Common use of TELEPHONE & EMERGENCY PROCEDURES Clause in Contracts

TELEPHONE & EMERGENCY PROCEDURES. If you need to contact Xxxxx Xxxxxx between sessions, please leave a message on her confidential voice mail at (000) 000-0000 and your call will be returned as soon as possible. Xxxxx Xxxxxx checks her messages a few times during the daytime only, unless she is out of town. If an emergency situation arises, indicate it clearly in your message and if you need to talk to someone right away, call the Police: 911. Please do not use email or faxes for emergencies. PAYMENTS & INSURANCE REIMBURSEMENT: The fee or copay for service is $ for an in person, telehealth, home and telephone session. Xxxxx Xxxxxx reserves the right to periodically adjust the fee and will notify client in advance. Fees (including co-pays) are payable at time service is rendered. You can pay by check, cash, Venmo, Health Savings Account, or credit card via Square. Please note that there is an additional transaction fee of 4% for credit and debit cards. Please ask Xxxxx Xxxxxx if you wish to discuss a written agreement that specifies an alternative payment procedure. Please inform Xxxxx Xxxxxx if you wish to utilize health insurance to pay for services. If Xxxxx Xxxxxx is a contracted provider for your insurance company, she will discuss the procedure for billing your insurance. The amount of reimbursement and the amount of any co-payments or deductible depends on the requirements of you specific insurance plan. You should be aware that you are responsible for verifying and understanding the limits of your insurance coverage. Although Xxxxx Xxxxxx is happy to assist you in your efforts to seek insurance reimbursement, there is no guarantee whether your insurance will provide payment for the services provided to you. This means that you are financially responsible for any unpaid amount. Please discuss any questions or concerns that you may have about this with Xxxxx Xxxxxx. If for some reason you are unable you continue paying for therapy, you should inform Xxxxx Xxxxxx. She will help you to consider any options that may be available to you at this time. DELINQUENT ACCOUNT POLICY: If your account is overdue (unpaid) and there is no written agreement on a payment plan, Xxxxx Xxxxxx can use legal or other means (courts, collection agencies, etc.) to obtain payment. MEDIATION & ARBITRATION: All disputes arising out of, or in relation to, this agreement to provide psychotherapy services shall preferably first be referred to mediation before the initiation of arbitration or litigation. The mediator shall be a neutral third party chosen by agreement of Xxxxx Xxxxxx and the client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed upon. In the event that mediation is unsuccessful or not an agreed-upon option, any unresolved controversy related to this agreement should preferably be submitted to and settled by binding arbitration, in accordance with the rules of the American Arbitration Association which are in effect at the time the request for arbitration is filed. Please, note that neither mediation nor arbitration is mandatory. In the event that your account is overdue (unpaid) and there is no agreement on a payment plan, Xxxxx Xxxxxx can use legal means (court, collection agency, etc.) to seek payment. If there is arbitration, the prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum as and for attorney's fees. In the case of arbitration, the arbitrator will determine that sum. In the case of a court case, the court will determine the sum. PATIENT LITIGATION: Xxxxx Xxxxxx will not voluntarily participate in any litigation, or custody dispute in which client and another individual, or entity, are parties. Xxxxx Xxxxxx has a policy of not communicating with client’s attorney and will not write or sign letters, reports, declarations, or affidavits be used in client’s legal matter. Xxxxx Xxxxxx will not provide records or testimony to be used in client’s legal matter. There are occasions where Xxxxx Xxxxxx will make an exception and charge the fee of $225.00 per hour for writing a clinical summary and treatment recommendations. Should Xxxxx Xxxxxx be subpoenaed, or ordered by a court of law, to appear as a witness in an action involving the client, client agrees to reimburse at $400.00 per hour for a minimal of ½ day of service. THE PROCESS OF THERAPY/EVALUATION AND SCOPE OF PRACTICE: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. Xxxxx Xxxxxx will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. Xxxxx Xxxxxx may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, Xxxxx Xxxxxx is likely to draw on various psychological approaches according, in part, to the problem that is being treated and his/her assessment of what will best benefit you. These approaches include, but are not limited to, behavioral, cognitive-behavioral, psychodynamic, mind/body modalities, existential, family systems, developmental (adult, child, family), humanistic and/or psycho-educational. Xxxxx Xxxxxx provides neither custody evaluation recommendation nor medication or prescription recommendation nor legal advice, as these activities do not fall within her scope of practice.

