215.00 per 45-50-minute therapy session. Sessions longer than 50-minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient Representative will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-party payerspayors, or by agreement with Therapist. Fees are payable at the time that services are rendered. Please ask your therapist if you wish to discuss a written agreement that specifies an alternative payment procedure. Therapist accepts cash, checks, and major credit cards. The agreed upon fee between Therapist and Representative is $215.00/45-50 minute session. Therapist reserves the right to periodically adjust fee. Representative will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient Representative for purposes other than sched- uling scheduling sessions. Patient Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay In addition, from time-to- time, Therapist may engage in telephone contact with third parties at Representative’s request and with Patient’s advance written authorization. Representative is responsible for services at payment of the time services are rendered. Therapist accepts cash, or major credit cardsagreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received receives a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or a person with the authority to waive the privilege on Patient’s representativebehalf. Patient When a patient is a minor child, the holder of the psychotherapist-patient privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-patient privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-patient privilege with his/her attorney. Patient, or Representative, should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient Patient, or Representative, should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 100 per 50-minute session. Sessions longer than 50-minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient Representative will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, HMOs, managed care organizations, or other third-party payerspayors, or by agreement with Therapist. The agreed upon fee between Therapist and Representative is [insert usual and customary fee, or other agreed upon fee] . Therapist reserves the right to periodically adjust fee. Representative will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient or Representative for purposes other than sched- uling scheduling sessions. Patient Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are In addition, from time-to-time, Therapist may engage in telephone contact with third parties at the request of Patient or Representative and with the advance written authorization of Patient or Representative. Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Representative is expected to pay for services at the time services are rendered. Therapist accepts cash, or major credit cardschecks.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-psychotherapist- patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-psychotherapist- patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 322.50 per intake session. The fee for service is $215.00 per 45-50-minute therapy session. Sessions longer than 50-minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-third- party payerspayors, or by agreement with Therapist. Fees are payable at the time that services are rendered. Please ask your therapist if you wish to discuss a written agreement that specifies an alternative payment procedure. Therapist accepts cash, checks, and major credit cards. The agreed upon fee between Therapist and Patient is $215.00/45-50 minute session. Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is responsible for services at payment of the time services are rendered. Therapist accepts cash, or major credit cardsagreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-psychotherapist patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapistPsychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-psychotherapist patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 160 for initial 60 minute intake session and $140 per 50-minute sessionsession thereafter. Sessions longer than 50-minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-party payers, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is $160 for initial intake session and $140 for every 50-minute session thereafter. Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, or checks, and most major credit cards.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-psychotherapist- patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. attorney Fee and Fee Arrangements The usual and customary fee for service is $100.00 120 per 50-minute session. Sessions longer than 50-50- minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-party payers, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is _. Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, or checks, and major credit cards.cards Cancellation Policy Patient is responsible for payment of the agreed upon fee for any missed session(s). Patient is also responsible for payment of the agreed upon fee for any session(s) for which Patient failed to give Therapist at least 24 hours notice of cancellation. Cancellation notice should be left on Therapist’s voice mail at 323.304.5777

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-psychotherapist- patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-psychotherapist- patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 110 per 5060-minute sessionsession (for individuals), or $140 for an 90 min. Sessions longer than 50-minutes session (in the case of couples and family sessions). Longer sessions are charged for the additional time pro ratarata (based on the usual fee). Therapist reserve reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-party payerspayors, or by agreement with Therapist. Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance, by at least 30 days. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, or checks, PayPal, and major credit cards.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 120 per 50-minute session. Sessions longer than 50-minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-party payerspayors, or by agreement with Therapist. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are renderedbeginning of each session. Therapist accepts cash, or checks, and major credit cardscards Insurance Patient is responsible for any and all fees not reimbursed by his/her insurance company, managed care organization, or any other third-party payor. Patient is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments and deductibles. Therapist is not a contracted provider with any insurance company, managed care organization. Should Patient choose to use his/her insurance, Therapist will provide Patient with a statement, which Patient can submit to the third-party of his/her choice to seek reimbursement of fees already paid to therapist.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-psychotherapist- patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-psychotherapist- patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 240 per intake session. The fee for service is $160 per 45-50-minute therapy session. Sessions longer than 50-minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-third- party payerspayors, or by agreement with Therapist. Fees are payable at the time that services are rendered. Please ask your therapist if you wish to discuss a written agreement that specifies an alternative payment procedure. Therapist accepts cash, checks, and major credit cards. The agreed upon fee between Therapist and Patient is $160.00/45-50 minute session. Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is responsible for services at payment of the time services are rendered. Therapist accepts cash, or major credit cardsagreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-psychotherapist- patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements Your first (intake) session fee is $125.00. This session is a higher fee due to the extensive assessment done. The usual and customary fee for service is $100.00 per 50-minute session. Sessions Some sessions may last longer than 50or need more time. The fee for service per 75-minutes are charged for the additional time pro rataminute session is $120. Therapist reserve reserves the right to periodically adjust this feethese fees. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-party payers, or by agreement with Therapist. Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, or checks, and major credit cards. The Therapist reserves the right to collect balances that have been unpaid by using collection agencies if necessary. The Therapist will make several attempts to rectify a balance issue before a collection agency is considered.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-psychotherapist- patient privilege. If Therapist received receives a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or a person with the authority to waive the privilege on Patient’s representativebehalf. Patient When a patient is a minor child, the holder of the psychotherapist-patient privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-patient privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist- patient privilege with his/her attorney. Patient, or Parent/Representative, should be aware that he/she might be waiving the psychotherapist-psychotherapist- patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient Patient, or Representative, should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 150 per 5045-50- minute session. Sessions longer than 50-50- minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient Representative will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance companies, managed care organizations, or other third-party payers, or by agreement with Therapist. From time-to-time, Therapist may engage in telephone contact with Patient or Parent/Representative for purposes other than sched- uling scheduling sessions. Patient Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are In addition, from time-to-time, Therapist may engage in telephone contact with third parties at the request of Patient or Representative and with the advance written authorization of Patient or Representative. Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Parent/Representative is expected to pay for services at the time services are rendered. Therapist accepts cash, or checks, and major credit cards.. Insurance Parent/Representative is responsible for any and all fees not reimbursed by his/her insurance company, managed care organization, or any other third-party payor. Parent/Representative is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co- payments and deductibles. Therapist is not a contracted provider with any insurance company, managed care organization. Should Representative choose to use his/her insurance, Therapist will provide Representative with a statement, which Representative can submit to the third-party of his/her choice to seek reimbursement of fees already paid. Cancellation Policy Parent/Representative is responsible for payment of the agreed upon fee for any missed session(s). Representative is also responsible for payment of the agreed upon fee for any session(s) for which Representative failed to give Therapist at least 24 hours notice of cancellation. Cancellation notice should be left on Therapist’s voice mail at 949.838.7289

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-psychotherapist- patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-doctor- patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 120.00 per 50-minute session. Sessions longer than 50-50- minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-party payerspayors, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is . Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, or checks, and major credit cards.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary pre-approved fee for service is $100.00 $ 120 per 5050- minute session. The Therapist offers a few spaces for sliding scale fee Patients. In this case, the agreed upon fee between Therapist and Patient is ( ) Co-Pay per 50 minute session. Sessions longer than 50-minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-party payerspayors, or by agreement with Therapist. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, or checks, and major credit cards, including Visa, MasterCard, Discover and American Express.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- cally• Typically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. • Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. • Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Initials Fee and Fee Arrangements • The usual and customary fee for service is $100.00 175.00 per 50-minute session. Sessions longer than 50-minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-party payerspayors, or by agreement with Therapist. • The agreed upon fee between Therapist and Patient is $175.00. Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment 30 days in advance. • From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient’s request and with Patient’s advance written authorization. • Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. • Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, or checks, and major credit cards.. If payment is not received, Therapist can xxxx Patient a $25.00 late fee. Initials

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-psychotherapist- patient privilege. If Therapist received receives a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or a person with the authority to waive the privilege on Patient’s representativebehalf. Patient When a patient is a minor child, the holder of the psychotherapist-patient privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-patient privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-patient privilege with his/her attorney. Patient, or Representative, should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient Patient, or Representative, should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 100 per 50-minute session. Sessions longer than 50-50- minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient Representative will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, HMOs, managed care organizations, or other third-third- party payerspayors, or by agreement with Therapist. The agreed upon fee between Therapist and Representative is . Therapist reserves the right to periodically adjust fee. Representative will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient or Representative for purposes other than sched- uling scheduling sessions. Patient Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are In addition, from time- to-time, Therapist may engage in telephone contact with third parties at the request of Patient or Representative and with the advance written authorization of Patient or Representative. Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Representative is expected to pay for services at the time services are rendered. Therapist accepts cash, or checks, and major credit cards. Insurance Representative is responsible for any and all fees not reimbursed by his/her insurance company, managed care organization, or any other third-party payor. Representative is responsible for verifying and understanding the limits of his/her coverage, as well as his/her co-payments and deductibles. Therapist is not a contracted provider with any insurance company, managed care organization. Should Representative choose to use his/her insurance, Therapist will provide Representative with a statement, which Representative can submit to the third-party of his/her choice to seek reimbursement of fees already paid. Cancellation Policy Representative is responsible for payment of the agreed upon fee for any missed session(s). Representative is also responsible for payment of the agreed upon fee for any session(s) for which Representative failed to give Therapist at least 24 hours notice of cancellation. Cancellation notice should be left on Therapist’s voice mail at 916.715.6420.