Common use of TELEPHONE & EMERGENCY PROCEDURES Clause in Contracts

TELEPHONE & EMERGENCY PROCEDURES. If you need to contact me between sessions, please leave a voicemail message at (000) 000-0000 and your call will be returned as soon as possible. I check my messages several times each day, unless I am out of town. If an emergency arises, please indicate it clearly in your message. If you need to talk to someone right away you may consider calling your family physician. PAYMENTS & INSURANCE REIMBURSEMENT: My practice is currently online via Thera-link due to Covid-19 concerns. Payment is due upon logging in for the appointment unless other arrangements have been made. Each 50-minute session is billed at $185.00 due at the time of the meeting. If your insurance will cover this type of counseling, I will supply you with an insurance billing form that you can submit to your insurance provider for direct reimbursement. Yes, I will need an insurance xxxx for reimbursement PHONE, EMAILS AND LETTERS: Phone calls requiring more than five (5) minutes and emails including any information other than scheduling an appointment shall cost the same hourly rate as a counseling session for the time required to print and read the emails. REFERRALS: If in the course of our working together I determine that I cannot assist you to the full degree you are in need of, I will refer you to another professional(s) who would likely be more able to assist you in your efforts to produce change and growth in your life. DUAL RELATIONSHIPS: Therapy never involves sexual or business relationships or any other dual relationship that impairs the therapist’s objectivity, clinical judgment, therapeutic effectiveness or can be exploitative in nature. CANCELLATION: Appointments are arranged so that we share a consistent, ongoing weekly or biweekly scheduled time together. If your appointment must be canceled, a minimum of 24 hours prior notice is expected to avoid being charged for that session. You will also be charged if you “No Show” for your scheduled time. Initials MY AGREEMENT TO YOU: I agree to assist you in gaining awareness and understanding of the obstacles you face, and to help you gain new skills to make healthy choices in your life, however, this in no way guarantees that the changes you would like to have happen will occur. I have read the above Office Policies and General Information Agreement carefully; I understand them and agree to comply with them. Client Name (print) Date Signature

TELEPHONE & EMERGENCY PROCEDURES. If you need to contact me between sessions, please leave a voicemail message at (000) 000-0000 and your call will be returned as soon as possible. I check my messages several times each day, day unless I am out of town. If an emergency arises, please indicate it clearly in your message. If you need to talk to someone right away you may consider calling your family physician. Initials PAYMENTS & INSURANCE REIMBURSEMENTand RETAINERS: My practice is currently online via Thera-link due to Covid-19 Covid- 19 concerns. Payment is due upon logging in for the appointment unless other arrangements have been made. Each 50-minute session is will be billed at the rate of $185.00 due per session. Clients also agree to pay and maintain a retainer in the amount of $370.00. The retainer will be used to cover costs described below and may also be used to draft the Memo of Understanding at the time conclusion of the meetingour process. If your insurance will cover this type of counseling, I will supply you with an insurance billing form that you can submit to your insurance provider for direct reimbursementUnused retainers shall be returned when our process is complete. Yes, I will need an insurance xxxx for reimbursement PHONE, EMAILS AND LETTERSPHONE & EMAILS: Phone calls requiring more than five (5) minutes and emails including any information other than scheduling an appointment shall cost the client the same hourly rate as a counseling session for the time required to print and read the emails. REFERRALSDual Relationships: If in the course of our working together I determine that I cannot assist you to the full degree you are in need of, I will refer you to another professional(s) who would likely be more able to assist you in your efforts to produce change and growth in your life. DUAL RELATIONSHIPS: Therapy Confidential mediation never involves sexual or business relationships or any other dual relationship that impairs the therapistMediator’s objectivityobjectify, clinical judgment, therapeutic and effectiveness or can be exploitative in nature. CANCELLATION: Appointments are arranged so that we share a consistent, ongoing weekly or biweekly scheduled time together. If your appointment must be canceled, a minimum of 24 hours prior notice is expected to avoid being charged for that session. If one parent cancels the session in less than 24 hours, that parent will be responsible for the entire cost of the missed session. You will also be charged if you “No Show” for your scheduled time. Initials MY AGREEMENT TO YOU: I agree Retainers can be used to assist you in gaining awareness and understanding of the obstacles you face, and to help you gain new skills to make healthy choices in your life, however, this in no way guarantees that the changes you would like to have happen will occurcover these costs. I have read the above Office Policies and General Information and Agreement for Confidential Mediation carefully; I understand them and agree to comply with them. Client Name (print) Date Signature