TELEPHONE & EMERGENCY PROCEDURES. If you need to contact Xxxxx Xx. Xxxxxx between sessions, please leave a message on her confidential voice mail at (000) 000-0000 000.000.0000 and your call will be returned as soon as possible. Xxxxx Xx. Xxxxxx checks her messages a few times during the daytime only, unless she is out of town. If an emergency situation arises, indicate it clearly in your message and if you need to talk to someone right away, away call the Police: 911. Please do not use email or faxes for emergencies. Xx. Xxxxxx does not always check her email or faxes daily. PAYMENTS & INSURANCE REIMBURSEMENT: The Clients are expected to pay the standard fee agreed upon between client and Xx. Xxxxxx at the end of each session or copay unless other arrangements have been made. Telephone conversations, site visits, writing and reading of reports, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed upon otherwise. Please notify Xx. Xxxxxx if any problems arise during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance companies. Unless agreed upon differently, Xx. Xxxxxx will provide you with a copy of your receipt on a monthly basis, which you can then submit to your insurance company for service is $ for an reimbursement, if you so choose. As was indicated in person, telehealth, home and telephone session. Xxxxx Xxxxxx reserves the right to periodically adjust the fee and will notify client in advance. Fees (including co-pays) are payable at time service is rendered. You can pay by check, cash, Venmosection, Health Savings AccountInsurance & Confidentiality of Records, or credit card via Square. Please note that there is an additional transaction fee of 4% for credit and debit cards. Please ask Xxxxx Xxxxxx if you wish to discuss a written agreement that specifies an alternative payment procedure. Please inform Xxxxx Xxxxxx if you wish to utilize health insurance to pay for services. If Xxxxx Xxxxxx is a contracted provider for your insurance company, she will discuss the procedure for billing your insurance. The amount of reimbursement and the amount of any co-payments or deductible depends on the requirements of you specific insurance plan. You should must be aware that you submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems, which are responsible for verifying and understanding dealt with in psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the limits specifics of your insurance coverage. Although Xxxxx Xxxxxx is happy to assist you in your efforts to seek insurance reimbursement, there is no guarantee whether your insurance will provide payment for the services provided to you. This means that you are financially responsible for any unpaid amount. Please discuss any questions or concerns that you may have about this with Xxxxx Xxxxxx. If for some reason you are unable you continue paying for therapy, you should inform Xxxxx Xxxxxx. She will help you to consider any options that may be available to you at this time. DELINQUENT ACCOUNT POLICY: If your account is overdue (unpaid) and there is no written agreement on a payment plan, Xxxxx Xx. Xxxxxx can use legal or other means (courts, collection agencies, etc.) to obtain payment. MEDIATION & ARBITRATION: All disputes arising out of, or in relation to, this agreement to provide psychotherapy services shall preferably first be referred to mediation before the initiation of arbitration or litigation. The mediator shall be a neutral third party chosen by agreement of Xxxxx Xxxxxx and the client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed upon. In the event that mediation is unsuccessful or not an agreed-upon option, any unresolved controversy related to this agreement should preferably be submitted to and settled by binding arbitration, in accordance with the rules of the American Arbitration Association which are in effect at the time the request for arbitration is filed. Please, note that neither mediation nor arbitration is mandatory. In the event that your account is overdue (unpaid) and there is no agreement on a payment plan, Xxxxx Xxxxxx can use legal means (court, collection agency, etc.) to seek payment. If there is arbitration, the prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum as and for attorney's fees. In the case of arbitration, the arbitrator will determine that sum. In the case of a court case, the court will determine the sum. PATIENT LITIGATION: Xxxxx Xxxxxx will not voluntarily participate in any litigation, or custody dispute in which client and another individual, or entity, are parties. Xxxxx Xxxxxx has a policy of not communicating with client’s attorney and will not write or sign letters, reports, declarations, or affidavits be used in client’s legal matter. Xxxxx Xxxxxx will not provide records or testimony to be used in client’s legal matter. There are occasions where Xxxxx Xxxxxx will make an exception and charge the fee of $225.00 per hour for writing a clinical summary and treatment recommendations. Should Xxxxx Xxxxxx be subpoenaed, or ordered by a court of law, to appear as a witness in an action involving the client, client agrees to reimburse at $400.00 per hour for a minimal of ½ day of service. THE PROCESS OF THERAPY/EVALUATION AND SCOPE OF PRACTICE: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. Xxxxx Xxxxxx will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. Xxxxx Xxxxxx may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, Xxxxx Xxxxxx is likely to draw on various psychological approaches according, in part, to the problem that is being treated and his/her assessment of what will best benefit you. These approaches include, but are not limited to, behavioral, cognitive-behavioral, psychodynamic, mind/body modalities, existential, family systems, developmental (adult, child, family), humanistic and/or psycho-educational. Xxxxx Xxxxxx provides neither custody evaluation recommendation nor medication or prescription recommendation nor legal advice, as these activities do not fall within her scope of practice.