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for psychotherapeutic service is $100.00 120.00 per 50-minute session. Sessions Clinical interviews required for psycho-social reporting fee is $150.00 per 60 minutes and each 60-minute hour thereafter in preparation for a written report. Sessions/interviews longer than 5060-minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. fees and Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-party payers, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is $______. Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. Patients are expected to pay for services at the time services are rendered. There will be a $25 charge for payment returned as non-sufficient or non-payable. Therapist accepts cash, checks, and major credit cards, including Visa, MasterCard, Discover and AmEx. Initial/s here: ______________________. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling sessionsscheduling sessions or coordination of care with other professionals. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Patient’s request and with Patient’s advance written authorization regarding treatment. Patient is responsible for services at payment of the time services are renderedagreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Therapist accepts cash, or major credit cardsInitial/s here: ________________________.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received receives a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or a person with the authority to waive the privilege on Patient’s representativebehalf. Patient When a patient is a minor child, the holder of the psychotherapist-patient privilege is either the minor, a court appointed guardian, or minor’s counsel. Parents typically do not have the authority to waive the psychotherapist-patient privilege for their minor children, unless given such authority by a court of law. Representative is encouraged to discuss any concerns regarding the psychotherapist-patient privilege with his/her attorney. Patient, or Representative, should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient Patient, or Representative, should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 per 50-minute session. Sessions longer than 50-minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient Representative will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, HMOs, managed care organizations, or other third-party payers, or by agreement with Therapist. The agreed upon fee between Therapist and Representative is or the co-pay amount of is required at the time of each visit. If there is a deductible or if the insurance claim is denied, then the patient is responsible for the agreed upon fee as stated within. Therapist reserves the right to periodically adjust fee. Representative will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient or Representative for purposes other than sched- uling scheduling sessions. Patient Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are In addition, from time-to-time, Therapist may engage in telephone contact with third parties at the request of Patient or Representative and with the advance written authorization of Patient or Representative. Representative is responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Representative is expected to pay for services at the time services are rendered. Therapist accepts cash, or checks, and major credit cards, including Visa, Master Card and American Express.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-patient privilege. If Therapist received receives a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representativeRepresentative. Patient Patient, should be aware that he/she might be waiving the psychotherapist-patient privilege if he/he/ she makes his/her mental or emotional state an issue in a legal proceeding. Patient Patient, should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/his/ her attorney. Fee and Fee Arrangements The usual and customary fee for service is $100.00 240 per intake session. The fee for service is $160 per 45-50-minute therapy session. The fee for service is $50/per session for 12-week group therapy session. Sessions longer than 50-minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-party payerspayors, or by agreement with Therapist. Fees are payable at the time that services are rendered. Please ask your therapist if you wish to discuss a written agreement that specifies an alternative payment procedure. Therapist accepts cash, checks, and major credit cards. The agreed upon fee between Therapist and Representative is $160.00/45-50 minute session. Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay In addition, from time-to-time, Therapist may engage in telephone contact with third parties at Representative’s request and with Patient’s advance written authorization. Patient is responsible for services at payment of the time services are rendered. Therapist accepts cash, or major credit cardsagreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-psychotherapist- patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is a sliding scale of $100.00 80 to $100 per 50-minute session. Sessions longer than 50-minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this fee may be adjusted by contract with in- surance insurance companies, managed care organizations, or other third-party payerspayors, or by agreement with Therapist. The agreed upon fee between Therapist and Patient is . Therapist reserves the right to periodically adjust fee. Patient will be notified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, or major credit cardschecks, and money orders.

Psychotherapist-Patient Privilege. The information disclosed by Patient, as well as any records created, is subject to the psychotherapist-patient privilege. The psychotherapist-patient privilege results from the special relationship between Therapist and Patient in the eyes of the law. It is akin to the attorney-client privilege or the doctor-patient privilege. Typi- callyTypically, the patient is the holder of the psychotherapist-psychotherapist- patient privilege. If Therapist received a subpoena for records, deposition testimony, or testimony in a court of law, Therapist will assert the psychotherapist-patient privilege on Patient’s behalf until instructed, in writing, to do otherwise by Patient or Patient’s representative. Patient should be aware that he/she might be waiving the psychotherapist-patient privilege if he/she makes his/her mental or emotional state an issue in a legal proceeding. Patient should address any concerns he/she might have regarding the psychotherapist-patient privilege with his/her attorney. Fee and Fee Arrangements The usual and customary fee for service is [$100.00 150] per 50-minute session. Sessions longer than 50-50- minutes are charged for the additional time pro rata. Therapist reserve reserves the right to periodically adjust this fee. Patient will be notified of any fee adjustment in advance. In addition, this The agreed upon fee may between Therapist and Patient is [ $150 ]. Therapist reserves the right to periodically adjust fee. Patient will be adjusted by contract with in- surance companies, managed care organizations, or other third-party payers, or by agreement with Therapistnotified of any fee adjustment in advance. From time-to-time, Therapist may engage in telephone contact with Patient for purposes other than sched- uling scheduling sessions. Patient is responsible for payment of the agreed upon fee (on a pro rata basis) for any tele- phone telephone calls longer than ten minutes. In addition, from time-to-time, Therapist may engage in telephone con- tact contact with third parties at Patient’s request and with Patient’s advance written authorization. Patient is respon- sible responsible for payment of the agreed upon fee (on a pro rata basis) for any telephone calls longer than ten minutes. Patients are expected to pay for services at the time services are rendered. Therapist accepts cash, or checks, and major credit cards, including pay pal and money orders.