Common use of TERMINATION OF TREATMENT Clause in Contracts

TERMINATION OF TREATMENT. If I determine that I cannot provide appropriate services to you for any reason, I will terminate our treatment and refer you to other professionals. If you request and authorize it in writing, I will talk to the new therapist in order to help with the transition. If at any time you want another professional’s opinion or wish to consult with another therapist, I will assist you with referrals. Upon termination of therapy for any reason, the termination will be confirmed in writing. Professional Fees: My fee for individual therapy is set at $140 per 50 minute session. Other services or no-show/late cancellation fees may have varying charges. You are expected to pay for each session at the time it is held. In addition to psychotherapy sessions, I charge this amount for other professional services you may need or request, such as report writing, telephone conversations of ten minutes or more, consultation with other professionals with your written permission, and preparation of records or treatment summaries. The time spent performing any other service you may request of me will incur additional charges. I will pro-rate the cost if I work for periods of less than 45 minutes. Please note that the “therapy hour” is actually 45- to 50 minutes in length, and is the usual session duration. Litigation Policy: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (including but not limited to divorce and custody disputes, injuries, lawsuits, etc..), neither you, your attorneys or anyone acting on your behalf will subpoena records from my office, or subpoena me to testify in court or in any legal proceeding. By your signature below, you agree to abide by this agreement. If I am subpoenaed to provide records or testimony in violation of this agreement, you acknowledge and agree you will pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. If you become involved in any legal matter that requires my services, there is a fee of $250 per hour and this includes preparation time, travel time, attendance at any legal proceeding or any other time spent in this endeavor. I also reserve the right to terminate our professional, therapeutic relationship immediately and refer you to other mental health providers. I will NOT provide custody evaluations or recommendations of any kind. I will NOT provide medication or prescription recommendations. I will NOT provide legal advice. None of these activities are within scope of my practice. I do not do counseling for the purpose of meeting court or probation related assessments or counseling. It important that each client in the initial interview or at the first opportunity disclose fully to me if he/she has past, current, pending or potential legal issues. Insurance Reimbursement: Generally I do not participate in network with any insurance programs. I am licensed in Texas as a Psychologist. Your insurance company may reimburse you according to guidelines they have established for out of network providers. Your health insurance policy will usually provide some coverage for mental health treatment. I will give you a receipt after each session so you can file with your insurance company. However, you (not your insurance company) are responsible for full payment of my fees. You are responsible for knowing what mental health services your insurance policy covers. If you have questions about the coverage, call your plan administration. Charge for Missed Appointments: There is a fee charge for missed appointments or cancellations made without 24 hour notice. The charge may be waived in the case of a reasonable emergency. I reserve the right to request that you provide a credit card number to be kept on file so that it may be charged for any missed appointments. Please see my fee schedule for charges.

TERMINATION OF TREATMENT. If at any point during psychotherapy I determine assess that I canam not provide appropriate services effective in helping you reach your therapy goals I am obliged to discuss it with you for any reasonand if appropriate, to terminate treatment. In such cases, I will terminate our treatment and refer give referrals that may be of help or direct you back to other professionalsyour insurance company. If you request and authorize it in writing, I will talk to the new therapist psychotherapist of your choice in order to help with the transitiontransition if it is requested and a release of information is provided. If at any time you want another professional’s opinion or wish to consult with another therapist, I will assist you in finding someone qualified, and, if you provide a written consent, I will provide the essential information needed. You have the right to terminate therapy at any time. If you choose to do so, I will offer to provide you with referralsthe names of other qualified professionals whose services you might prefer. Upon termination PROFESSIONAL FEES My hourly fee, or Usual and Customary Rate (UCR), is $145. In addition to weekly appointments, I charge this amount for other professional services you may need, though I will break down the hourly cost if I work for periods of therapy for less than one hour. ‘Other’ services are generally not reimbursed by your insurance plan. These other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any reasonother service you may request of me. If you become involved in legal proceedings that require my participation, the termination you will be confirmed in writingexpected to pay for my professional time even if I am called to testify by another party. Professional Fees: My fee Because of the difficulty of legal involvement, I charge $275 per hour for individual therapy preparation and attendance at any legal proceedings. Travel to and from my office is set billed at $140 per 50 minute sessionthe same rate. Other services or no-show/late cancellation fees may have varying charges. BILLING AND PAYMENTS You are will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. In addition to psychotherapy sessions, I charge this amount Payment schedules for other professional services you will be agreed to when