TELEPHONE & EMERGENCY PROCEDURES. If you need to contact Xxxxx Xxxxxx Xxxxx, LCSW between sessions, : please leave a message on her confidential voice mail at (000) -000-0000 and your call will be returned as soon as possible. Xxxxx possible - typically within 24 hours during the Mon-Friday business week Xxxxxx Xxxxx, LCSW checks her messages a few times during the daytime only, : unless she is out of town. If an emergency situation arises, indicate it clearly in your message and if you need to To talk to someone right away, away call Psychiatric or Behavioral/Mental Health Emergency Services. (Maricopa County): 000-000-0000 (24-hour crisis line) (Phoenix area) or the Police: 911. Please do not use email or faxes for emergencies. Xxxxxx Xxxxx, LCSW does not always check her email or faxes daily. If Xxxxxx Xxxxx, LCSW is incapacitated, please contact Xxxxx Xxxxxxxxxxx, PhD at 000-000-0000. PAYMENTS & INSURANCE REIMBURSEMENT: The fee or copay For insurance company for service is $ for an in personreimbursement: if you so choose. Xxxxxx Xxxxx, telehealth, home and telephone session. Xxxxx Xxxxxx reserves the right to periodically adjust the fee LCSW contracts with various Insurance companies and will notify client in advance. Fees (including bill your insurance directly and only collect the co-pays) are payable pay or the deductible at the time service of your appointment. If Xxxxxx Xxxxx, LCSW bills your insurance she has hired a medical xxxxxx to assist in this billing Insurance process. This medical xxxxxx is renderedtrained in HIPAA and client confidentiality, as was indicated in the section: Health Insurance & Confidentiality of Records. You can pay by check, cash, Venmo, Health Savings Account, or credit card via Square. Please note that there is an additional transaction fee of 4% for credit and debit cards. Please ask Xxxxx Xxxxxx if you wish to discuss a written agreement that specifies an alternative payment procedure. Please inform Xxxxx Xxxxxx if you wish to utilize health insurance to pay for services. If Xxxxx Xxxxxx is a contracted provider for your insurance company, she will discuss the procedure for billing your insurance. The amount of reimbursement and the amount of any co-payments or deductible depends on the requirements of you specific insurance plan. You should must be aware that you submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems: which are responsible for verifying and understanding dealt with in psychotherapy: are reimbursed by insurance companies. It is your responsibility to verify the limits specifics of your insurance coverage. Although Xxxxx Xxxxxx is happy to assist you in your efforts to seek insurance reimbursement, there is no guarantee whether your insurance will provide payment for the services provided to you. This means that you are financially responsible for any unpaid amount. Please discuss any questions or concerns that you may have about this with Xxxxx Xxxxxx. If for some reason you are unable you continue paying for therapy, you should inform Xxxxx Xxxxxx. She will help you to consider any options that may be available to you at this time. DELINQUENT ACCOUNT POLICY: If your account is overdue (unpaid) and there is no written agreement on a payment plan: Xxxxxx Xxxxx, Xxxxx Xxxxxx LCSW can use legal or other means (courts, : collection agencies, etc.) to obtain payment. MEDIATION & ARBITRATIONFor self-pay or if you are handling your own insurance submittal: All disputes arising out of, or in relation to, this agreement Clients are expected to provide psychotherapy services shall preferably first be referred to mediation before pay the initiation of arbitration or litigation. The mediator shall be a neutral third party chosen by agreement of Xxxxx Xxxxxx and the client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed upon. In the event that mediation is unsuccessful or not an agreed-upon option, any unresolved controversy related to this agreement should preferably be submitted to and settled by binding arbitration, in accordance with the rules of the American Arbitration Association which are in effect at the time the request for arbitration is filed. Please, note that neither mediation nor arbitration is mandatory. In the event that your account is overdue (unpaid) and there is no agreement on a payment plan, Xxxxx Xxxxxx can use legal means (court, collection agency, etc.) to seek payment. If there is arbitration, the prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum as and for attorney's fees. In the case of arbitration, the arbitrator will determine that sum. In the case of a court case, the court will determine the sum. PATIENT LITIGATION: Xxxxx Xxxxxx will not voluntarily participate in any litigation, or custody dispute in which client and another individual, or