TELEPHONE & EMERGENCY PROCEDURES. If you need to contact me between sessions, please leave a voicemail message at (000) 000-0000 and your call will be returned as soon as possible. I check my messages several times each day, unless I am out of town. If an emergency arises, please indicate it clearly in your message. If you need to talk to someone right away you may consider calling your family physician. PAYMENTS & INSURANCE REIMBURSEMENT: My practice is currently online via Thera-link due to Covid-19 concerns. Payment is due upon logging in for the appointment unless other arrangements have been made. Each 50-minute session is billed at $185.00 due at the time of the meeting. If your insurance will cover this type of counseling, I will supply you with an insurance billing form that you can submit to your insurance provider for direct reimbursement. Yes, I will need an insurance xxxx bill for reimbursement PHONE, EMAILS AND LETTERS: Phone calls requiring more than five (5) minutes and emails including any information other than scheduling an appointment shall cost the same hourly rate as a counseling session for the time required to print and read the emails. REFERRALS: If in the course of our working together I determine that I cannot assist you to the full degree you are in need of, I will refer you to another professional(s) who would likely be more able to assist you in your efforts to produce change and growth in your life. DUAL RELATIONSHIPS: Therapy never involves sexual or business relationships or any other dual relationship that impairs the therapist’s objectivity, clinical judgment, therapeutic effectiveness or can be exploitative in nature. CANCELLATION: Appointments are arranged so that we share a consistent, ongoing weekly or biweekly scheduled time together. If your appointment must be canceled, a minimum of 24 hours prior notice is expected to avoid being charged for that session. You will also be charged if you “No Show” for your scheduled time. Initials MY AGREEMENT TO YOU: I agree to assist you in gaining awareness and understanding of the obstacles you face, and to help you gain new skills to make healthy choices in your life, however, this in no way guarantees that the changes you would like to have happen will occur. I have read the above Office Policies and General Information Agreement carefully; I understand them and agree to comply with them. Client Name (print) Date Signature

TELEPHONE & EMERGENCY PROCEDURES. If you need to contact me Xx. Xxxxxxxx between sessions, please leave a message on the voicemail message at (000415­754­0451) 000-0000 and your call will be returned as soon as possible. I check my Dr. Zief­Balteriski checks her messages several times each dayon a daily basis, unless I am she is out of towntown; she generally returns messages during normal work hours. If an emergency situation arises, please indicate it clearly in your message. In case of a mental health crisis, please refer to one of the 24/7 crisis call centers, 1­800­273­ 8255 or 415­781­0500. In case of other of emergencies needing immediate attention please contact 911 for assistance. PSYCHOLOGICAL EVALUATION/TESTING: Clients are expected to pay the standard fee of $175.00 per hour for psychological testing, scoring of tests, test interpretation, feedback of the results, consultation, travel time, behavioral observation, and report writing. The same rate will be charged for consultation with other professionals. Clients will be given an estimate of the total cost after the first session. If concerns arise for memory, attention, learning disability, or neuropsychological impairment additional testing may be needed to provide a comprehensive evaluation. Clients should understand that each individual case differs in regards to time required to complete the testing procedures. If desired, a written report will be provided to the client or sent to another professional after an oral feedback session and after the account is paid in full. The cost for scoring of tests is two hours ($350.00). The cost for report writing is two­four hours of time depending on the length of the evaluation. Please note that many insurance companies do not reimburse for psychological testing. PSYCHOTHERAPY CHARGES: Clients are expected to pay the agreed upon fee for each 50 minute therapy session. For clients using insurance, you are responsible for copayment and updating any changes to your insurance plan. The client will be charged the full fee without a 48­hour­notice of cancellation, with the exception of emergencies. If you need are a student or sliding fee agreement you will be charged that rate. If you are a client covered by insurance, you will be charged the standard rate. Sliding Fee rate: Standard Rate: Intial: MEDIATION & ARBITRATION: All disputes arising out of or in relation to talk ther agreement to someone right away you may consider calling your family physicianprovide psychotherapy services shall first be referred to mediation, before, and as a pre­condition of, the initiation of arbitration. PAYMENTS & INSURANCE REIMBURSEMENT: My practice The mediator shall be a neutral third party chosen by agreement of Xx. Xxxxxxxx and client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is currently online via Thera-link due unsuccessful, any unresolved controversy related to Covid-19 concerns. Payment is due upon logging ther agreement should be submitted to and settled by binding arbitration in for Sacramento County, California in accordance with the appointment unless other arrangements have been made. Each 50-minute session is billed at $185.00 due rules of the American Arbitration Association which are in effect at the time of the meetingdemand for arbitration is filed. If your insurance will cover this type of counselingNotwithstanding the foregoing, I will supply you with an insurance billing form that you can submit to your insurance provider for direct reimbursement. Yes, I will need an insurance xxxx for reimbursement PHONE, EMAILS AND LETTERS: Phone calls requiring more than five (5) minutes and emails including any information other than scheduling an appointment shall cost the same hourly rate as a counseling session for the time required to print and read the emails. REFERRALS: If in the course event that your account is overdue (unpaid) and there is no agreement on a payment plan, Dr. Zief­Balteriski can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceeding shall be entitled to recover a reasonable sum as well as attorneys’ fees. In the case of our working together I arbitration, the arbitrator will determine that I cannot assist you to the full degree you are in need of, I will refer you to another professional(s) who would likely be more able to assist you in your efforts to produce change and growth in your lifesum. DUAL RELATIONSHIPS: Therapy never involves sexual or business relationships or any other dual relationship that impairs the therapist’s objectivity, clinical judgment, therapeutic effectiveness or can be exploitative in nature. CANCELLATION: Appointments are arranged so that we share a consistent, ongoing weekly or biweekly scheduled time together. If your appointment must be canceled, a minimum of 24 hours prior notice is expected to avoid being charged for that session. You will also be charged if you “No Show” for your scheduled time. Initials MY AGREEMENT TO YOU: I agree to assist you in gaining awareness and understanding of the obstacles you face, and to help you gain new skills to make healthy choices in your life, however, this in no way guarantees that the changes you would like to have happen will occur. I have read the above Office Policies and General Information Agreement carefully; I understand them and agree to comply with them. Client Name (print) Date SignatureInitial p. !3