they are requested. In circumstances of unusual financial hardship, I may need be willing to negotiate a fee adjustment or requestpayment installment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such as report writinglegal action is necessary costs will be included in the claim. In most collection situations, telephone conversations the only information I release regarding a patient’s treatment is name, the type of ten minutes or more, consultation with other professionals with your written permissionservices provided (psychotherapy), and preparation of records or the amount due. INSURANCE REIMBURSEMENT In order for us to set realistic treatment summaries. The time spent performing any other service you may request of me will incur additional charges. I will pro-rate the cost if I work for periods of less than 45 minutes. Please note that the “therapy hour” is actually 45- to 50 minutes in length, goals and is the usual session duration. Litigation Policy: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential naturepriorities, it is agreed that should there be legal proceedings (including but not limited important to divorce and custody disputes, injuries, lawsuits, etc..), neither you, your attorneys or anyone acting on your behalf will subpoena records from my office, or subpoena me evaluate what resources you have available to testify in court or in any legal proceeding. By your signature below, you agree to abide by this agreement. If I am subpoenaed to provide records or testimony in violation of this agreement, you acknowledge and agree you will pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another partyyour treatment. If you become involved in any legal matter that requires my services, there is have a fee of $250 per hour and this includes preparation time, travel time, attendance at any legal proceeding or any other time spent in this endeavor. I also reserve the right to terminate our professional, therapeutic relationship immediately and refer you to other mental health providers. I will NOT provide custody evaluations or recommendations of any kind. I will NOT provide medication or prescription recommendations. I will NOT provide legal advice. None of these activities are within scope of my practice. I do not do counseling for the purpose of meeting court or probation related assessments or counseling. It important that each client in the initial interview or at the first opportunity disclose fully to me if he/she has past, current, pending or potential legal issues. Insurance Reimbursement: Generally I do not participate in network with any insurance programs. I am licensed in Texas as a Psychologist. Your insurance company may reimburse you according to guidelines they have established for out of network providers. Your health insurance policy policy, it will usually provide some coverage for mental health treatment. I will give fill out forms and provide you a receipt after each session so with whatever assistance I can in helping you can file with your insurance company. Howeverreceive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. You are responsible for knowing It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrationadministrator. Charge Of course I will provide you with whatever information I can based on my experience and will be happy to help you understand the information you receive from your insurance company. If it is necessary to clarify any confusion, I would be willing to call the insurance company on your behalf. Due to the rising costs of health care, insurance benefits have become increasingly complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for Missed Appointments: There is mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a fee charge for missed appointments or cancellations made without 24 hour noticeperson’s usual level of functioning. The charge It may be waived necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case case, I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of a reasonable emergencythe entire record (in rare cases). This information can become part of the insurance company files. All insurance companies are required to keep such information confidential. I reserve will review any information I am required to submit for insurance purposes with you if you request it, before submission. I will always inform you a request has been made. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have the right to request pay for my services yourself to avoid the problems described above, unless prohibited by contract. The advantage here is that records stay with me and with the exception of a court order I will not release them to anyone. On court order or any other required disclosure (legally speaking) I will contact my patient first, and when necessary seek legal counsel on such requests prior to releasing records. CONTACTING ME I am often not immediately available by telephone. While I am usually in my office between 4 PM and 9 PM Monday through Friday, I will not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by an answering machine. I will make every effort to return your call on the same day I receive the call, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available for me to return your call. If you have a life threatening emergency, please call 911 or go to the nearest emergency room. For other types of situations, call my office (000) 000-0000 Opt 2 and mark the message as urgent and I will return your call as quickly as possible. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of your records, or I can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and may be upsetting to untrained readers. If you wish to see your records, I recommend that you provide a credit card number to be kept on file review them in my presence so that it we can discuss the content. There may be a fee charged to conduct a review meeting. Patients will be charged an appropriate fee for any missed appointmentsprofessional time spent in responding to information requests if your insurance company does not cover the service. Please see my fee schedule for chargesTypically they do not.