entity, are parties. Xxxxx Xxxxxx has a policy of not communicating with client’s attorney and will not write or sign letters, reports, declarations, or affidavits be used in client’s legal matter. Xxxxx Xxxxxx will not provide records or testimony to be used in client’s legal matter. There are occasions where Xxxxx Xxxxxx will make an exception and charge the standard fee of $225.00 130 for intakes, $100.00 per 45 minute therapy session or S120.00 per hour therapy session at the end of each session or prior to each session unless other arrangements have been made. The no-show fee, missed appointment or late cancellation fee with under 48 hours’ notice is $120. Xxxxxx Xxxxx, LCSW may automatically charge your card on file for missed appointments unless other arrangements have been agreed upon between you and Xxxxxx Xxxxx, LCSW such as your insurance discounted rate. Telephone conversations, site visits, writing and reading of reports: consultation with other professionals: release of information: reading records: longer sessions: travel time: etc. will be charged at the same rate: unless indicated and agreed upon otherwise. Notify Xxxxxx Xxxxx, LCSW if any problems arise during the course of therapy regarding your ability to make timely payments. Clients who carry Insurance not contracted with Xxxxxx should remember that professional services are rendered and charged to the clients and not to the insurance companies, Xxxxxx Xxxxx, LCSW will provide you with a clinical summary and treatment recommendations. Should Xxxxx Xxxxxx be subpoenaed, or ordered by a court copy of law, your receipt per your request which you can then submit to appear as a witness in an action involving the client, client agrees to reimburse at $400.00 per hour your insurance company for a minimal of ½ day of servicereimbursement. THE PROCESS OF THERAPY/, EVALUATION AND SCOPE OF PRACTICE: Participation in therapy is voluntary and can result in m a number of benefits to you, : including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, : however, : requires effort on your part. Psychotherapy requires your very active involvement, : honesty, : and openness in order to change your thoughts, feelings, : and/or behavior. Xxxxx Xxxxxx Xxxxx, LCSW will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. honestly Sometimes more than one approach can be is helpful in dealing with a certain situation. During evaluation or therapy, : remembering or talking about unpleasant events, : feelings, : or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, : sadness, : worry, : fear, etc., : or experiencing anxiety, : depression, insomnia, : etc. Xxxxx Xxxxxx Xxxxx, LCSW may challenge some of your assumptions or perceptions or propose different ways of looking at, : thinking about, : or handling situations, : which can cause you to feel very upset, angry, : depressed, : challenged, : or disappointed. Attempting to resolve issues that brought you to therapy in the first place, : such as personal or interpersonal relationships, : may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, : employment, : substance use, : schooling, : housing, : or relationships. Sometimes a decision that is IS positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, : but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, Xxxxx Xxxxxx Xxxxx, LCSW is likely to draw on various psychological approaches according, : in part, : to the problem that is being treated and his/her assessment of what will best benefit you. These approaches includeXxxxxx Xxxxx, but are not limited to, behavioral, cognitive-behavioral, psychodynamic, mind/body modalities, existential, family systems, developmental (adult, child, family), humanistic and/or psycho-educational. Xxxxx Xxxxxx LCSW provides neither custody evaluation recommendation nor medication or prescription recommendation recommendations nor legal advice, : as these activities do not fall within her scope of practice. Discussing your compliance with medications (such as asking you what meds you take) in the interest of discussing progress may be addressed in session but Xxxxxx Xxxxx, LCSW advises you to discuss all medical and medication management issues with your prescriber. You may withdraw from therapy services at any time. TREATMENT PLANS: Within a reasonable period of time after the initiation of treatment: Xxxxxx Xxxxx, LCSW will discuss with you her working understanding of the problem: treatment plan: therapeutic objectives: and his/her view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy: their possible risks: Xxxxxx Xxxxx, LCSW’s expertise in employing them: or about the treatment plan: please ask and you will be answered fully. You also have the right to ask about other treatments for your condition arid their risks and benefits.