TELEPHONE & EMERGENCY PROCEDURES. If you need to contact me between sessions, please leave a voicemail message at on my answering machine (000) 000-0000 and your call will be returned as soon as possible. I check my messages several a few times each day, unless I am out of town. If an emergency situation arises, please indicate it clearly in your message. If you need to talk to someone right away you may consider calling your family physiciancall Xxxxxx Center for Psychiatry at (000) 000-0000, or the Police/Sheriff’s Department (911). PAYMENTS & INSURANCE REIMBURSEMENT: My practice is currently online via TheraFor the Shared Parenting Support Program method of co-link due parenting counseling, a retainer of $1,800.00 will need to Covid-19 concernsbe paid at the first session. Payment is due upon logging in There will also be an additional cost for the appointment unless other arrangements have been madematerials totaling $75.00. Each 50-50 minute session will be deducted from the retainer at the rate of $180.00 per session. For any other co-parenting counseling, clients agree to participate in a minimum of eight (8) sessions. Each 50 minute session will be at the rate of $180.00 per session. If there is billed at $185.00 due a need for co-parenting counseling to extend beyond eight sessions, clients will pay for each additional session at the time of the meeting. If your insurance will cover this type of counseling, I will supply you with an insurance billing form that you can submit to your insurance provider for direct reimbursement. Yes, I will need an insurance xxxx for reimbursement PHONE, EMAILS AND LETTERS: Phone calls requiring more than five (5) minutes and emails including any information other than scheduling an appointment shall cost the client the same hourly rate as a counseling session for the time required to print and read the emails. REFERRALSIf a letter is needed and agreed upon by both parents, the client shall be charged a minimum of $100.00, the cost shall increase if the time required extends over 20 minutes. THE PROCESS OF CO-PARENTING COUNSELING: Change happens because a person consciously decides to speak and behavior differently. Growth does not happen without purposeful choice and effort by that individual. Your co-parenting relationship will improve to the degree both parents make the wise choice apply themselves and make the necessary changes. Only you can determine what you will say and do. Please know clearly that your children will thrive to the degree their parents provide a tension free environment and peaceful parental exchanges. Referrals: If in the course of our working together I determine that I cancan not assist you to the full degree you are in need of, I will refer you to another professional(s) who would likely be more able to assist you in your efforts to produce change and growth in your life. DUAL RELATIONSHIPSDuel Relationships: Therapy never involves sexual or business relationships or any other dual relationship that impairs the therapist’s objectivity, clinical judgment, and therapeutic effectiveness or can be exploitative in nature. CANCELLATION: Appointments are arranged so that we share a consistent, ongoing weekly or biweekly scheduled time together. If your appointment must be canceled, a minimum of 24 hours prior notice is expected to avoid being charged for that session. You will also be charged if you “No Show” for your scheduled time. Initials MY AGREEMENT TO YOU: I agree to assist you in gaining awareness and understanding of the obstacles you face, and to help you gain new skills to make healthy choices in your life, however, this in no way guarantees that the changes you would like to have happen will occur. I have read the above Office Policies and General Information Agreement carefully; I understand them and agree to comply with them. Client Name (print) Date Signature.