TERMINATION OF TREATMENT. During the initial intake process and the first few sessions, I will assess if I can be of benefit to you. If you have requested online counseling, my assessment will include your suitability to psychotherapy delivered via technology. Not everyone is suited to distance counseling. Also, each therapist’s skills and styles are different. I determine want to be sure that we have a good match between client and therapist. I do not accept clients who, in my opinion, I cannot provide appropriate services to you for any reasonhelp. In such a case, I will terminate our treatment give you a number of referrals that you may contact. If at any point during psychotherapy, I assess that I am not effective in helping you reach your therapeutic goals, I am obligated to discuss this with you, up to and refer including termination of treatment. In such a case, I will give you a number of referrals that may be of help to other professionalsyou. If you request and authorize it in writing, I will talk to with the new therapist psychotherapist of your choice in order to help with the transition. If at any time you want another professional’s opinion or wish to consult with another therapist, I will assist you in finding someone qualified and if I have you written consent, I will provide him or her with referrals. Upon termination of therapy for any reason, the termination will be confirmed in writing. Professional Fees: My fee for individual therapy is set at $140 per 50 minute session. Other services or no-show/late cancellation fees may have varying chargesessential information needed. You are expected have the right to pay for each session terminate therapy at the time it is heldany time. In addition If you choose to psychotherapy sessionsdo so, I charge this amount for will offer to provide you with names of other professional qualified professionals whose services you might prefer. CONFIDENTIALITY & PRIVACY All information disclosed within sessions and the written records pertaining to those sessions are confidential and may need or request, such as report writing, telephone conversations of ten minutes or more, consultation with other professionals with not be revealed to anyone without your written permission, except where disclosure is required by law. Likewise, you are expected to keep our communications confidential and preparation you understand that all records of communication between client and therapist remain the property of Xxxxx Xxxxxx. Most of the provisions explaining when the law requires disclosure were described to you in the Notice of Privacy Practices that you received with this form. WHEN DISCLOSURE IS REQUIRED BY LAW Some of the circumstances in which disclosure is required by law include: 1) when there is a reasonable suspicion of child, dependent, or elder abuse or neglect; 2) when a client presents a danger to self, to others, to property, or is gravely disabled. For more details, see the Notice of Privacy Practices form. WHEN DISCLOSURE MAY BE REQUIRED Disclosure may be required pursuant to a legal proceeding. If you are involved in a custody dispute or if you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by me. In couples and family therapy, or treatment summaries. The time spent performing any other service you may request of me will incur additional chargeswhen different family members are seen individually, confidentiality and privilege do not apply between couple or among family members. I will prouse my clinical judgment when revealing such information. I will not release records to any outside party unless I am authorized do so by all adult family members who were part of the treatment or unless compelled to do so by law or a valid court order. HARM TO SELF OR OTHERS If there is an emergency during our work together or if in the future after termination I become concerned about your personal safety, the possibility of your injuring someone else, or about you receiving proper psychiatric care, I will do whatever I can within the limits of the law to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, I may also contact law enforcement, hospital, or an emergency contact whose name you have provided. CONFIDENTIALITY OF EMAIL, CHAT, CELL PHONE, AND FAX COMMUNICATIONS Therapeutic e-rate mail and chat exchanges are delivered via HushMail. You agree to work with me online using HushMail or anther encrypted email/chat service determined to be suitable by Xxxxx Xxxxxx. If you choose to e-mail me from your personal email account, please limit the cost contents to housekeeping issues such as cancellation or change in contact information. I will not respond to personal and clinical concerns via regular email. If you call me, please be aware that unless we are both on land line phones, the conversation is not confidential. Likewise, text messages are not confidential. If you send a fax to me, my fax line is in a secure location. Any computer files referencing our communication are maintained using secure and encrypted measures. If you wish to use email as a way to “journal” information between sessions, you understand that I may not have the opportunity to review your journal emails until our next scheduled session. You understand that emails between sessions that contain confidential information will be sent using encryption. I make every effort to keep all information confidential. Likewise, if we are working online together, I work for periods of less than 45 ask that you determine who has access to your computer and electronic information from your location. This would include family members, co-workers, supervisors, and friends. I encourage you to only communicate through a computer that you know is safe (where confidentiality can be ensured). Be sure to fully exit all online counseling sessions and emails. If we are unable to connect or are disconnected during a session due to a technological breakdown, please try to reconnect within 10 minutes. Please note that the “therapy hour” If reconnection is actually 45- not possible, e-mail me to 50 minutes in length, and is the usual schedule a new session durationtime. Litigation Policy: LITIGATION LIMITATION Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (including such as, but not limited to to: divorce and custody disputes, injuries, lawsuits, etc...), neither youyou (client) nor your attorney, your attorneys or nor anyone else acting on your behalf will subpoena records from my office, or subpoena call on me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested. CONSULTATION I consult regularly with other professionals regarding my clients, however, the client’s name or other identifying information is never disclosed. The client’s identity remains completely anonymous and confidentiality is fully maintained. RELEASE OF INFORMATION Considering all the above exclusions, if it is still appropriate, upon your request and signed Release of Information, I will release information to any agency/person you specify unless I conclude that releasing such information might be harmful in any legal proceedingway. By If you were referred by your signature belowfamily physician, a release of information signed by you would be necessary to discuss matters regarding your treatment. Also please be aware that for purposes of billing insurance, your diagnosis and dates of service will be required to collect payment of services. EMERGENCY PROCEDURES Established clients who need to make contact with me between appointments to alert me of an emergency may call 000-000-0000 but an immediate response is not guaranteed. Your call will be returned as soon as possible. Messages are checked daily during regular business hours (less frequently after hours, weekends, or holidays). My practice does NOT have the capability to respond immediately to counseling emergencies. In the event of a life- threatening emergency, please call the emergency National Suicide Hotline at 000-000-0000 or dial 911. Additional crisis hotlines are listed on my website. If a life-threatening crisis should occur, you agree to abide contact a crisis hotline, dial 911, or go to a hospital emergency room. FEES Current rates for therapeutic services are posted on my website. PAYMENT INFORMATION Payment is expected prior to your appointment. Session payments via debit or credit card can be processed through PayPal, Google Checkout, or XxxxxxxxxxxxXxxxxxx.xxx. Sessions are usually purchased in 30 and 60 minute increments. Therapeutic email exchanges can be purchased one at a time or as a package. Clients who are attending therapeutic sessions face-to-face (in person) in my office may provide payment at the time of their session. In-person session payments may be cash, check, or money order. INSURANCE PLANS Please note that most insurance companies only cover services that are provided face-to-face. Insurance plans do no usually cover services that are provided at a distance. For clients who are attending therapeutic sessions face-to-face (in person) in my office, I am able to accept some insurance plans and would be pleased to bill them for you. Please have your insurance card and co-payment amount with you to help accelerate this process. Although a claim for your session is issued to your insurance company that does not guarantee payment from the insurance company (you will be responsible for payment). If your insurance provider is not one of the insurance plans I accept, you have the option to pay privately or use your insurance provider’s “out of network” service (if that is part of your insurance plan). That would involve your paying in full at time of service and then you would submit a super bill to the insurance provider to recover whatever percentage they pay. There is usually an upfront “out of network” deductible. I will be happy to help you with this process. MEDIATION & ARBITRATION All disputes arising out of or in relation to this agreement to provide therapeutic services shall first be referred to mediation before, and as a precondition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of Xxxxx Xxxxxx and the client(s). The cost, if any, of such mediation shall be split equally, unless otherwise agreed in writing. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in accordance with the rules of the American Arbitration Association that are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, I can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitrator will determine that sum. CANCELLATION Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours notice is required for rescheduling or cancelling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification. If I am subpoenaed not able to provide records keep the scheduled appointment and did not give you 24 hours prior notice, I will offer you a session free of charge. Our time is equally valuable. CONSENT FOR EVALUATION AND TREATMENT You as the client understand that phone and email sessions have limitations compared to in-person sessions. This includes the lack of “personal” face-to-face interactions, the lack of visual and audio cues in the therapy process, and the fact that most insurance companies will not cover this type of therapy. You understand that psychotherapy with me is not a substitute for medication under the care of a psychiatrist or testimony in violation of this agreementdoctor. You understand that online and telephone therapy is not appropriate if you are