TELEPHONE & EMERGENCY PROCEDURES. If you need to contact Xxxxx Xxxxxx me between sessions, please text me or leave a message on her confidential with my voice mail at (000) 000-0000 and your call will be returned as soon as possible. Xxxxx Xxxxxx checks her I check my messages several times a few times during the daytime onlyday, unless she is I am out of town. If an emergency situation arises, please indicate it clearly in your message and if voice mail message. If you need to talk to someone right awaygain immediate assistance, please call the Police: 911. Payments & Insurance Reimbursement: Clients are expected to pay the agreed-upon fee at the end of each session unless other arrangements have been made. Site visits, report writing, in-person consultation (as requested by you) with other professionals, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed otherwise. Please do notify me if any problem arises during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that rendered professional services are charged to the clients and not use email to the insurance companies. Unless agreed upon differently, I can provide you with a copy of your receipt which you can then submit to your insurance company for reimbursement if you so choose. For any last-minute cancellations or faxes no-show appointments, you responsible for emergencies. PAYMENTS & INSURANCE REIMBURSEMENT: The fee or copay for service is $ for an in person, telehealth, home and telephone session. Xxxxx Xxxxxx reserves the right to periodically adjust full payment of both the fee and will notify client in advance. Fees (including co-pays) are payable at time service is renderedpay and what would normally be covered by the insurance company. You can pay by check, cash, VenmoAs was indicated in the section, Health Savings AccountInsurance & Confidentiality of Records, or credit card via Square. Please note that there is an additional transaction fee of 4% for credit and debit cards. Please ask Xxxxx Xxxxxx if you wish to discuss a written agreement that specifies an alternative payment procedure. Please inform Xxxxx Xxxxxx if you wish to utilize health insurance to pay for services. If Xxxxx Xxxxxx is a contracted provider for your insurance company, she will discuss the procedure for billing your insurance. The amount of reimbursement and the amount of any co-payments or deductible depends on the requirements of you specific insurance plan. You should must be aware that you submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems, which are the focus of psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage prior to the initiation of services. You will be responsible for verifying and understanding all services rendered in the limits of event that you discover afterwards that your insurance coveragecoverage does not cover the costs of therapy services. Although Xxxxx Xxxxxx is happy to assist you in your efforts to seek insurance reimbursement, there is no guarantee whether your insurance will provide payment for the services provided to you. This means that you are financially responsible for any unpaid amount. Please discuss any questions or concerns that you may have about this with Xxxxx Xxxxxx. If for some reason you are unable you continue paying for therapy, you should inform Xxxxx Xxxxxx. She will help you to consider any options that may be available to you at this time. DELINQUENT ACCOUNT POLICY: If your account is overdue (unpaid) and there is no written agreement on a payment plan, Xxxxx Xxxxxx can use legal or other means (courts, collection agencies, etc.) to obtain payment. MEDIATION Mediation & ARBITRATION: Arbitration All disputes arising out of, of or in relation to, to this agreement to provide psychotherapy services shall preferably first be referred to mediation before mediation, before, and as a pre-condition of, the initiation of arbitration or litigationarbitration. The mediator shall be a neutral third party chosen by agreement of Xxxxx Xxxxxx and the client(s)between us. The cost of such mediation, if any, shall be split equally, unless otherwise agreed uponagreed. In the event that mediation is unsuccessful or not an agreed-upon optionunsuccessful, any unresolved controversy related to this agreement should preferably be submitted to and settled by binding arbitrationarbitration in Yolo County, CA in accordance with the rules of the American Arbitration Association which that are in effect at the time the request demand for arbitration is filed. PleaseNotwithstanding the foregoing, note that neither mediation nor arbitration is mandatory. In in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, Xxxxx Xxxxxx can I may use legal means (court, collection agency, etc.) to seek obtain payment. If there is arbitration, the The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum as and for attorney's attorneys’ fees. In the case of arbitration, the arbitrator will determine that sum. In the case The Process of a court case, the court will determine the sum. PATIENT LITIGATION: Xxxxx Xxxxxx will not voluntarily participate in any litigation, or custody dispute in which client and another individual, or entity, are parties. Xxxxx Xxxxxx has a policy of not communicating with client’s attorney and will not write or sign letters, reports, declarations, or affidavits be used in client’s legal matter. Xxxxx Xxxxxx will not provide records or testimony to be used in client’s legal matter. There are occasions where Xxxxx Xxxxxx will make an exception and charge the fee of $225.00 per hour for writing a clinical summary and treatment recommendations. Should Xxxxx Xxxxxx be subpoenaed, or ordered by a court of law, to appear as a witness in an action involving the client, client agrees to reimburse at $400.00 per hour for a minimal of ½ day of service. THE PROCESS OF THERAPYTherapy/EVALUATION AND SCOPE OF PRACTICE: Evaluation Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, feelings and/or behavior. Xxxxx Xxxxxx I will ask for your feedback and views on your therapyour work together, its progress, and other aspects of the therapy and will expect encourage you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During the initial phase of the evaluation or throughout the course of ongoing therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you your experiencing considerable discomfort or strong including feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. Xxxxx Xxxxxx I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which situations that can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often often, it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, Xxxxx Xxxxxx is I am likely to draw on various psychological approaches according, in part, to address the problem that is being treated and his/her my assessment of what will best benefit you. These approaches include, but are not limited to, behavioralmay include those from the psychodynamic, cognitive-behavioral, psychodynamic, mindsystem/body modalities, existential, family systemsfamily, developmental (adult, child, family), humanistic and/or or psycho-educationaleducational perspectives. Xxxxx Xxxxxx provides neither custody evaluation recommendation nor medication or prescription recommendation nor legal adviceYour appointment will last 50 minutes. If I am providing services to your child, as these activities please do not fall within drop him/her scope off in the waiting room without checking in with me first. I ask that you please be prompt in picking up your child after his/her appointment as I often have appointments scheduled each hour and would not want to risk leaving your child in the lobby unsupervised, unless specific arrangements are made with you. I routinely offer clients a lollipop and cup of practicetea or hot chocolate at the beginning of sessions. If you or your child has any dietary restrictions concerning any of these items, please let me know. By signing this form, you are agreeing to not hold me legally responsible for any incidental liquid xxxxx or unanticipated allergic reactions that may result from the consumption of these items.

TELEPHONE & EMERGENCY PROCEDURES. If you need to contact Xxxxx Xxxxxx Monarch Counseling between sessions, please leave a message on her confidential voice mail at (000) 000-0000 with your therapist and your call will be returned as soon as possible. Xxxxx Xxxxxx checks her Monarch Counseling therapists check messages a few times during the daytime only, unless she is out of towndaytime. If an emergency situation arises, indicate it clearly in your message and if you need to talk to someone right away, away call the Police24-hour crisis line: (000) 000-0000 or call 911. Please do not use email or faxes for emergencies. Monarch Counseling does not always check email or faxes daily. PAYMENTS & INSURANCE REIMBURSEMENT: Monarch Counseling will submit claims to your insurance company on your behalf. The fee or copay for service is $ for insurance company will process the claim and send an in person, telehealth, home explanation of benefits to you and telephone sessionto Monarch Counseling. Xxxxx Xxxxxx reserves the right to periodically adjust the fee and The explanation of benefits will notify client in advance. Fees (including outline your financial responsibility such as; co-pays) are payable at time service is rendered. You can pay by checkpay, cash, Venmo, Health Savings Accountco-insurance, or credit card via Squaredeductible. Please note that there It is an additional transaction fee of 4% for credit and debit cards. Please ask Xxxxx Xxxxxx if you wish YOUR