experiencing a crisis or having suicidal or homicidal thoughts. As stated previously, if a life-threatening crisis should occur, you acknowledge agree to contact a crisis hotline, call 911, or go to a hospital emergency room. You also understand that I follow the laws and agree professional regulations of the State of Arizona (USA) and the psychotherapy treatment will be considered to take place in the State of Arizona (USA). You signature below indicates that you will pay have reviewed the information available on my website and have read and understand this Informed Consent and the HIPPA Notice of Privacy Practices. Consent is hereby given for all evaluation and treatment under the terms described in this consent document. It is agreed that either of my professional time, including preparation and transportation costs, even if I am called to testify by another party. If you become involved in any legal matter that requires my services, there is a fee of $250 per hour and this includes preparation time, travel time, attendance us may discontinue the treatment at any legal proceeding or any other time spent in this endeavor. I also reserve the right to terminate our professional, therapeutic relationship immediately and refer you to other mental health providers. I will NOT provide custody evaluations or recommendations of any kind. I will NOT provide medication or prescription recommendations. I will NOT provide legal advice. None of these activities are within scope of my practice. I do not do counseling for the purpose of meeting court or probation related assessments or counseling. It important that each client in the initial interview or at the first opportunity disclose fully to me if he/she has past, current, pending or potential legal issues. Insurance Reimbursement: Generally I do not participate in network with any insurance programs. I am licensed in Texas as a Psychologist. Your insurance company may reimburse you according to guidelines they have established for out of network providers. Your health insurance policy will usually provide some coverage for mental health treatment. I will give you a receipt after each session so you can file with your insurance company. However, you (not your insurance company) are responsible for full payment of my fees. You are responsible for knowing what mental health services your insurance policy covers. If you have questions about the coverage, call your plan administration. Charge for Missed Appointments: There is a fee charge for missed appointments or cancellations made without 24 hour notice. The charge may be waived in the case of a reasonable emergency. I reserve the right to request that you provide a credit card number are free to be kept on file so that it may be charged for any missed appointmentsaccept or reject the treatment provided. Please see my fee schedule for charges.Client Name (printed): Client Signature: Date:

TERMINATION OF TREATMENT. If at any point during psychotherapy I determine assess that I canam not provide appropriate services effective in helping you reach the therapeutic goals, I am obliged to discuss it with you for any reasonand, if appropriate, to terminate treatment. In such a case, I will terminate our treatment and refer you give a number of referrals that may be of help to other professionalsyou. If you request it and authorize it in writing, I will talk to the new therapist psychotherapist of your choice in order to help with the transition. If at any time you want another professional’s opinion or wish to consult with another therapist, I will assist you in finding someone qualified, and, if you provide a written consent, I will provide the essential information needed. You have the right to terminate therapy at any time. If you choose to do so, I will offer to provide you with referralsthe names of other qualified professionals whose services you might prefer. Upon termination PROFESSIONAL FEES My hourly fee is $150. In addition to weekly appointments, I charge this amount for other professional services you may need, though I will break down the hourly cost if I work for periods of therapy for any reason, the termination will be confirmed in writing. Professional Fees: My fee for individual therapy is set at $140 per 50 minute sessionless than one hour. Other services are generally not reimbursed by your insurance plan. These other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records or no-show/late cancellation fees treatment summaries, and the time spent performing any other service you may have varying chargesrequest of me. If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $300 per hour for preparation and attendance at any legal proceeding. BILLING AND PAYMENTS You are will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. In addition to psychotherapy sessions, I charge this amount Payment schedules for other professional services you will be agreed to when they are requested. In circumstances of unusual financial hardship, I may need be willing to negotiate a fee adjustment or requestpayment installment plan. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. If such as report writinglegal action is necessary, telephone conversations of ten minutes or moreits costs will be included in the claim. In most collection situations, consultation with other professionals with your written permissionthe only information I release regarding a patient’s treatment is his/her name, and preparation of records or treatment summaries. The time spent performing any other service you may request of me will incur additional charges. I will pro-rate the cost if I work for periods of less than 45 minutes. Please note that the “therapy hour” is actually 45- to 50 minutes in length, and is the usual session duration. Litigation Policy: Due to the nature of the therapeutic process services provided, and the fact that it often involves making a full disclosure with regard amount due. INSURANCE REIMBURSEMENT In order for us to many matters which may be of a confidential natureset realistic treatment goals and priorities, it is agreed that should there be legal proceedings (including but not limited important to divorce and custody disputes, injuries, lawsuits, etc..), neither you, your attorneys or anyone acting on your behalf will subpoena records from my office, or subpoena me evaluate what resources you have available to testify in court or in any legal proceeding. By your signature below, you agree to abide by this agreement. If I am subpoenaed to provide records or testimony in violation of this agreement, you acknowledge and agree you will pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another partyyour treatment. If you become involved in any legal matter that requires my services, there is have a fee of $250 per hour and this includes preparation time, travel time, attendance at any legal proceeding or any other time spent in this endeavor. I also reserve the right to terminate our professional, therapeutic relationship immediately and refer you to other mental health providers. I will NOT provide custody evaluations or recommendations of any kind. I will NOT provide medication or prescription recommendations. I will NOT provide legal advice. None of these activities are within scope of my practice. I do not do counseling for the purpose of meeting court or probation related assessments or counseling. It important that each client in the initial interview or at the first opportunity disclose fully to me if he/she has past, current, pending or potential legal issues. Insurance Reimbursement: Generally I do not participate in network with any insurance programs. I am licensed in Texas as a Psychologist. Your insurance company may reimburse you according to guidelines they have established for out of network providers. Your health insurance policy policy, it will usually provide some coverage for mental health treatment. I will give fill out forms and provide you a receipt after each session so with whatever assistance I can in helping you can file with your insurance company. Howeverreceive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of my fees. You are responsible for knowing It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrationadministrator. Charge Of course I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for Missed Appointments: There is mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a fee charge for missed appointments or cancellations made without 24 hour noticeperson’s usual level of functioning. The charge It may be waived necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case case, I will do my best to find another provider who will help you continue your psychotherapy. You should also be aware that most insurance companies require you to authorize me to provide them with a clinical diagnosis. Sometimes I have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files and will probably be stored in a reasonable emergencycomputer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I reserve will provide you with a copy of any report I submit, if you request it. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have the right to request pay for my services yourself to avoid the problems described above, unless prohibited by contract. CONTACTING ME I am often not immediately available by telephone. While I am usually in my office between 10 AM and 7 PM Monday throughThursday and between 9 AM and 4 PM on Friday, I probably will not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by an answering machine when I am in the office which I monitor frequently and voice mail when I am away from the office . I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available for me to return your call. If you have a life threatening emergency, please call 911 or go to the nearest emergency room. For other types of crises, my pager (cell phone) number is 000-000-0000. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. PROFESSIONAL RECORDS The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of your records, or I can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or may be upsetting to untrained readers. If you wish to see your records, I recommend that you provide a credit card number to be kept on file review them in my presence so that it we can discuss the contents. There may be a fee charged to conduct a review meeting. Patients will be charged an appropriate fee for any missed appointmentsprofessional time spent in responding to information requests. Please see MINORS If you are under eighteen years of age, please be aware that the law may provide your parents the right to examine your treatment records. It is my fee schedule policy to request an agreement from parents that they agree to give up access to your records. If they agree, I will provide them only with general information about our work together, unless I feel there is a high risk that you will seriously harm yourself or someone else. In this case, I will notify them of my concern. I will also provide them with a summary of your treatment when it is complete. Before giving them any information, I will discuss the matter with you, if possible, and do my best to handle any objections you may have with what I am prepared to discuss. At the end of your treatment, I will prepare a summary of our work together for chargesyour parents, and we will discuss it before I send it to them.