responsibility to discuss a written agreement that specifies an alternative payment procedure. Please inform Xxxxx Xxxxxx if you wish to utilize health insurance to pay for services. If Xxxxx Xxxxxx is a contracted provider for check with your insurance company, she will discuss company to verify benefits and coverage. Questions you may want to ask your insurance company include the procedure for billing your insurance. The amount of reimbursement your co-pay, co-insurance, and the amount of any co-payments or deductible depends on the requirements of you specific insurance planthat will be applied to your deductible. You should be aware that you are responsible expected to make your payment at time of service. Monthly payment plans are also available for verifying and understanding the limits of your insurance coverage. Although Xxxxx Xxxxxx is happy to assist you in your efforts to seek insurance reimbursement, there is no guarantee whether your insurance will provide payment for the services provided to you. This means that you are financially responsible for any unpaid amountthose who need assistance. Please discuss any questions or concerns that you may have about this speak with Xxxxx Xxxxxxthe office manager to set up a payment plan if necessary. If for some reason you are unable you continue paying for therapy, you should inform Xxxxx Xxxxxx. She will help you to consider any options that may be available to you at this time. DELINQUENT ACCOUNT POLICY: If your account is overdue (unpaid) and there is no written agreement payment plan on a payment planfile, Xxxxx Xxxxxx Monarch Counseling can use legal or other means (courts, collection agencies, etc.) to obtain payment. .( ) initial MEDIATION & ARBITRATION: All disputes arising out of, or in relation to, this agreement to provide psychotherapy services shall preferably first be referred to mediation before mediation, before, and as a pre-condition of, the initiation of arbitration or litigationarbitration. The mediator shall be a neutral third party chosen by agreement of Xxxxx Xxxxxx Monarch Counseling and the client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed upon. In the event that mediation is unsuccessful or not an agreed-upon optionunsuccessful, any unresolved controversy related to this agreement should preferably be submitted to and settled by binding arbitration, arbitration in Nebraska in accordance with the rules of the American Arbitration Association which are in effect at the time the request demand for arbitration is filed. PleaseNotwithstanding the foregoing, note that neither mediation nor arbitration is mandatory. In in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, Xxxxx Xxxxxx Monarch Counseling can use legal means (court, collection agency, etc.) to seek obtain payment. If there is arbitration, the The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum as and for attorney's fees. In the case of arbitration, the arbitrator will determine that sum. In the case of a court case, the court will determine the sum. PATIENT LITIGATION: Xxxxx Xxxxxx will not voluntarily participate in any litigation, or custody dispute in which client and another individual, or entity, are parties. Xxxxx Xxxxxx has a policy of not communicating with client’s attorney and will not write or sign letters, reports, declarations, or affidavits be used in client’s legal matter. Xxxxx Xxxxxx will not provide records or testimony to be used in client’s legal matter. There are occasions where Xxxxx Xxxxxx will make an exception and charge the fee of $225.00 per hour for writing a clinical summary and treatment recommendations. Should Xxxxx Xxxxxx be subpoenaed, or ordered by a court of law, to appear as a witness in an action involving the client, client agrees to reimburse at $400.00 per hour for a minimal of ½ day of service. THE PROCESS OF THERAPY/EVALUATION AND SCOPE OF PRACTICE: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. Xxxxx Xxxxxx I will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. Xxxxx Xxxxxx I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, Xxxxx Xxxxxx is I am likely to draw on various psychological approaches according, in part, to the problem that is being treated and his/her my assessment of what will best benefit you. These approaches include, but are not limited to, behavioral, cognitive- behavioral, cognitive-behavioral, psychodynamic, mind/body modalities, existential, family systemssystem/family, developmental (adult, child, family), humanistic and/or or psycho-educational. Xxxxx Xxxxxx provides neither Monarch Counseling does not provide custody evaluation recommendation nor recommendations, medication or prescription recommendation nor recommendations or legal advice, as these activities do not fall within her our scope of practice.

TELEPHONE & EMERGENCY PROCEDURES. If you need to contact Xxxxx Xxxxxx me between sessions, please leave a message on her confidential voice mail my voicemail at (000) 000-0000 and your call will be returned as soon as possible. Xxxxx Xxxxxx checks her I check my messages a few times during the daytime only, day unless she is I am out of towntown or out of cell service. I may provide a contact (licensed provider) for you if I am on vacation. If an emergency situation arises, indicate it clearly in your message and if you need to talk to someone right away, call the Police: away please go to your local emergency room or dial 911. Please do not use email or faxes for emergencies. I do not always check my email or faxes daily. PAYMENTS & INSURANCE REIMBURSEMENT: The Clients are expected to pay the standard fee or copay for service is $ for an in personper session at the end of each session unless other arrangements have been made. Telephone conversations, telehealthsite visits, home writing and telephone sessionreading of reports, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc. Xxxxx Xxxxxx reserves will be charged at the right to periodically adjust the fee same rate, unless indicated and will notify client in advance. Fees (including co-pays) are payable at time service is rendered. You can pay by check, cash, Venmo, Health Savings Account, or credit card via Squareagreed upon otherwise. Please note that there is an additional transaction fee notify me if any problems arise during the course of 4% therapy regarding your ability to make timely payments. I do provide the service of billing your insurance carrier for credit and debit cards. Please ask Xxxxx Xxxxxx your sessions if you wish choose to discuss a written agreement that specifies use your insurance to get reimbursed for your sessions. Sometimes the out of network insurance carrier will pay an alternative payment procedureamount less than my standard fee. Please inform Xxxxx Xxxxxx if Since I am not contracted with the insurance carrier you wish are responsible for paying the difference between what the insurance carrier pays and my standard xxx.Xxx are responsible for contacting your insurance company before the first session to utilize health make an informed decision about using or not using your insurance to pay for servicesyour sessions. If Xxxxx Xxxxxx is a contracted provider for your insurance companyAs was indicated in the section, she will discuss the procedure for billing your insurance. The amount Health Insurance & Confidentiality of reimbursement and the amount of any co-payments or deductible depends on the requirements of Records, you specific insurance plan. You should must be aware that you submitting a mental health claim for reimbursement carries a certain amount of risk. Not all issues/conditions/problems, which are responsible for verifying and understanding dealt with in psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the limits specifics of your insurance coverage. Although Xxxxx Xxxxxx is happy to assist you in your efforts to seek insurance reimbursement, there is no guarantee whether your insurance will provide payment for the services provided to you. This means that you are financially responsible for any unpaid amount. Please discuss any questions or concerns that you may have about this with Xxxxx Xxxxxx. If for some reason you are unable you continue paying for therapy, you should inform Xxxxx Xxxxxx. She will help you to consider any options that may be available to you at this time. DELINQUENT ACCOUNT POLICY: If your account is overdue (unpaid) and there is no written agreement on a payment plan, Xxxxx Xxxxxx can use legal or other means (courts, collection agencies, etc.) to obtain payment. MEDIATION & ARBITRATION: All disputes arising out of, or in relation to, this agreement to provide psychotherapy services shall preferably first be referred to mediation before the initiation of arbitration or litigation. The mediator shall be a neutral third party chosen by agreement of Xxxxx Xxxxxx and the client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed upon. In the event that mediation is unsuccessful or not an agreed-upon option, any unresolved controversy related to this agreement should preferably be submitted to and settled by binding arbitration, in accordance with the rules of the American Arbitration Association which are in effect at the time the request for arbitration is filed. Please, note that neither mediation nor arbitration is mandatory. In the event that your account is overdue (unpaid) and there is no agreement on a payment plan, Xxxxx Xxxxxx can use legal means (court, collection agency, etc.) to seek payment. If there is arbitration, the prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum as and for attorney's fees. In the case of arbitration, the arbitrator will determine that sum. In the case of a court case, the court will determine the sum. PATIENT LITIGATION: Xxxxx Xxxxxx will not voluntarily participate in any litigation, or custody dispute in which client and another individual, or entity, are parties. Xxxxx Xxxxxx has a policy of not communicating with client’s attorney and will not write or sign letters, reports, declarations, or affidavits be used in client’s legal matter. Xxxxx Xxxxxx will not provide records or testimony to be used in client’s legal matter. There are occasions where Xxxxx Xxxxxx will make an exception and charge the fee of $225.00 per hour for writing a clinical summary and treatment recommendations. Should Xxxxx Xxxxxx be subpoenaed, or ordered by a court of law, to appear as a witness in an action involving the client, client agrees to reimburse at $400.00 per hour for a minimal of ½ day of service. THE PROCESS OF THERAPY/EVALUATION AND SCOPE OF PRACTICE: Participation in therapy can result in a number of several benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. .Working toward these benefits, however, requires effort on your part. Psychotherapy requires your very highly active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. Xxxxx Xxxxxx I will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. Xxxxx Xxxxxx I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. .There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, Xxxxx Xxxxxx is I will likely to draw on various psychological approaches according, in part, to the problem that is being treated and his/her my assessment of what will best benefit you. .These approaches include, but are not limited to, behavioral, cognitive- behavioral, cognitive-behavioral, psychodynamic, mind/body modalities, existential, family systemssystem/family, developmental (adult, child, family), humanistic and/or or psycho-educational. Xxxxx Xxxxxx provides I provide neither custody evaluation recommendation nor medication or prescription recommendation nor legal advice, as these activities do not fall within her my scope of practice.